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Table 18.1. Review of the literature: women
Chapter 18 The Artificial Urinary Sphincter
277
Aut hor N Median follow-up Success Revisions
Diokno 32 2.5 91% 21%
Mundy 29 ? 19% 2%
Webster 25 2.4 92% 0
Norlen 7 5.5 4% 1%
a
Buzelin
Richard 89 4.2 88% 17%
Schreiter 164 8.7 91% 41%
Total 442 88.8% 24%
a
Buzelin: implanted and injected material, 1996.
Table 18.2. Review of the literature: men
Aut hor N Success Revisions
Barret (1997) 417 88.2% 23.1%
Thomas (1996) 28 86% 28%
Casale (2002) 142 86% 25%
Wilson (2002) 37 66%
Spiess (2002) 30 83% 40%
Mulcahy (1996) 97 88% (double cuff)
Schreiter (1999) 369 86% 29%
96 2.5 82% 17%
(years)
males (48/321 patients after RRP, 15% in our casuistic) and female patients (22/144 patients, 15.2% of patients).
Despite the introduction of the narrow-backed cuff in 1987, fluid loss due to cuff
leakage remained the most frequent late (after more than 5 years) mechanical complication in males (32/321 patients after RRP, 10%) and females (19/144 patients, 13.2%).
Some of the results of the literature are summarized in Tables 18.1 and 18.2.
18.8 Conclusion
The artificial sphincter (AMS 800) is the only model available today. The results
achieved are excellent if the indication is correct and perioperative management is
careful and adequate. The ideal patient is one with genuine stress urinary incontinence and normal bladder function, although hyper- or hyporeflexia is not an absolute
contraindication if treated before or after sphincter implantation. The surgical technique is relatively simple and the only challenge is the choice of the appropriate cuff
and reservoir size. Complications include urethral atrophy, erosion, infection and
bladder instability. The mechanical failures of the prosthesis have diminished with improved design and manufacturing. Patient satisfaction is high. Currently the only
method to treat urinary incontinence in a physiological way is the implantation of the
artificial urinary system (AMS 800).
278
Roberto Olianas, M.Fisch
References
Bishoff J,Motley G, Optenberg S, Stein C,Moon K, Browning S, Sabanegh E,Foley P, Thompson I
(1998) Incidence of fecal and urinary incontinence following radical perineal and retropubic
prostatectomy in a national population.J Urol 160:454–458
Elliott DS, Barrett DM (1998) Mayo Clinic long-term analysis of the functional durability of the
AMS 800 artificial urinary sphincter: a review of 323 cases. J Urol 159: 1206–1208
Foley F (1947) An artificial urinary sphincter: a new device and operation for control of enuresis
and urinary incontinence. J Urol 58 :250–259
Furlow W (1981) Implantation of a new semiautomatic artificial genitourinary sphincter: experi-
ence with primary activation and deactivation in 47 patients.J Urol 126: 741–744
Guralnick ML, Miller E, Toh KL, Webster GD (2002) Transcorporal artificial urinary sphincter
cuff placement in cases requiring revision for erosion and urethral atrophy. J Urol 167:
2075–2079
Hald T (1986) Artificial urinary sphincter.World J Urol 4: 41–44
Hodges CV (2002) Vesicourethral anastomosis after radical prostatectomy: experience with the
Jewett modification.J Urol 118: 209–210
Holtedahl K,Hunskaar S (1998) Prevalence, 1 year incidence and factors associated with urinary
incontinence: a population-based study of women 50–74 years of age in primary care. Matu-
ritas 28 :205–211
Lee W, Schultheiss T, Hanlon A, Hanks G (1996) Urinary incontinence following external-beam
radiotherapy for clinically localized prostate cancer.Urology 48: 95–99
McConnell J (1994) Benign prostatic hyperplasia guideline panel. Direct treatment outcome –
urinary incontinence. Benign prostatic hyperplasia, diagnosis and treatment, pp 105–106
Montague D (1981) The Scott-Bradley-Timm artificial urinary sphincters. J Urol 125: 796–798
Perez L,Webster G (1992) Successful outcome of artificial urinary sphincters in men with post-
prostatectomy urinary incontinence despite adverse implantation features. J Urol 148 :
1166–1170
Rudy DC,Woodside JR, Crawford ED (1984) Urodynamic evaluation of incontinence in patients
