Artificial Urinary Sphincter Failure Research Articles

Evaluation and Revision of Artificial Urinary Sphincter Failure for Male Stress Urinary Incontinence

Evaluation and Revision of Artificial Urinary Sphincter Failure for Male Stress Urinary Incontinence

The impact of cognitive impairment in urologic implants: a narrative review.

With the general population aging and thus more patients developing bothersome erectile dysfunction, stress urinary incontinence and overactive bladder, there will likely be a higher demand for three common interactive implants in urology, the penile prosthesis, artificial urinary sphincter (AUS) and sacral neuromodulation (SNM). Further, the prevalence of mild and major neurocognitive disorders (also known as mild cognitive impairment and dementia, respectively) is expected to increase. While the aforementioned urologic implants have excellent short and long term outcomes, there are also known device issues such as malfunction or misuse that may require surgical removal and/or revision. The objective of this narrative review is to describe the association of cognitive impairment and urologic implants. We performed a search on PubMed between the years 1975-2023 for English language articles that reported on any type or severity of cognitive impairment and its association with penile prosthesis, AUS and/or SNM. While peer-reviewed published manuscripts were prioritized, abstracts that fit our search criteria were also included. Data assessing outcomes of patients with cognitive impairment who undergo placement of a urologic implant are limited. There is an association between AUS failure or misuse with cognitive impairment. SNM is efficacious in this population in the short term. In patients who develop dementia, an inflatable penile prosthesis can be deflated via in-office needle puncture and an AUS can be deactivated. The Memory Alteration Test, Quick Screen for Mild Cognitive Impairment and the Saint Louis University Mental Status Examination are relatively quick screening tests with good sensitivity and specificity for mild cognitive impairment. While data on the association between urologic implants and cognitive impairment are sparse, there are tools that urologists can use to screen patients for cognitive impairment. With screening, urologists can provide appropriate preoperative counseling (including recommending against implantation) and can provide closer postoperative monitoring. Further study is required to assess which patients should be excluded from device implantation and how to properly assess for cognitive impairment in a manner that is both beneficial for the patient and convenient and efficient for a urologist.

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.

Clinical and Urodynamic Determinants of Earlier Time to Failure for the Artificial Urinary Sphincter

ObjectiveTo determine clinical, surgical and urodynamic attributes associated with earlier AUS reintervention. The artificial urinary sphincter (AUS) is the gold standard treatment for postprostatectomy stress urinary incontinence. Factors impacting long-term device survival have not been investigated. Materials and MethodsWe identified men with post-prostatectomy incontinence who underwent AUS reintervention from 2011 to 2021 at a single center. Urodynamic study, pad weights and voiding diaries are routinely assessed prior to AUS placement. Relationships between clinical, urodynamic and surgical variables and AUS reintervention were assessed using cox regression. Multiple imputation of chained equations was used to handle missing data elements, with truncated linear regression for continuous variables and logistic regression for binary variables. ResultsA total of 524 records were reviewed and 92 met inclusion. Median time to AUS reintervention was 5.7 years (2.3, 9.4). Indications were mechanical failure (38; 41.3%), sub-cuff atrophy (37; 40.2%), erosion/infection (11; 11.9%) and other (6; 6.5%). On univariable testing, earlier intervention was associated with pad weight (P < .01), nocturnal voids (P = .01), bladder capacity (P = .01), bladder volume at strong sensation (P = .03), detrusor overactivity (P < .01) and maximum voiding pressure (P = .02). On multivariable analysis, earlier surgical intervention was associated with detrusor overactivity (HR 1.95, P < .01 CI 1.22-3.1) and pad weight (HR 1.0006, P = .02, CI 1.000-1.001). ConclusionsDetrusor overactivity is associated with significantly shorter time to AUS failure. This information may allow for more individualized counseling.

A0585 - Pre-existing detrusor overactivity leads to earlier artificial urinary sphincter failure and need for revision

A0585 - Pre-existing detrusor overactivity leads to earlier artificial urinary sphincter failure and need for revision

Improved artificial urinary sphincter outcomes using a transcorporal cuff placement in patients with a "fragile urethra".

