Implantation of the AMS 800 usually takes 45 to 90 minutes. Following is a brief summary of the surgical procedure.

Caution: This information is for educational purposes only. Refer to O.R. manuals and procedure videos for more detailed instructions on this surgical procedure.

There are a number of possible surgical approaches for implanting the AMS 800. In the following steps we outline both the transverse scrotal approach and the perineal approach.

Transverse Scrotal Approach

Step 1—Incision
Make an upper transverse scrotal incision through the subcutaneous tissue. Move the incision up the penis and stabilize with a surgical retractor and blunt stay hooks at 1, 3, 5, 7, 9 and 11 o'clock.

Step 2—Expose the Tunica Albuginea
Sharply expose the tunica albuginea of both corpora cavernosa. Pass the Metzenbaum scissors proximally along the ventral surface of the tunica to the proximal corpora. When deep exposure of the proximal corpora is secured, place an intact Deaver retractor on the side of the urethra for caudal traction. Repeat on the contralateral side, exposing the scrotal septum.

Step 3—Dissection
Sharply dissect the scrotal septum off the bulbar urethra. To mobilize the urethra, sharply dissect the webs of Buck's fascia binding the diverging corpora cavernosum to the corpora spongiosum.

Step 4—Dissect and Measure Urethra
Because the patient is in the supine position, the urethra is mobile. Use a right angle clamp to conduct the posterior dissection of the urethra almost under direct vision. Spread the right angle clamp to create sufficient space for the placement of the occlusive cuff. Measure the urethra.

Step 5—Place the Cuff
Place the proper size cuff around the circumference of the urethra.

Step 6—Place the Pressure-Regulating Balloon
There are two ways to place the pressure-regulating balloon (PRB):

• With the bladder empty and the surgical retractor and stays removed, retract the tissue to the side of the penis. Place the PRB in the retropubic space by locating the inguinal ring and sharply piercing the transversalis fascia. After the PRB implantation, narrow the opening with an absorbable suture.
• Alternatively, displace the scrotal incision over the inguinal area and inguinal ring location. Finger dissection is used to develop a pouch beneath the rectus but anterior to the transversalis fascia (cephalad to the inguinal ring). This avoids the necessity of piercing the fascia in patients with scarred retroperitoneum after the PRB is implanted. Narrow the opening with an absorbable suture. Balloon tubing is rooted superficially to the control pump.

Step 7—Place the Pump
Elevate the inferior aspect of the scrotal incision. Develop a space underneath the scrotal skin and dartos muscle to serve as a pouch for the pump. Begin the development of the tunnel about 2 cm from the skin edge in order to facilitate eventual tubing and connector concealment. Loosely tie purse string suture around the opening of the tunnel to secure the pump position.

Step 8—Trim Tubing and Make Connections
Trim the excess tubing. Connect the tubing with AMS Suture-Tie Connectors or AMS Quick Connect Sutureless Window Connectors. In most cases, use the straight connectors. Right angle connectors should always be used when the tubing makes a sharp curve at the point of connection.

Step 9—Deactivate and Close
To deactivate the device, squeeze and release the pump several times to empty the fluid from the cuff. When the pump is refilled so there is a slight dimple in it, push the button to lock the cuff open during the healing process. It is important to leave a slight indentation in the pump bulb to ensure that there is enough fluid in the pump to activate the device later. Close the incision.

Perineal Approach

Step 1—Incision and Dissection
Place a Foley catheter or a 20Fr sound into urethra to help identify it during dissection. Make a midline perineal incision and bluntly dissect bulbocavernous muscle from around the bulbous urethra. Place cuff sizer (or Penrose drain) around urethra where cuff is to be implanted. It should fit snugly without constricting urethra. Note: If catheter or sound is in urethra, remove it before measuring the urethra. Do not stretch cuff sizer before use. Surgeon should use his or her judgment in choosing an appropriate cuff size, the measuring tape only provides approximate measurement of bulbous urethra circumference. The inside circumference of cuff is somewhat smaller than the outside circumference of cuff.

Step 2—Place the Cuff
Select cuff size that corresponds to measured length. Prepare cuff for implantation. Position cuff around the urethra with the "pillow" side toward urethra.

Step 3—Place the Pressure Regulating Balloon
Select appropriate size pressure regulating balloon. Make a suprapubic incision, divide rectus fascia transversely, and use a spreading motion to separate the linea alba to reach prevesical space. Use blunt dissection to create a space for balloon. Position the balloon in prevesical space.

Step 4—Place the Pump
Use blunt dissection to create a dependent subdartos pouch in the scrotum. Note: Control pump should be placed on same side as the pressure-regulating balloon. Place pump into scrotal pouch with deactivation button facing outward so that it is palpable. Route the tubing to abdominal incision. Note: The pump tubing should be above rectus muscle and fascia in abdominal incision.

Step 5—Make Connections
AMS Suture-Tie Connectors or AMS Quick Connect Sutureless Window Connectors may be used to connect the tubing. In most cases, use the straight connectors. Right angle connectors should always be used when the tubing makes a sharp curve at the point of connection.

Step 6—Deactivate and Close
To deactivate the device, squeeze and release the pump several times to empty the fluid from the cuff. When the pump is refilled so there is a slight dimple in it, push the button to lock the cuff open during the healing process. It is important to leave a slight indentation in the pump bulb to ensure that there is enough fluid in the pump to activate the device later. Close the incision.