undergoing modified Campbell radical retropubic prostatectomy: a prospective study. J Urol
132: 708–712
Scott F (1985) The use of the artificial sphincter in the treatment of urinary incontinence in the
female. Urol Clin Am 12 :305–315
Scott F (1989) The artificial urinary sphincter, experience in adults. Urol Clin Am 16 :105–117
Scott F, Bradley W, Timm G (1973) Treatment of urinary incontinence by an implantable pros-
thetic sphincter.Urology 1: 252–259
Thom D (2003) Variation in estimates of urinary incontinence prevalence in the community: ef-
fects of differences in definition, population characteristics and study type. J Am Geriatr Soc
46: 473–480
Walsh PC, Partin AW, Epstein JI (1994) Cancer control and quality of life following anatomical
radical retropubic prostatectomy: results at 10 years.J Urol 152: 1831–1836
18
Part VI
Operative Therapy
of Fecal Incontinence
VI
Chapter 19
Sphincteroplasty
Tilman T. Zittel
Chapter 19 Sphincteroplasty
281
19
Contents
19.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 282
19.2 Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . . 282
19.3 Operative Technique . . . . . . . . . . . . . . . . . . . . . 284
19.4 Functional Results . . . . . . . . . . . . . . . . . . . . . . 285
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
19
282
Tilman T.Zittel
19.1 Introduction
Fecal incontinence constitutes a severe social problem for the person afflicted and reduces quality of life considerably. A rising incidence has been described with increasing age, and it is estimated that about 1%–2% of a Western population suffer from severe fecal incontinence, defined as the involuntary loss of solid stool at least once a
week. There is a variety factors that influence continence such as reduced sphincter
strength, impaired sphincter integrity, short anal canal length, reduced stool consistency,reduced rectal compliance, reduced anorectal sensation,abnormal rectoanal inhibitory reflex, perineal descent, previous sphincter repair, and mental or congenital
disorders.Fecal incontinence can be grouped according to its etiology: traumatic,neuropathic and congenital (Jorge and Wexner 1993). Only patients with a traumatic
sphincter defect are candidates for a sphincteroplasty,most of them women after vaginal deliveries, and to a lesser extent patients after accidents or iatrogenic surgical
sphincter injuries.
19.2 Diagnostic Evaluation
A careful history should be taken. This includes the symptom duration of fecal incontinence, stool consistency, stool frequency, the estimated time to maximally withhold
stool, the frequency of incontinence episodes, whether gas,liquid or solid stool is lost,
a careful obstetric history, and whether perianal, anorectal or abdominal surgery has
been performed in the past. It might be best to use a structured interview,working up
a catalog of standard questions, which might be done by a trained nurse. To quantify
fecal incontinence,a grading system according to Parks (0 = perfect continence,1 = incontinence to gas,2 = incontinence to liquid stool,3 = incontinence to solid stool) or a
simple scoring system such as the Cleveland Clinic Incontinence Score (0 points = perfect continence, 20 points = total incontinence) should be used. For study purposes,
general quality-of-life measures such as the short form 36 (SF-36),and disease-specific quality-of-life measures such as the fecal incontinence quality-of -life scale, which
has been endorsed by the American Society of Colon and Rectal Surgeons (ASCRS),
might be used (Vaizey et al. 1999; Baxter et al. 2003).
If a reduced stool consistency or frequent diarrhea is reported by the patient,a gastroenterological work-up is necessary, as the treatment of fecal incontinence is frustrating under these preconditions. The patient should be asked for urinary incontinence symptoms as well,as a considerable proportion of patients,estimated as high as
30%–40%, has a combined incontinence problem. In that case, a gynecological or a
urological evaluation,and possibly a combined treatment plan is advisable.