The artificial urinary sphincter (AUS) is the most effective treatment option for incontinence after prostate cancer treatment. However, patients with a "fragile urethra" (defined as prior radiotherapy, previous failed AUS, or previous urethroplasty) are at increased risk of AUS failure. The aim of this study was to evaluate outcomes using standard and transcorporal cuff placement in this group of patients. A retrospective review was performed on patients with a fragile urethra who underwent AUS insertion between 2004 and 2017. The primary outcome was the need for AUS revision. Secondary outcome measures included change in pad use, patient satisfaction, continence (≤1 pad/day), improvement (≥50% change in pad use), and cuff erosion rates. Seventy-six patients met the criteria for inclusion, with a mean age of 71.6 years and a mean followup of 37.9 months. A total of 42.1% had prior radiotherapy, 56.6% had a history of failed AUS, and 19.7% had previous urethroplasty. Transcorporal cuff placement was performed in 31.6% (n=24). These patients had lower revision (20.8% vs. 36.5%; p=0.05) and erosion rates (8.3% vs. 17.3%; p=0.09). There was no significant difference in functional outcomes such as continence (66.7% vs. 73.1%; p=0.57), improvement (100% vs. 90.4%;p=0.17), or satisfaction (82.6% vs. 69.4%; p=0.26), nor for 90-day complications (4.2% vs. 9.6%; p=0.41). AUS insertion is an effective treatment option for post-prostatectomy incontinence in the setting of a fragile urethra. Transcorporal cuff placement in this subset of patients may be recommended, as it is associated with lower revision and erosion rates compared to standard cuff placement.

MP40-12 USE OF ISOTONIC CONTRAST SOLUTION IN PRESSURE REGULATING BALLOON DOES NOT IMPACT ARTIFICIAL URINARY SPHINCTER LONGEVITY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I (MP40)1 Apr 2020MP40-12 USE OF ISOTONIC CONTRAST SOLUTION IN PRESSURE REGULATING BALLOON DOES NOT IMPACT ARTIFICIAL URINARY SPHINCTER LONGEVITY Brian Inouye*, William Boysen, and Andrew Peterson Brian Inouye*Brian Inouye* More articles by this author , William BoysenWilliam Boysen More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000889.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Artificial urinary sphincter (AUS) is the gold standard for treatment of male stress urinary incontinence. The device can be filled with normal saline (NS) or isotonic contrast solution. Contrast can be useful for trouble shooting an AUS failure, to assess for fluid leak or sub-cuff atrophy. Many surgeons are hesitant to use contrast in the device due to concerns about the impact on device malfunction and longevity, but no studies have addressed this issue. We used industry data to identify differences in outcomes between NS and contrast-filled AUS. METHODS: Each AUS placement requires the submission of a patient information form that is sent to the manufacturer in order to track outcomes. This includes details of device preparation and the filling fluid. All patients in the industry database (Boston Scientific) from 2001 to 2016 were included. Groups were divided into AUS filled with NS and AUS filled with contrast. Patient demographics were recorded. Longevity of the device was defined as time to the need for reoperation (device removal, revision, or replacement). The groups were compared using t-test and chi-square test. A Kaplan Meier curve was created to compare device survival between AUS with filled NS versus contrast. RESULTS: A total of 39,591 patients were included in the cohort, of which 39,363 (99.5%) were male. 34,920 (88.2%) devices were filled with NS while 4,671 (11.8%) were filled with contrast. The reoperation rate overall was 16.1%, with no difference between groups (15.8% NS versus 18.1% contrast). The rate of fluid loss and device malfunction precipitating device removal did not differ between the groups (3.3% NS vs 4.1% contrast; 0.8% NS vs 0.9% contrast). The infection rate was similar between groups (1.9% NS vs 2.7% contrast). The mean time to reoperation overall was 3.9 years (± 3.4), and was significantly longer in the contrast filled cohort (3.8 ± 3.3 years NS vs 5.1 ± 3.9 years contrast, p<0.01). On Kaplan Meier analysis, the time to reoperation was longer in the contrast filled cohort (Figure 1). CONCLUSIONS: The use of contrast in the AUS did not change rates of device malfunction or fluid loss, and devices filled with contrast lasted longer than those filled with NS. We find that contrast in the device is useful for troubleshooting when a patient returns with recurrent incontinence, and should be considered by AUS implanters since this practice does not impact outcomes. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e590-e590 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Inouye* More articles by this author William Boysen More articles by this author Andrew Peterson More articles by this author Expand All Advertisement PDF downloadLoading ...

