Urinary incontinence after prostatectomy is an incapacitating problem affecting quality of life. Artificial urinary sphincters have commonly been used for the treatment of severe UI in men. The AMS-800™ (American Medical System, Minnetonka, MN) is considered the gold standard for the treatment of post-prostatectomy urinary incontinence.
Generally, at the conclusion of surgery, a urinary catheter is placed; it is then removed the next morning. However, a possible complication is persistent urinary retention, requiring suprapubic tube (ST) placement to decrease the risk of erosion.1-3 
Tubing is usually arranged in the shortest path, from the tubing entry point in the retropubic abdominal area to the reservoir. This involves a central position of tubing which can be damaged in case of laparotomy or suprapubic tube (Figure 1). A critical issue in AMS 800 artificial urinary sphincter implant is tubing positioning, which was not standardized. In this video we show the surgical technique and report the outcomes of lateral tube positioning technique for AMS-800 placement to avoid the risk of damage of the tubing system in case of suprapubic tube, or laparotomy is required.

In this prospective study we evaluated all males who underwent AMS-800 insertion from January 2014 to March 2019. Positioning of cuff and pump were not modified from the standard technique. In our modified tubing-positioning technique, we performed a McBurney, or a short midline incision for abdominal access. Electrocautery was used to dissect the fat from the aponeurosis of the external abdominal oblique muscle in lateral direction. Limits of dissection were: I. Lower: the abdominal face of the pubic symphysis and pectineal ligament; II. Lateral: the insertion of the aponeurosis at the external abdominal oblique muscle. The abdominal fascia was incised more laterally to position the balloon as far as possible from the midline. A first suture was placed to fix the tubing 2 cm laterally the reservoir. A second suture was placed where the tubing begins to curve; this point is generally in the anatomic area of the inguinal triangle. The last suture was placed to fix the tubing close to the pubic bone 1-2 cm before the tunnel for the scrotum. Figure 1 show the ideal positioning of sutures and surgical placement. Figure 2 shows sutures positioning, and tube placement documented by 3D CT scanning in a left hand patient.

We evaluated 51 males. Mean f-up was 30.2 (1-59) months. There was no mechanical failure. Cuff erosion rate was 7.8% (4 males). We had no complications, nor infections attributed to the new tubing path. Visual analog scale (VAS) showed postoperative pain intensity as none in 76%, and mild in 24%. Urinary retention longer than 48 hours occurred in 9.8% of the patients (5 cases), and suprapubic tube placement was easy, fast, and safe with any tubing damage.

In case of urinary retention longer than 48 hours suprapubic tube positioning is suggested.1 However, the usual tubing path due to its placement, from the entry point in the retropubic abdominal area to the reservoir, is in a more central and dangerous location in comparison with our technique. Our modified tubing positioning helps guarantee a lower risk of damaged tubing in case of suprapubic tube placement or laparotomy. In the cases requiring suprapubic tube placement the procedure was safe, easy and tubing sparing.
Our novel tube positioning technique is quick, easy to perform, and offers the advantage of allocating tubing in a more safe position in the case a suprapubic tube is required.

Linder BJ, Piotrowski JT, Ziegelmann MJ, Rivera ME, Rangel LJ, Elliott DS. Perioperative Complications following Artificial Urinary Sphincter Placement. J Urol. 2015 Sep;194(3):716-20
Wingate J.T., Erickson B.A., Murphy G. et al: Multicenter analysis of patient reported outcomes following artificial urinary sphincter placement for male stress urinary incontinence. J Urol, Sep 28, 2017.
Viers B.R., Linder B.J., Rivera M.E. et al: Long-Term Quality of Life and Functional Outcomes among Primary and Secondary Artificial Urinary Sphincter Implantations in Men with Stress Urinary Incontinence. J Urol, 196: 838, 2016.