The physical examination, best done in lithotomy position on a proctology chair,
should include a careful inspection,including the underwear of the patient. Scars,previous episiotomies, a gaping anus or stool soiling might give hints at fecal incontinence. The patients should squeeze and press under visual observation,and the lack of
a contractile activity of the sphincter, the use of gluteal muscles during squeezing, the
loss of gas or stool, the protrusion of hemorrhoids or rectal mucosa, and an increased
pelvic floor descent during straining might be observed. Perianal sensation and the
anocutaneous reflex should be assessed, followed by a rectal digital examination to
provide information on the resting sphincter tone, the squeeze pressure, or whether a
rectocele is present.The puborectalis muscle sling can be palpated dorsally and should
Chapter 19 Sphincteroplasty
relax during straining. Proctoscopy and rectoscopy allow for inspecting the anal canal
and the rectal mucosa visually. In particular, intussusception, which might produce
incontinence symptoms such as stool soiling, might be detected during proctoscopy
only.
In case of fecal incontinence, we always use endoanal ultrasonography to detect
sphincter defects, most being observed ventrally after obstetric injuries (Fig. 19.1).Also, the thickness and the length of the external and internal sphincter muscles can be
assessed accurately. Currently, endoanal ultrasonography is the best available tool to
define the anatomy of the sphincter apparatus (Cook and McMortensen 1998), and
surgery for fecal incontinence should not be considered without it. Unfortunately,the
accuracy of endosonography is investigator-dependent,the learning curve being rather flat.
The resting pressure and the squeeze pressure of the sphincter muscles, as well as
the length of the anal canal, can be assessed by anorectal manometry. A balloon attached to the tip of the manometry catheter can measure rectal sensation, the compliance of the rectal wall and can detect the rectoanal inhibitory reflex. Although experienced investigators are able to correctly assess sphincter strength by digital examination, a quantification of the sphincter pressures by anorectal manometry is advisable
in case surgery for fecal incontinence is contemplated, as it provides proof of reduced
sphincter pressures preoperatively. It also provides information for follow-up investigations comparing sphincter pressures before and after conservative or surgical therapy, and manometric squeeze pressure differences have been shown to parallel functional outcome after sphincter repair (Ha et al.2001).
Defecography, also termed videoproctography or evacuation proctography, can detect internal rectal prolapse (intussusception), which is sometimes difficult to detect
on clinical investigation and which might cause stool soiling.Also, the pelvic floor descent during straining can be measured, and rectoceles are easily recognized. The anorectal angle, which contributes to continence and in a way has a valve function, can
be measured during rest and straining, and should decrease during squeezing and increase during straining. However, the treatment of fecal incontinence related to
sphincter weakness does not necessarily require this investigation (Diamant et al.
1999). We use pudendal nerve terminal motor latency (PNTML) very rarely, as there
are very conflicting results regarding the prediction of sphincter repair failure in case
283
Fig. 19.1.
Endoanal ultrasonography,
showing a ventral sphincter
defect after obstetric trauma more than 20 years before, extending from 10 h to
2 h in lithotomy position
19
284
Tilman T.Zittel
of a prolonged PNTML (Baig and Wexner 2000), and PNTML has not influenced our
decision to perform sphincter repair in the past.
19.3 Operative Technique
A bowel preparation is done with 2 l of polyethyleneglycol (Macrogol),and patients receive low-molecular-weight heparin subcutaneously the evening before surgery. Perioperative antibiotic cover is started with a third-generation cephalosporin and metronidazole when the patient is anesthetized, and continued until the 3rd postoperative
day. The patient can be placed in either the lithotomy or prone jack-knife position,the
latter of which we prefer. The buttocks are spread to both sides by tapes,and a urethral
catheter is inserted and left in place for 3 days. A headlamp might ease the view, although in the jack-knife position, we do not use it routinely. On the operating table, the
rectum and the vagina are both flushed with Betadine.