Urethral atrophy is now a rare cause for artificial urinary sphincter revision surgery in the contemporary 3.5 cm cuff era.

Urethral atrophy has long been suggested as the leading cause of artificial urinary sphincter (AUS) revision. Since the introduction of the 3.5 cm AUS cuff in 2010, precise cuff sizing primarily has been suggested to reduce revisions due to urethral atrophy. We evaluated a large contemporary series of reoperative AUS cases to determine reasons for revision surgery. We retrospectively reviewed our tertiary referral center database of male AUS procedures performed by a single surgeon from 2007-2019. AUS revision or replacement procedures were included for analysis. Cuff sizes and reasons for reoperation were recorded based on intraoperative findings and evaluated for temporal trends. Patients with cuff erosion or lacking follow-up were excluded. Among 714 AUS cases, 177 revisions or replacements were identified. Of these, 137 met inclusion criteria [mean age 71.7 years, median follow-up 52.7 months (IQR 22.3-94.6 months)]. Urethral atrophy was cited as the cause of AUS failure in 8.0% (11/137) of cases overall, virtually never among those with a 3.5 cm cuff placement (1/51, 2.0%). In those with ≥4.0 cm cuffs, urethral atrophy was the reason for revision in 10/86 (11.6%). Pressure regulating balloon (PRB) failure was the most frequently cited cause of failure (47/137, 34.3%). Cuff-related failure (23/137, 16.8%) and mechanical failure of unspecified device component (16/137, 11.8%) were the next most frequent causes of failure. Urethral atrophy has become a rare cause of AUS revision surgery since the availability of smaller cuffs. PRB-related failure is now the leading cause of AUS reoperation.

Re: Patterns and Timing of Artificial Urinary Sphincter Failure.

Re: Patterns and Timing of Artificial Urinary Sphincter Failure.

Causes of Artificial Urinary Sphincter Failure and Strategies for Surgical Revision: Implications of Device Component Survival

BackgroundUp to 50% of patients receiving an artificial urinary sphincter (AUS) require surgical revision after initial placement. However, the literature is heterogeneous regarding the leading causes of AUS failure and appropriate surgical management. ObjectiveTo inform a revision approach by tabulating the causes of AUS failure, assessing AUS component survival, and examining the single-component revision efficacy. Design, setting, and participantsWe retrospectively reviewed 168 patients receiving AUS placements carried out by a single surgeon from 2008 to 2016 at a high-volume academic institution. The median follow-up from initial placement was 2.7 yr, with 37.5% experiencing recurrent incontinence. The cuff size ranged from 4.0 to 5.5cm, with median size of 4.5cm. InterventionPatients without infection or erosion underwent systematic device interrogation and revision, starting with the pressure-regulating balloon (PRB) and then, if necessary, the urethral cuff. Device revision involved either PRB-only correction or cuff and PRB revision. Outcome measurements and statistical analysisWe used bootstrapped intervals to estimate the mean time to failure for individual AUS components. Kaplan-Meier estimates were used to compare survival for individual components and for revised devices by revision technique. Results and limitationsPRB malfunction most commonly caused device failure, while cuff or pump malfunction was rare. Among patients undergoing surgical revision, those with PRB-only correction had similar outcomes to those with more extensive device correction (cuff and PRB exchange; p=0.46). This study, while systematic and detailed, is limited by sample size, follow-up length, and its retrospective nature. ConclusionsPRB malfunction most commonly caused AUS failure in our cohort. PRB-only correction may satisfactorily restore AUS function in select patients. Consequently, initial interrogation of the PRB may avoid a second incision and urethral exposure for many patients requiring AUS revision. Patient summaryArtificial urinary sphincters remain prone to failure over time. In many instances, correcting only the pressure-regulating balloon may effectively restore device function, allowing for a less invasive revision.

