Artificial Urinary Sphincter Cuff Research Articles

Clinical case of primary transcorporal artificial urinary sphincter cuff implantation

Among surgical methods of treatment of male stress urinary incontinence, implantation of an artificial urinary sphincter is the leading technique. Despite its acceptable effectiveness, the intervention carries a risk of complications, some of which require removal of a component or the entire device.The article presents a clinical case of primary artificial urinary sphincter cuff placement and literature review on this topic.

Management of male stress urinary incontinence in high-risk patients: a narrative review.

The artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence (SUI). However, highly complex patients such as those with bulbar urethral compromise, bladder pathology, and lower urinary complications pose a particular challenge for the surgeon. In this article, we will address critical risk factors and synthesize existent data across relevant disease states to support surgeons in successful management of SUI in high-risk patients. A comprehensive review of current literature was performed utilizing the search term "artificial urinary sphincter" in conjunction with any of the following additional terms: "radiation", "urethral stricture", "posterior urethral stenosis", "vesicourethral anastomotic stenosis", "bladder neck contracture", "pelvic fracture urethral injury", "penile revascularization", "inflatable penile prosthesis", and "erosion". Guidance is provided based upon expert opinion where existing literature was sparse or nonexistent. Several known patient risk factors are associated with AUS failure and can ultimately lead to device explantation. Each risk factor requires careful consideration and investigation, or intervention as appropriate, prior to device placement. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients. Several surgical strategies to decrease device complications can be considered: optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation. A number of patient risk factors are associated with AUS failure and can ultimately lead to device explantation. We present an algorithm for management of high-risk patients. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients.

Editorial Comment.

No AccessJournal of UrologyAdult Urology25 Apr 2023Editorial CommentThis article comments on the following:Urethral Stricture Formation After Artificial Urinary Sphincter Cuff Erosion Is Uncommon in the Absence of Pelvic Radiation George E. Koch George E. KochGeorge E. Koch Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003431.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. – REFERENCES 1. . Adjuvant and salvage radiotherapy after prostatectomy: ASTRO/AUA guideline amendment 2018-2019. J Urol. 2019; 202(3):533-538. Link, Google Scholar 2. . Urethral stricture formation after artificial urinary sphincter cuff erosion is uncommon in the absence of pelvic radiation. J Urol. 2023; 210(1):000-000. Google Scholar Submitted November 14, 2022; accepted March 10, 2023; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology22 Mar 2023Urethral Stricture Formation After Artificial Urinary Sphincter Cuff Erosion Is Uncommon in the Absence of Pelvic Radiation Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information George E. Koch Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee More articles by this author Expand All Submitted November 14, 2022; accepted March 10, 2023; published 000. Advertisement PDF downloadLoading ...

Transalbugineal Artificial Urinary Sphincter: A Refined Implantation Technique to Improve Surgical Outcomes.

The artificial urinary sphincter (AUS) implantation is an effective treatment of post-prostatectomy urinary incontinence (PPI). Still, it may result in troublesome complications such as intraoperative urethral lesion and postoperative erosion. Based on the multilayered structure of the tunica albuginea of the corpora cavernosa, we evaluated an alternative transalbugineal surgical technique of AUS cuff placement with the aim to decrease perioperative morbidity while preserving the integrity of the corpora cavernosa. A retrospective study was conducted in a tertiary referral center from September 2012 to October 2021, including 47 consecutive patients undergoing AUS (AMS800®) transalbugineal implantation. At a median (IQR) follow-up of 60 (24-84) months, no intraoperative urethral injury and only one noniatrogenic erosion occurred. The actuarial 12 mo and 5 yr overall erosion-free rates were 95.74% (95% CI: 84.04-98.92) and 91.76% (95% CI: 75.23-97.43), respectively. In preoperatively potent patients, the IIEF-5 score remained unchanged. The social continence (0-1 pads per day) rate was 82.98% (CI 95%: 68.83-91.10) at 12 mos and 76.81% (CI 95%: 60.56-87.04) at 5 yrs follow-up. Our technically refined approach to AUS implantation may help to avoid intraoperative urethral lesions and lower the risk of subsequent erosion without compromising sexual function in potent patients. Prospective and adequately powered studies are necessary to achieve more compelling evidence.

The role of transcorporal cuff placement in high-risk and ultra-high-risk patients: are they actually helpful?