A 180-degree curvilinear incision is made over the defect, most often the perineal
body,a flap is raised and the sphincter muscle with its scar is delineated. The skin incision should extend well beyond the sphincter defect. If the sphincter defect results
from an obstetric injury, the entire rectovaginal septum is opened. The external
sphincter is dissected out best at both sides of the defect first, and no attempt is made
to dissect the internal muscle from the external muscle.A division of the sphincter or
an excision of the scar is unnecessary (Slade et al. 1977).Direct apposition of the muscle ends is usually performed at the time of injury, while the overlapping sphincteroplasty is the operation of choice in incontinent patients with an isolated sphincter defect detected by endoanal ultrasonography, where the trauma usually occurred years
or decades ago (Baig and Wexner 2000; Soffer and Hull 2000).The sphincter is plicated with 4/0 PDS or Prolene sutures,and all sutures are tied once the repair is completed (Fig. 19.2). Overlapping sphincteroplasty is recommended, as direct sphincter apposition has a higher failure rate of about 40% (Blaisdell 1940).In women after an obstetric trauma, both sides of the levator ani muscles are approximated by 4/0 PDS or
Prolene sutures once the sphincteroplasty is completed. Bleeding must be controlled
meticulously by diathermy, and we inject 2–5 ml of adrenaline 1 :100.000 at the end of
the repair into the operating field. The operating field is cleaned with Betadine before
the wound is closed by subcutaneous and skin sutures, both done with 3/0 Vicryl. In
case of lost perineum after an obstetric injury, a double Z-plasty can be performed to
increase the distance between the anal verge and the introitus vaginae (Keighley 1993).
We use one or two 12 Charrière closed suction drains, which are removed on the 2nd
or 3rd postoperative day.
The routine use of a covering stoma seems to be unnecessary (Slade et al. 1977; Sitzler and Thomson 1996; Hasegawa et al. 2000),although it might be advisable in redo or
technically difficult cases and in patients with a history of perianal sepsis, severe perianal trauma, Crohn’s disease or with an increased risk for a wound infection (Scott et
al. 1989; Fleshman et al. 1991; Keighley 1993; Baig and Wexner 2000; Soffer and Hull
2000). In that case, a laparoscopic ileostoma might be created first,followed by sphincter repair during the same operation. Injuring the rectal wall during sphincter repair
might require a covering stoma as well (Keighley 1993). Postoperatively, the patient is
restricted to liquid diet for 3 days, although this might be unnecessary (Nessim et al.
1999).We usually keep the patient in the hospital for 3–5 days postoperatively, although
an accelerated stay program for overlapping sphincter repair has been shown to be
safe (Rosenberg and Kehlet 1999). We recommend not to bathe for 10 days, but taking
Chapter 19 Sphincteroplasty
Fig. 19.2. Schematic drawing of overlapping
sphincteroplasty. In case of an obstetric trauma
underlying a sphincter defect, anterior levatorplasty is performed as well
a shower is allowed. The main threat to a successful outcome is a wound infection,
which might render the repair a failure (Keighley 1993). The morbidity is low, usually
below 10%, and mortality has been described only rarely in older series (Slade et al.
1977; Fang et al. 1984). Repeat sphincter repairs can be tried if the procedure fails, the
previous repair not affecting clinical outcome (Giordano et al. 2002).
