Artificial hydraulic urinary sphincters (AUS) are the gold standard for the treatment of male stress urinary incontinence. The satisfaction rate is more than 90% however there is still a significant rate of reoperations. The main problems are a sub cuff atrophy and/or an erosion of the urethra. Key factors are the urethral blood flow on the one hand as well as diabetes, hypogonadism and radiotherapy on the other hand and the preventive factors for atrophy and erosion [1]. Adjustment to the lowest pressure needed to provide continence should assure optimal long term results.

The VICTO adjustable artificial urinary sphincter consists of a urethral cuff, a pressure regulating balloon and a pump, which is equipped with a port for percutaneous adjustment any time after implantation. The system pressure can be adjusted from 0 to 100 cm of water. For patients who are unable to interrupt the stream, VICTO+ is offered with an additional stress balloon which is placed in the preperitoneal region. Thereby abdominal pressure peeks are directly transferred to the urethral cuff. Both versions are delivered preconnected.

The video shows a perineal incision and preparation of the urethra as first step of the surgery. As a second step the musculus bulbospongiosus is divided. Once the urethra is isolated, the circumference is measured. As you can see in the video, positioning and closure of the cuff is easily performed with a mosquito clamp. The pressure regulating balloon is placed intraperitoneally to avoid capsule formation that might influence the system pressure. When using a VICTO+ System, the stress balloon is positioned extraperitoneally. As you can see next the transfer of the preconnected cuff to the perineum is performed using a camera bag and a clamp. The tube to the cuff is parallel to the urethra, thereby avoiding possible oblige forces increasing the risk for erosion. Finally, you see the pump being positioned in the scrotum by blunt dissection and the wounds being closed.

For filling the pump is deactivated using a soft vascular clamp. The filling and evacuation of air can easily be performed using two 10 milliliters syringes, filled with 10 and 3 milliliters for the VICTO and 10 and 10 milliliters for the VICTO+. For both, isotonic contrast medium or saline is used. Air should be removed, however tiny bubbles do not change the function or the pressure.

In the period from December 2016 until October 2017 we implanted 25 VICTO systems. Ten oft them VICTO Plus and 15 of them VICTO Systems. After this first year we have had no explantations and all patients with activated VICTO's are dry or significantly improved with some adjustments still coming up.

Our Experiences with the possibility of adjusting the system pressure to the lowest level necessary to provide continence are very satisfying. It gives us the expectation that we will be able to reduce sub cuff atrophy and erosion rates to a minimum. Having zero explantations after one year emphasizes the remarkable safety of this implant and is hardly found in any other hydraulic system.