To assess the incidence of artificial urinary sphincter (AUS) explant in high-risk patients and to evaluate the relationship between transcorporal cuff (TCC) placement and explant risk in this population. We retrospectively reviewed all AUS insertions performed on high-risk patients by a single surgeon from 2010 to 2020. "High-risk" was defined as having ≥ 1 urethral risk factor: pelvic radiation, urethroplasty, recalcitrant urethral/bladder neck stenosis, urethral stenting, or previous AUS erosion/infection. Patients with ≥ 2 factors were "ultra-high-risk." Time-to-event analyses were used to assess all-cause-, infection/erosion-related-, and mechanical failure-related explant-free survival. Subgroup analyses were performed for patients with a history of radiation and urethral dissection. The final cohort included 68 men, mean age of 67years (SD 11), and 77 AUS cuffs. Mean follow-up was 32months (IQR 6-50). 29% of cuffs (n = 22) were transcorporal. 32 cuffs (42%) were explanted. All-cause explant-free survival was 64% at 1year and 52% at 2years. Classification as "ultra-high-risk" was not associated with explant risk (all p-values > 0.05). TCC placement was associated with an increased risk of explant for infection/erosion across all patients (HR 2.74, p = 0.03) and in radiated patients (n = 50; HR 4.1, p = 0.04), but not in patients with prior urethral dissection (n = 52; HR 1.98, p = 0.21). High-risk patients have a high rate of AUS explant and TCC placement may not be protective in this population. TCC placement was associated with an increased risk of infection/erosion in radiated patients, but not in those with a history of open urethral surgery.

Editorial Comment.

No AccessJournal of UrologyAdult Urology30 Jan 2023Editorial CommentThis article comments on the following:Artificial Urinary Sphincter Cuff Downsizing Improves Continence and Patient Satisfaction in Cases of Sub-cuff Atrophy Bradley A. Erickson Bradley A. EricksonBradley A. Erickson Division of Functional Urology, University of Iowa, Iowa City, Iowa More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003138.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. – REFERENCES 1. . Artificial urinary sphincter cuff downsizing improves continence and patient satisfaction in cases of sub-cuff atrophy. J Urol.2023; 209(4). Google Scholar 2. . Proof of concept: exposing the myth of urethral atrophy after artificial urinary sphincter via assessment of circumferential recovery after capsulotomy and intraoperative pressure profiling of the pressure regulating balloon. Investig Clin Urol.2018; 59(4):275-279. Google Scholar 3. . Urethral atrophy after implantation of an artificial urinary sphincter: fact or fiction?BJU Int.2016; 117(4):669-676. Google Scholar 4. . Difference between urethral circumference and artificial urinary sphincter cuff size, and its effect on postoperative incontinence. J Urol.2014; 191(1):138-142. Link, Google Scholar Submitted July 27, 2022; accepted December 6, 2022; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology30 Dec 2022Artificial Urinary Sphincter Cuff Downsizing Improves Continence and Patient Satisfaction in Cases of Sub-cuff Atrophy Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bradley A. Erickson Division of Functional Urology, University of Iowa, Iowa City, Iowa More articles by this author Expand All Submitted July 27, 2022; accepted December 6, 2022; published 000. Advertisement PDF downloadLoading ...

Editorial Comment.

No AccessJournal of UrologyAdult Urology30 Jan 2023Editorial CommentThis article comments on the following:Artificial Urinary Sphincter Cuff Downsizing Improves Continence and Patient Satisfaction in Cases of Sub-cuff Atrophy O. Lenaine Westney O. Lenaine WestneyO. Lenaine Westney University of Texas MD Anderson Cancer Center, Houston, Texas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003138.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. –

Changes and debates in male stress urinary incontinence surgery practice patterns: a contemporary review.

Surgery plays a crucial role in the definitive management of male stress urinary incontinence (SUI). The most utilized and well-studied surgical options include the artificial urinary sphincter (AUS) and the male sling (MS). The AUS has long been considered the "gold standard" and more versatile option in this space, showing effectiveness in mild, moderate, and severe SUI cases, whereas the MS is preferred in cases of mild to moderate SUI. Not surprisingly, and importantly, much of the published literature on male stress incontinence has focused on determining the "ideal" candidate for each procedure and identifying which clinical, device-specific, and patient factors play an important role in the objective and subjective success rates. There are, however, more granular, and sometimes debatable, topics to assess regarding the real-life practice patterns of male SUI surgery. The aim of this clinical practice review is to examine current trends of several of these topics including: AUS vs. MS utilization, the prevalence of outpatient procedures, 3.5 cm AUS cuff use, preoperative urine studies utilization, and intraoperative and postoperative antibiotics. As with many things in surgery, dogma rather than evidence-based medicine can significantly influence everyday clinical decision making. We seek to highlight which practice patterns in male SUI surgery are changing and/or being challenged and debated.