285
19.4 Functional Results
Parks and McPartlin in 1971 first reported their results with overlapping repair (Parks
and McPartlin 1971). Usually, satisfactory results are achieved in 70%–80% of patients
(Cook and McMortensen 1998; Baig and Wexner 2000). A variety of factors predictive
of a treatment failure have been identified, such as age,the duration of incontinence,
obesity,a prolonged pudendal nerve latency,an abnormal rectoanal inhibitory reflex,
a perineal descent, a previous sphincter repair, a persistent anal sphincter defect, a
short anal canal length after sphincteroplasty or an internal anal sphincter defect
(Laurberg et al. 1988; Londono-Schimmer et al. 1994; Briel et al. 1998; Cook and
McMortensen 1998; Gilliland et al.1998; Baig and Wexner 2000; Soffer and Hull 2000;
Gutierrez et al. 2004). Other studies have refused age, neuropathy and prior incontinence surgery as negative predictive factors (Simmang et al. 1994; Chen et al. 1998;
Young et al. 1998; Baig and Wexner 2000; Giordano et al. 2002). As study results are
contradictory on the one hand and the presence of a negative predictive factor does
not preclude a successful outcome on the other hand (Soffer and Hull 2000), overlapping sphincteroplasty can be offered to most patients with an isolated sphincter defect. The difference in manometric squeeze pressure between pre- and postoperative
periods and the increase in anal canal length were both related to postoperative continence (Ha et al. 2001; Hool et al. 1999). Also,the clinical improvement correlated with
286
Tilman T.Zittel
Fig. 19.3.
Endoanal ultrasonography
after overlapping sphincteroplasty in the same patient as shown in Fig. 19.1
an improvement in the appearance of endoanal ultrasonography (Fig. 19.3; Pinedo et
al. 1999).
Unfortunately,results deteriorate with time (Rothbarth et al.2000). Beyond 5 years
of follow-up,patients are rarely fully continent, and a successful outcome has been observed in 8%–37% only (Malouf et al. 2000; Halverson and Hull 2002; Gutierrez et al.
2004). Nevertheless, 74% of patients remained satisfied with the results of the procedure (Gutierrez et al.2004), supporting the importance of the patient’s view.
19
References
Baig MK,Wexner SD (2000) Factors predictive of outcome after surgery for faecal incontinence.
Br J Surg 87: 1316–1330
Baxter NN, Rothenberger DA,Lowry AC (2003) Measuring fecal incontinence.Dis Colon Rectum
46: 1591–1605
Blaisdell PC (1940) Repair of the incontinent sphincter ani.Surg Gynecol Obstet 70: 692–697
Briel JW, de Boer LM, Hop WCJ, Schouten WR (1998) Clinical outcome of anterior overlapping
external anal sphincter repair with internal anal sphincter imbrication. Dis Colon Rectum 41 :
209–214
Chen AS, Luchtefeld MA, Senagore AJ et al (1998) Pudendal nerve latency. Does it predict out-
come of anal sphincter repair? Dis Colon Rectum 41: 1005–1009
Cook TA,McMortensen NJ (1998) Management of faecal incontinence following obstetric inju-
ry.Br J Surg 85: 293–299
Diamant NE, Kamm MA, Wald A et al (1999) AGA position paper on anorectal testing tech-
niques. Gastroenterology 116 :735–760
Fang DT, Nivatvongs S,Vermeulen FD,Herman FN, Goldberg SM,Rothenberger DA (1984) Over-
lapping sphincteroplasty for acquired anal incontinence.Dis Colon Rectum 27 :720–722
Fleshman JW, Peters WR,Semesh EI, Fry RD, Kodner IJ (1991)Anal sphincter reconstruction: an-
terior overlapping muscle repair.Dis Colon Rectum 34 :739–743
Gilliland R, Altomare DF, Moreira H et al (1998) Pudendal neuropathy is predictive of failure fol-
lowing anterior overlapping sphincteroplasty.Dis Colon Rectum 41 :1516–1522
Giordano P, Renzi A, Efron J, Gervaz P, Weiss EG, Nogueras JJ,Wexner SD (2002) Previous sphinc-
ter repair does not affect the outcome of repeat repair.Dis Colon Rectum 45 :635–640
Gutierrez AB,Madoff RD,Lowry AC,Parker SC, Buie WD,Baxter NN (2004) Long-term results of
anterior sphincteroplasty. Dis Colon Rectum 47 :727–731
Ha HT, Fleshman JW, Smith M, Read TE, Kodner IJ, Birnbaum EH (2001) Manometric squeeze
pressure difference parallels functional outcome after overlapping sphincter reconstruction.
Dis Colon Rectum 44: 655–660
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