197 Artificial Urinary Sphincter Revision for Recurrent Incontinence: Single Component Replacement is Both Feasible and Efficacious

Artificial Urinary Sphincter (AUS) placement is the gold-standard for moderate to severe post-prostatectomy stress urinary incontinence. Up to 50% of patients will require AUS revision due to recurrent incontinence secondary to mechanical failure or urethral atrophy. However, it is controversial if single component revision is feasible and effective or if the entire device should be replaced. We retrospectively identified 168 patients from 2008-2016 receiving an AUS from a single surgeon. Patients were presumed to have a functional AUS until they presented for recurrent incontinence or at last review of the database. During AUS revision, the pressure regulating balloon (PRB) was interrogated and if defective replaced. If the PRB was functional, it was left in-situ and the additional components interrogated with only the defective part replaced. Revisions were performed as outpatient procedures and devices left active unless the pump was replaced. At a median follow-up of 2.7 years, 63 patients (37.5%) required revision. The most common cause of AUS failure was PRB malfunction (36.5%) followed by urethral atrophy (22.2%). History of adjuvant radiation and prior sling placement were predictive of failure. On Kaplan-Meier analysis, PRB (84.3%) had significantly shorter survival at 5 years compared to urethral cuff (95.9%) and control pump (96.6%). Patients who underwent single component PRB replacement had similar device survival compared to a total AUS replacement (2.5 year survival: 71.1% vs. 87.5%, p =0.20).

Patterns and timing of artificial urinary sphincter failure.

To assess population-based trends in artificial urinary sphincter (AUS) placement after prostatectomy and determine the effect of timing on device survival and complications. We identified patients who underwent prostatectomy and AUS placement in SEER-Medicare from 2002 to 2011. We analyzed factors affecting the time of reoperation from AUS implantation and prostatectomy using multivariable Cox proportional hazard models. In total, 841 men underwent AUS placement at a median 23months after prostatectomy. Patients who underwent reoperation (28.5%) had higher clinical stage, more likely underwent open prostatectomy, or had prior sling placement (p<0.03). There were no differences in rates of diabetes, smoking status, prior radiation therapy, or Charlson Comorbidity Index between those requiring reoperation vs. not (all p>0.15). Patients with AUS placement >15months after prostatectomy (75%) initially experienced less need for operative reinterventions. Patients with later AUS placement were significantly more likely to have received radiation therapy [22.9 vs. 3.8% (p<0.01)]. Nonetheless, late implantation was confirmed to be protective on multivariate analysis during the first 5years after AUS placement [HR 0.79 (95% CI 0.67-0.92); p<0.01]. Factors independently associated with a shorter interval time until reoperation included history of radiation [HR 1.93 (95% CI 1.33-2.80); p<0.01] and history of prior sling [HR 1.70 (95% CI 1.08-2.68); p=0.02]. Even for patients who underwent radiation therapy, delayed AUS implantation reduced reoperative risk. Late AUS implantation in the Medicare population is associated with prolonged device survival initially, while radiation and prior sling surgery predict for earlier reoperation. Patients with delayed AUS implantation experience less immediate complications. Further work is required to identify patient-specific factors which may explain variability in timing for AUS.

Can time to failure predict the faulty component in artificial urinary sphincter device malfunctions?

Artificial urinary sphincter malfunctions can occur in any of the individual components. Preoperative identification of the malfunctioning component can be valuable for patient counseling and surgical planning. The optimal strategy for repair of failed artificial urinary sphincter components is debated given the relative rarity of the situation. The aim of the present study was to evaluate the relationship of time to failure with failed artificial urinary sphincter component and to compare our outcomes of specific component versus complete device replacement. From 1983 to 2011, 1805 artificial urinary sphincter procedures were carried out at Mayo Clinic (Rochester, Minnesota, USA), of which 1072 patients underwent primary artificial urinary sphincter placement. Clinical variables, including time to failure, were evaluated for association with component failure. Bootstrap analysis was used to estimate the differences in time to reach a fixed percentage of component failure. A total of 115 patients experienced device failure at a median follow up of 4.2 years. Urethral cuff, abdominal reservoir, scrotal pump and tubing malfunction occurred in 53 (4.9%), 26 (2.4%), 11 (1%) and 25 (2.3%) patients, respectively. Increasing age at the time of primary surgery was protective of cuff malfunction (hazard ratio 0.97, P = 0.04). Time to 3% urethral cuff failure outpaced other component failures (P < 0.05). Secondary failure-free rates after whole device versus specific component revisions were comparable (P = 0.38). Clinical predictors for artificial urinary sphincter failure continue to be difficult to establish. Although single component versus entire device replacement have similar outcomes, if pursuing single component revision, we recommend cuff-first interrogation in devices in place for >3 years, as this represents the most likely component to fail.

Risk factors for resurgery in men with artificial urinary sphincter: Role of urethral strictures.