Indications and Outcomes for Intermittent Catheterization following Bulbar AUS Cuff Placement

ObjectiveTo evaluate the functional and surgical impact of CIC protocols in men with a bulbar AUS in place. Stress urinary incontinence (SUI) and poor bladder emptying are both sequelae of prostate cancer treatment, though there is sparse data to guide concomitant management. The safety of intermittent catheterization (CIC) in men with an artificial urinary sphincter (AUS) at the bulbar urethra remains unclear. MethodsWe performed a retrospective review of all bulbar urethral AUS procedures at our institution. Inclusion criteria were patients with a history of prostate cancer treatment, AUS placement for SUI, and a history of CIC before and/or after AUS placement. All eligible cases were retrospectively reviewed. Surgical and continence outcomes were analyzed. ResultsA total of 57 patients were identified with a history of CIC and AUS placement under the care of two surgeons. Eighteen continued to perform CIC or first initiated CIC after AUS placement and 39 discontinued CIC prior to AUS placement. The incidence of erosion was no different amongst patients who continued or discontinued CIC after AUS placement (17.9% vs 22.2%, P = .79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, P = .41). Both groups experienced improvement in urinary incontinence after placement of an AUS. ConclusionBulbar AUS placement in the setting of continuous intermittent catheterization can be considered in patients who are not surgical candidates for definitive treatment of their outlet obstruction.

Artificial urinary sphincter cuffs and safe instrument/catheter passage guidelines

The artificial urinary sphincter (AUS) is the gold standard for males with urinary incontinence. It is generally a safe procedure with a high degree of satisfaction. However, there is a lifelong risk of infection and erosion. AUS cuffs are commonly placed around the bulbar urethral area. There is always a risk of trauma and erosion of cuffs with catheterization or endoscopy. At this time, there is little guidance as to which size catheters or scopes can pass through each AUS cuff sizes safely. The goal of this study was to determine which size of catheters/scopes can pass through different cuff sizes safely in an ex vivo setting. All AUS cuff sizes available (3.5 cm up to 6.0 cm), catheter sizes between 12and22 Fr, and scope sizes 19 Fr flexible/rigid, 21-26 Fr rigid scopes were examined. We used deflated assembled cuffs on the bench (ex vivo) and three different blind observers to measure the free space left between the wall of the cuff and the catheter/scope to be sure that there was consistency. We created a scale from 1 to 3 to determine the ease of passage for each catheter/scope. We also had an MRI radiologist examine bulbar urethra thickness in 20 male patients to determine the average thickness without the bulbospongiosus muscle. Using our average bulbar urethral thickness, we were able to estimate how much free space remained within the urethral lumen and how easy and safe it was to pass each catheter/scope. For 3.5 cm cuffs, 12 Fr catheters pass easily and safely, 14-16 Fr catheters and 19 Fr flexible/rigid scopes can pass through with some mild risk of trauma. Larger catheter/scope sizes cannot pass through without a significant risk of trauma. For 4.0 cm cuffs, 12-14 Fr catheters pass easily and safely. 16-18 Fr catheters and 19-21 Fr rigid/flexiblescopes can pass with some mild risk of trauma. Larger catheter/scope sizes cannot pass through safely. For 4.5 cm cuffs, 12-18 Fr catheters and 19 Fr flexible/rigid scopes pass easily and safely. 20-22 Fr catheters and 21 Fr rigid scopes can pass with some mild risk of trauma. Larger catheter/scope sizes cannot pass through safely. For 5.0 cm cuffs, 12-22 Fr catheters and 19-21 Fr flexible/rigid scopes can pass easily and safely. 22-26 Fr scopes can pass with some mild risk of trauma. For 5.5 cm cuffs, all catheters/scopes can pass easily and safely. However, the 26 Fr rigid scope can pass with some mild risk of trauma. For 6 cm cuffs, all catheters/scopes examined can pass easily and safely. Our study can guide urologists in the management of patients with an AUS who need urethral catheters or endoscopy. These recommendations are based on the measurements of our study along with bulbar urethral thickness. In general, greater caution is needed with smaller cuff sizes (3.5-4.5 cm). Our recommendations, with minimal urethral compression, are purposely conservative and safe to avoid trauma and erosion of the AUS cuffs.

