EDITORIAL COMMENT

Abstract

The paper above adds to the growing body of evidence that the pressure regulating balloon (PRB) of the artificial urinary sphincter (AUS) system plays a critical role in controlling and effecting continence rates. Many urologists who perform AUS insertion feel that the pressure generated from the PRB can be inconsistent and there is a real need for future investigations to evaluate PRBs with a manometer to better analyze pressures. Perhaps these authors will prospectively assess this in future patients to better pinpoint revision approach. Also, there are many instances when performing an AUS revision that there is fluid loss in the PRB without any discernible evidence of leak from any of the components. This presents a conundrum to clinicians and frequently necessities compete revision with an entire new AUS system. Regardless, the results of this small series suggest that improved continence rates can be obtained by switching the 61-70 cm H2O pressure PRB to a 71-80 cm H2O pressure in select situations. The obvious advantage to this revision technique is it greatly simplifies the procedure by avoiding urethral dissection and allows patients to immediately reactivate the device, because there will be no scrotal swelling associated with the new placement of a pump. It would have been helpful if the authors had been able to identify those patients who had prior AUS with reasons for previous explant, but the retrospective nature of this series did not allow this. In addition, there is a clear distinction between patients with persistent vs recurrent incontinence which was not evaluated in this series. Persistent incontinence indicates a possible cuff sizing issue, while recurrent incontinence is more consistent with a device malfunction, eg, like a PRB losing pressure. In general, all surgeons in this arena could benefit from a better systematic way to trouble-shoot the AUS and especially assess for urethral atrophy. Cystoscopic inspection can be fraught with uncertainty in some cases and the premise of this manuscript is upregulating the PRB is effective when urethral atrophy has not occurred. Finally, some continued sobering reminders that irradiated patients have a higher risk of erosion and in fact constituted the 3 erosions seen in this cohort.