The aims of the present study were to evaluate the outcome of implantation of an artificial urinary sphincter (AUS) in male patients with iatrogenic urinary incontinence and to analyse possible risk factors for resurgery, with particular focus on the effects of posterior urethral strictures (US). The outcomes of AUS implantation surgeries performed by 2 surgeons on consecutive patients between January 1999 and 2015 were evaluated retrospectively. Univariate analysis with Cox proportional hazard regression was used to assess correlations between resurgery (explantation or substitution of the urethral cuff) and risk factors. Hazard ratios (HR) associated with AUS survival and 95% confidence intervals (CI) were calculated and Kaplan-Meier were constructed. Patients who underwent resurgery for mechanical failure were excluded from the study. In all, 73 male patients were monitored for a maximum of 190 months (median follow-up duration 36 months). The risk of resurgery was 3.75-fold greater in patients with than without stenosis (HR 3.75; 95% CI 1.47-9.59). In addition, Kaplan-Meier survival curves showed a significantly shorter AUS survival time in patients with than without stenosis treatment. Prior treatment for US increases the relative risk of AUS failure. Despite not being an absolute contraindication for AUS implantation, we suggest that patients with previous treatment for US are informed of potential risks.

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OBJECTIVES/SPECIFIC AIMS: Stress urinary incontinence (SUI) significantly affects quality of life and occurs in 60% of men after radical prostatectomy, with 5% requiring surgical treatment. The artificial urinary sphincter (AUS) offers these patients excellent control of their post-prostatectomy SUI. The device contains 3 parts: the pump, urethral cuff, and pressure regulating balloon. Despite the effectiveness of AUS, up to 50% of patients require surgical revision after initial placement due to recurring SUI. Thus far, literature is heterogeneous regarding the causes of mechanical AUS failure and appropriate surgical management. Our study aims to characterize the most common reasons of AUS failure requiring surgical revision and the survival of each AUS component. METHODS/STUDY POPULATION: We report a series of 48 patients who received AUS placement and/or revision by 1 surgeon from 2010 to 2013. Upon presenting for revision, intraoperatively, the surgeon systematically evaluated the device for failure of the balloon, cuff and pump as well as urethral erosion and atrophy. In patients not requiring revision all device components were presumed functional. We conducted retrospective chart review to collect baseline characteristics, intraoperative findings, and postoperative outcomes. Using Kaplan-Meier estimates, we calculated incidence rates of component failure for the cuff, pump, and balloon. To identify risk factors for AUS failure, Cox regression was performed for univariate and multivariable testing. Multivariable modeling included those variables considered biologically plausible and significant in univariate testing. RESULTS/ANTICIPATED RESULTS: In total, 48 patients were studied with median follow up of 4.25 years. All patients received an AMS 800 device with a 61–70 mL balloon filled with 27 cc of isotonic contrast. Cuff sizes ranged from 3.5 to 5.5 cm, with 4.5 cm selected in 33/48 cases (68.8%); 19 of the patients required AUS correction (41.7%). Balloon leak constituted 57.9% (11/19) of failures, followed by cuff failure/urethral atrophy (21.1%), urethral erosion (10.5%), and individual cases of infection and pump failure. Median time to mechanical failure due to balloon leak was 3.67 years (IQR 2.17, 5.33); median time to failure for nonballoon causes was 0.54 years (IQR 0.25, 1.83). Survival of the balloon, cuff, and pump was 100%, 95.7%, and 97.9% at 1 year and 76.9%, 91.0%, and 97.9% at 5 years, respectively. DISCUSSION/SIGNIFICANCE OF IMPACT: Our study identifies fluid leakage from the balloon as the most common cause of AUS failure, particularly in patients presenting between 1 and 5 years after initial placement. For such patients, interrogating the balloon first can decrease infection risk and surgical morbidity as it can avoid manipulation of the urethral cuff. Furthermore, simply replacing lost fluid saves cost and allows for immediate reactivation of the AUS device.