Presenting signs and symptoms of artificial urinary sphincter cuff erosion.

ABSTRACTPurpose To characterize the most common presentation and clinical risk factors for artificial urinary sphincter (AUS) cuff erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these patients.Materials and Methods We retrospectively reviewed our tertiary center database to identify men who presented with AUS cuff erosion between 2007 – 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for symptom comparison. Risk factors for cuff erosion – pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) – were recorded for each patient. Presenting signs and symptoms of cuff erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (SI).Results Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) sustained cuff erosion. Most erosion patients (40/61, 66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling. Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with SI or obstructive symptoms presented significantly earlier than those with worsening incontinence (SI 14 ± 18 vs. obstructive symptoms 15 ± 16 vs. incontinence 37 ± 48 months after AUS insertion, p<0.01). Relative to the non-erosion control group (n=61), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 49%, p=0.02).Conclusion AUS cuff erosion most commonly presents as SI symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion.

V02-08 ARTIFICIAL URINARY SPHINCTER CUFF MODIFICATION AND OTHER “TRICKS OF THE TRADE”

You have accessJournal of UrologyCME1 May 2022V02-08 ARTIFICIAL URINARY SPHINCTER CUFF MODIFICATION AND OTHER “TRICKS OF THE TRADE” Jane Kurtzman, Preston Kerr, and Steven Brandes Jane KurtzmanJane Kurtzman More articles by this author , Preston KerrPreston Kerr More articles by this author , and Steven BrandesSteven Brandes More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002528.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Artificial Urethral Sphincter (AUS) is the gold standard for stress urinary incontinence (SUI). The AMS 800 AUS is the most widely used device and has well over a 30-year track record of excellent efficacy and durability. We describe tips for AUS placement and advanced troubleshooting for when you run into problems. METHODS: Proper placement of an AUS requires no bulbospongiosus muscle on the urethra. We utilize a split and roll to ensure a 2cm plane for the AUS. Prior to pump placement we cycle the AUS pump 5-10x for easier activation. We create a “Fuse Box” for future troubleshooting. in cases of mis-sizing an AUS cuff, we modify our cuff via a incision into the cuff and a carefully placed 4-0 prolene. Our technique for troubleshooting an AUS starts with assessing for pressure regulating balloon (PRB) fatigue. RESULTS: Use of our techniques has resulted in an excellent success record for AUS placement. Use of our cuff modification technique has shown no difference in survival or adverse events as a result of the modification. CONCLUSIONS: A properly placed and sized AUS is the gold standard for SUI. Principles for a successful placement of an AUS includes use of the Split and Roll technique, cycling the pump 5-10x prior to placement, creation of a “Fuse Box,” and salvaging an improperly sized cuff through use of our modification technique. During troubleshooting always check the PRB first. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e113 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jane Kurtzman More articles by this author Preston Kerr More articles by this author Steven Brandes More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP52-08 ARTIFICIAL URINARY SPHINCTER CUFF DOWNSIZING IMPROVES CONTINENCE AND PATIENT SATISFACTION IN CASES OF SUB-CUFF ATROPHY

