Editorial Comment

Abstract

This is a well presented and researched manuscript describing a multi-institutional retrospective review of 31 men with bulbar urethral strictures that occurred after artificial urinary sphincter (AUS) erosion who underwent delayed urethroplasty (after the erosion episode) with or without subsequent AUS replacement during 2009-2016. These patients represent a rather uncommon but extremely clinically challenging group even for experienced reconstructive urologists and AUS implant surgeons. Theirs is a very complex situation involving prior prostate surgery and/or radiation therapy, potential hormonal therapy, prior bladder neck and/or penile surgeries, multiple urethral surgeries, as well as other medical comorbidities such as metabolic syndrome, etc. The findings reported by the authors are certainly limited by the short clinical follow-up of the small number of patients who underwent a variety of pre- and post-AUS surgical procedures and/or other treatments. Taking these limitations into consideration, this collaborative group's report advances our understanding of this complex heterogeneous population of men and adds value to the existing reconstructive urology/implant literature and cancer survivorship literature. The authors' conclusion that urethroplasty appears to be very effective for these typically short densely spongiofibrotic urethral strictures is a welcome addition to the literature supporting this concept. Urologists familiar with effectively treating physiologically similar urethral strictures (such as perineal straddle injuries) with urethroplasty may find this conclusion fairly evident. In this small series, despite urethroplasty for AUS erosion related stricture being successful, the subsequent AUS replacement was found to have a high erosion rate in the short-term, perhaps greater than other series involving high risk patients. It is not possible in this small series to determine to what degree any prior prostate surgery and/or radiation play a main role; to what degree the urethroplasty and/or prior bladder neck/urethral/penile surgery play a part; to what degree their urethral vascularity is compromised or not; to what degree metabolic and hormonal factors are involved; etc. We recognize that all of this is multifactorial. Longer term follow-up with larger patient numbers will be helpful in terms of determining which patient characteristics and populations are at even higher risk for erosion than those men we already consider “high risk” going forward. This manuscript provides tangible value for surgeons when we are counseling our patients in the midst of them dealing withwhat is typically a devastating AUS erosion that may be followed by a consequent urethral stricture requiring additional surgical management in the hope of being able to potentially replace the AUS at a later date. This informed and shared decision making process requires a significant collaborative effort between us as urologic surgeons and our patients in an effort to provide them with best possible durable outcomes even in these most challenging clinical situations.