You have accessJournal of UrologyCME1 May 2022MP52-08 ARTIFICIAL URINARY SPHINCTER CUFF DOWNSIZING IMPROVES CONTINENCE AND PATIENT SATISFACTION IN CASES OF SUB-CUFF ATROPHY Kevin Krughoff, Brent D. Nosé, and Andrew C. Peterson Kevin KrughoffKevin Krughoff More articles by this author , Brent D. NoséBrent D. Nosé More articles by this author , and Andrew C. PetersonAndrew C. Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002627.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The management of suspected artificial urinary sphincter (AUS) sub-cuff atrophy remains controversial and clinical outcomes remain underreported. Our objective was to examine the impact of cuff downsizing on patient reported outcomes and pad use in cases of sub-cuff atrophy. METHODS: We reviewed our prospectively collected, institutional approved QI database from 2011 to 2021. IRB approval was obtained for the analysis. At our institution, the AUS is routinely filled with contrast solution and imaged radiographically upon initial activation for a baseline. This allows for better delineation between device failure or sub-cuff atrophy during standard multimodal workup of recurrent urinary incontinence with serial AP Pelvis radiography. Patients are seen on a routine basis following activation. Sub-cuff atrophy was diagnosed with serial AP pelvis films indicating atrophy, cystoscopy, assessment of symptom scores and pad use, and history and physical examination. Patients with post-prostatectomy incontinence who underwent cuff downsizing after the diagnosis of sub-cuff atrophy were included for analysis. Repeated measures T-tests were used to assess change in validated survey instruments, subjective outcomes measures and pad use. RESULTS: Over this time-period, 842 AUS devices were placed, 623 new and 219 revisions. Of these, 30 underwent cuff downsizing following a diagnosis of sub-cuff atrophy as determined by the appearance of more fluid in the cuff versus baseline on AP pelvis film, cystoscopy with incomplete coaptation, patient interview and questionnaires, and evaluation of number pads used per day. The initial AUS was in place for a median of 668 days (292, 1601) prior to the diagnosis of sub-cuff atrophy. Median follow up duration after cuff downsizing was 3561 days (2247, 4704). At time of most recent assessment, 23 (73.3%) of downsized cuffs remained in place, 2 (6.6%) were revised for mechanical failure, 2 (6.6%) for further atrophy and 3 (10.0%) for erosion. Following downsize, 96.7% reported subjective improvement and 92.0% experienced a decrease in pad count, with a median decrease of 2 and mean decrease of 2.21 (± 1.45) pads per day (p<0.01). Of those who completed the AUA Symptom Score before and after downsize, 82% experienced an improvement on the bother index score (mean decrease 1.63 ± 1.74, median 1, p=0.01). CONCLUSIONS: Cuff downsizing improves continence control and patient satisfaction in cases of multimodal diagnosed sub-cuff atrophy. Source of Funding: Boston Scientific Fellowship Grant © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e889 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Krughoff More articles by this author Brent D. Nosé More articles by this author Andrew C. Peterson More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP52-09 SAFETY OF TRANSURETHRAL ENDOSCOPIC TREATMENT IN MEN WITH AN ARTIFICIAL URINARY SPHINCTER: A 15 YEAR ANALYSIS

You have accessJournal of UrologyCME1 May 2022MP52-09 SAFETY OF TRANSURETHRAL ENDOSCOPIC TREATMENT IN MEN WITH AN ARTIFICIAL URINARY SPHINCTER: A 15 YEAR ANALYSIS Corey Weinstein, and Jaspreet Sandhu Corey WeinsteinCorey Weinstein More articles by this author , and Jaspreet SandhuJaspreet Sandhu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002627.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Incontinence after prostate treatment (IPT) is an uncommon but highly bothersome complaint for patients. Placement of an artificial urinary sphincter (AUS) is the gold standard treatment for IPT. Transurethral endoscopic treatment (TET) after AUS is typically avoided due to the presumed increased risk of AUS cuff erosion after passage of a cystoscope after AUS placement. We set out to determine the rate of erosion in patients undergoing TET after placement of an artificial urinary sphincter (AUS). METHODS: Patients with AUS devices implanted by two surgeons between January 1, 2006 and January 1, 2021 were examined. Patients undergoing a transurethral procedure were included; those that underwent TET for a work-up of a non-functioning AUS were excluded from analysis. Follow up was calculated by last assessment in the outpatient setting. RESULTS: 124 patients were identified that met inclusion criteria, 71 of which were in patients with a history of radiation therapy (RT). 179 AUS were implanted during the study period. Median follow up was 62.4 months. Mean number of TET was 2.5. Procedures included incision of bladder neck contracture, transurethral resection of bladder tumor, cystolitholapaxy, ureteroscopy, and surveillance cystoscopy. There were 10 device erosions (8%) during the follow up at an average of 26.5 months post AUS placement, 9 of which occurred in patients with a history of RT. CONCLUSIONS: TET is safe in patients post-AUS particularly in radiation naïve patients, and the rate of erosion in patients undergoing TET is similar to reported rates of erosion in all AUS patients within the literature. Further research with multi-institutional collaboration is necessary to better understand the risks of erosion in patients with an AUS device undergoing TET. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e889 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Corey Weinstein More articles by this author Jaspreet Sandhu More articles by this author Expand All Advertisement PDF DownloadLoading ...

When to Suspect Artificial Urinary Sphincter Cuff Erosion: An Analysis of Presenting Signs and Symptoms

ABSTRACT Introduction Presenting signs and symptoms of artificial urinary sphincter (AUS) cuff erosion are not well established in the urological literature. Objective We sought to characterize the most common presentation and clinical risk factors for erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these unfortunate patients. Methods We retrospectively reviewed our large tertiary center database to identify men who presented with cuff erosion between 2007 and 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for comparison. Risk factors for cuff erosion – pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) – were recorded for each patient. Presenting signs and symptoms of erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (“pump-itis”). Results Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) suffered cuff erosion. The vast majority of erosion patients (66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling (Figure). Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with worsening incontinence presented significantly later than those with pump-itis or obstructive symptoms (37 ± 48 vs. 14 ± 18 vs. 15 ± 16 months after AUS insertion, p&amp;lt;0.01). Relative to the non-erosion control group (n=95), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 53%, p=0.03). Rates of ADT (41 vs. 40 %, p = 0.96) and high-grade prostate cancer (39 vs. 38 %, p = 0.91) were similar. There was no difference in age at AUS placement (73 ± 7 vs 68 ± 7 years, p=0.70). Conclusions AUS cuff erosion most commonly presents as scrotal inflammatory symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Reconstruction of AUS Cuff Erosion: Defect Size Predicts Prognosis

ABSTRACT Introduction In-situ urethroplasty (ISU) has been proposed in conjunction with device explant as an acute management strategy after artificial urinary sphincter (AUS) cuff erosion. Previous studies have not shown a clear relationship between extent of erosion and long-term prognosis. Objective We hypothesize that more extensive erosions are associated with higher rates of lower urinary tract complications (LUTC) and increased need for urinary diversion (UD). Methods We performed a retrospective study of patients who underwent ISU for AUS cuff erosion from June 2007 to December 2020 with a minimum of 90-day follow up. Patients were stratified into two groups based on the degree of urethral erosion determined endoscopically at the time of device explant - mild erosions (&amp;lt;33% circumferential defect) and major erosions (&amp;gt; 33%). Outcomes included LUTC, AUS reimplantation, and UD. LUTC was defined as urethral strictures, diverticulum, fistulas, and erosions of a secondary AUS. UD was defined as suprapubic tube placement with or without urethral ligation or ileal conduit creation. Kaplan-Meier curves were created to compare outcomes between groups. Results A total of 40 patients underwent ISU for urethral cuff erosion and met the follow-up criteria. Median patient age was 76 years old with median erosion defect size of 46% (IQR: 20-50%); 15 men (37.5%) had mild erosions and 25 (62.5%) had major erosions. The overall LUTC rate was 53.5% with significantly fewer complications noted with mild erosions (28.6% vs 65.4%, p = 0.002) (Figure 1). Ultimately, 35.0% of patients required permanent UD with decreased rates in the case of mild erosions (13.3% vs 48.0%, p = 0.04) (Figure 2). On Kaplan-Meier analysis, mild erosion was associated with improved LUTC-free and UD-free survival but not associated with AUS reimplantation. Conclusions Prognosis after AUS cuff erosion is associated with size of the urethral defect. Patients with extensive cuff erosion are at high risk for LUTCs and permanent UD. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Urethral Stricture Formation Following Cuff Erosion of AMS Artificial Urinary Sphincter Devices: Implication for a Less Invasive Explantation Approach.

ObjectivesThe objective of this study is to describe a standardized less invasive approach in patients with artificial urinary sphincter (AUS) explantation due to cuff erosion and analyze success and urethral stricture rates out of a prospective database. Evidence regarding complication management is sparse with heterogenous results revealing high risk of urethral stricture formation despite simultaneous urethroplasty in case of AUS explantation.Patients and MethodsData of all patients undergoing AUS implantation due to stress urinary incontinence (SUI) in our tertiary center were prospectively collected from 2009 to 2015. In case of cuff erosion, AUS explantation was carried out in an institutional standardized strategy without urethroplasty, urethral preparation or mobilization nor urethrorrhaphy. Transurethral and suprapubic catheters were inserted for 3 weeks followed by radiography of the urethra. Further follow-up (FU) consisted of pad test, uroflowmetry, postvoiding residual urine (PVR), and radiography. Primary endpoint was urethral stricture rate.ResultsOut of 235 patients after AUS implantation, 24 (10.2%) experienced cuff erosion with consecutive explantation and were available for analysis. Within a median FU of 18.7 months after AUS explantation, 2 patients (8.3%) developed a urethral stricture. The remaining 22 patients showed a median Qmax of 17 ml/s without suspicion of urethral stricture. Median time to reimplantation was 4 months (IQR 3-4).ConclusionWe observed a considerably low stricture formation and could not prove an indication for primary urethroplasty nor delay in salvage SUI treatment possibilities. Therefore, the presented standardized less invasive explantation strategy with consequent urinary diversion seems to be safe and effective and might be recommended in case of AUS cuff erosion.

Most men with artificial urinary sphincter cuff erosion have low serum testosterone levels.

To evaluate the relationship between serum testosterone (T) levels and artificial urinary sphincter (AUS) cuff erosion in a population of incontinent men who underwent AUS placement. A retrospective analysis of our single-surgeon AUS database was performed to identify men with T levels within 24 months of AUS placement. Men were stratified into two groups based on serum testosterone: lowserum testosterone (LT) (<280 ng/dl) andnormalserum testosterone (NT) (>280 ng/dl). Multivariable analysis was performed to control for risk factors. The outcome of interest was the incidence of and time to spontaneous urethral cuff erosion; other risk factors for cuff erosion were also evaluated. Among 161 AUS patients with serum testosteronelevels, 84 (52.2%) hadLT(mean:136.8 ng/dl, SD: 150.4 ng/dl)and 77 (47.8%) had NT (mean: 455.8 ng/dl, SD: 197.3 ng/dl). Cuff erosion was identified in 42 men (26.1%) at a median of 7.1 months postoperatively (interquartile range:3.6-13.4 months), most of whom (30/42, 71.4%) were testosteronedeficient. LTlevels were less common (54/119, 45.4%) in the non-erosion cohort (p = 0.004). Men with low T were nearly three times as likely to suffer AUS erosion than men with normal T (odds ratio = 2.519,p = 0.021). LT level was the only factor associated with AUS erosion on multivariable analysis. LTis an independent risk factor for AUS cuff erosion. Men with LT are more likely to present with cuff erosion, but there is no difference in time to erosion.

118 Evaluation of Long Term Complication Rates of Primary Transcorporal Artificial Urinary Sphincter Cuff Placement

Transcorporal artificial urinary sphincter (AUS) cuff placement has been suggested as an option to reduce the risk of urethral erosion in patients with fragile urethras and to potentially reduce the rate of erosions/atrophy in the primary implant patient. Ourprevious published data demonstrated > 50% urethral erosions occur within two years of implantation. Therefore, we sought to evaluate if transcorporal (TC) AUS implantation in the primary, non-fragile urethra implant patient would reduce complication rates compared to primary non-transcorporal (nTC) AUS implant patients with a minimum of 2 years follow-up.

Comparison of 3.5 cm and transcorporal cuffs in high-risk artificial urinary sphincter populations.

The transcorporal (TC) artificial urinary sphincter (AUS) has traditionally been utilized in high-risk patients with urethral atrophy or prior urethral erosion. The 3.5 cm AUS cuff has been developed for use in a similar population. We compared the outcomes of TC AUS and 3.5 cm cuff patients to assess whether the TC approach was protective against urethral complications. We performed a retrospective review for all men who underwent TC AUS and 3.5 cm AUS implantation by a single surgeon from 2007 to 2018 at a tertiary medical center. Demographic and outcomes data were collected and analyzed after database review to evaluate for rates of urethral erosion. Multivariate logistic regression was performed to identify co-morbid factors associated with urethral erosion. In our database of 625 AUS patients, we identified 59 (9%) men with TC AUS and 168 (27%) having a 3.5 cm cuff. Over a median follow-up time of 49 months, 28 (47%) men with TC cuffs developed urethral erosion compared with 25 (15%) men with a 3.5 cm cuff. On univariate analysis, a TC cuff was associated with increased odds of erosion (OR 6.65, 95% CI: 3.20-14.4, P<0.0001) when compared with a 3.5 cm cuff. On multivariate analysis, TC cuffs continued to portend significantly increased odds of cuff erosion. With longer follow up, TC AUS may not be as protective against urethral complications as previously described.