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OBJECTIVES/SPECIFIC AIMS: Perineal urethral sling placement is an option for men with mild to moderate post-prostatectomy stress urinary incontinence (SUI). However, men with persistent incontinence after sling placement often require secondary artificial urinary sphincter (AUS) placement, made difficult by the sling occupying the proximal bulbar urethra. This proximal section has a thicker corpus spongiosum which may mitigate cuff-induced ischemia and subsequent urethral atrophy. The authors report a series of AUS placements after failed sling, using sling revision or removal to access the proximal urethra. METHODS/STUDY POPULATION: Cutting the sling arms during urethral cuff placement increased urethral exposure and mobility. If feasible, completely removing the sling allowed the most proximal cuff site; but if dissection was felt unsafe, the mesh was left in situ and the cuff placed distally. This study is a retrospective cohort design of patients with SUI who underwent AUS placement after failed sling from 2010 to 2016. Variables included baseline patient characteristics, SUI severity, intraoperative variables, and postoperative outcomes. AUS failure, defined as infection, erosion or urethral atrophy, was analyzed at 12 and 96 months using univariate and multivariable logistic regression. RESULTS/ANTICIPATED RESULTS: Over the study period, 29 patients underwent AUS placement after failed sling. At the time of AUS placement, mean urethral circumference was 6.2 cm and 68% of patients had a 4.5 cm cuff placed; no cases required a 3.5 cm cuff. Seventy-three percent of cases were after transobturator sling placement (27% bone-anchored) and 45% of slings were explanted. AUS failure rate at 12 and 96 months was 17.8% and 45%, respectively; atrophy was the most common indication. Prior transobturator sling placement had lower rates of both 12 month (9.1% vs. 57%, p=0.006) and 96 month (36% vs. 71%, p=0.11) failure, though the latter was not statistically significant. Sling explant was not a significant predictor of 12 month (p=0.12) or 96 month failure (p=0.17). DISCUSSION/SIGNIFICANCE OF IMPACT: Sling revision during AUS placement helps expose the wider proximal urethra, allowing larger cuff size placement. This procedure appears safe, with low rates of erosion and short-term failure—albeit with high rates of long-term urethral atrophy possibly due to more significant dissection causing devascularization. However, sling removal was not a significant predictor of failure. The transobturator sling’s smaller profile may result in less trauma to urethra—possibly explaining the improved outcomes.

Impact of perioperative anticoagulation on artificial urinary sphincter device survival

Objective: The aim of this study was to evaluate the impact of perioperative anticoagulation on artificial urinary sphincter (AUS) device outcomes.Methods: Following institutional review board approval, patients undergoing AUS surgery from 1983 to 2014 were evaluated to assess device survival in patients with warfarin use compared to individuals without warfarin use. Hazard regression analysis was used to determine the association between warfarin use and device outcomes.Results: From 1983 to 2014, there were 2125 AUS procedures at Mayo Clinic. Of these, information regarding anticoagulation use was available in 651, including 43 patients who were on warfarin and 608 who were not. On univariate analysis, the use of warfarin was associated with an increased rate of infection/erosion [hazard ratio (HR) 2.58, p = 0.02]. However, there was no increased risk of overall AUS failure (HR 1.66, p = 0.06), malfunction of AUS (HR 1.19, p = 0.74) or urethral atrophy (HR 1.09, p = 0.88). Kaplan–Meier assessment of device survival for individuals not on warfarin versus individuals on warfarin at 1 and 5 years was 91% versus 83% and 72% versus 57%, respectively (p = 0.058). On multivariate analysis, warfarin was not associated with an increased risk of infection/erosion (HR 1.37, p = 0.51).Conclusion: Perioperative management of AUS patients on warfarin requires expert care; however, long-term AUS device survival is not significantly affected by warfarin use. Recognition of these outcomes is important for improving preoperative patient counseling and surgical patient selection.

MP36-18 PATTERNS AND TIMING OF ARTIFICIAL URINARY SPHINCTER FAILURE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I1 Apr 2017MP36-18 PATTERNS AND TIMING OF ARTIFICIAL URINARY SPHINCTER FAILURE Andrew Cohen, Kristine Kuchta, Sangtae Park, and Jaclyn Corrine Milose Andrew CohenAndrew Cohen More articles by this author , Kristine KuchtaKristine Kuchta More articles by this author , Sangtae ParkSangtae Park More articles by this author , and Jaclyn Corrine MiloseJaclyn Corrine Milose More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1129AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The gold standard treatment for severe post-prostatectomy incontinence is implantation of an artificial urinary sphincter (AUS). There is a paucity of data regarding the timing of AUS placement after prostatectomy and other factors which predict device failure. METHODS We identified all patients who underwent prostatectomy and subsequent AUS placement in SEER-Medicare from 2002-2011. These patients' demographic, clinical and pathologic characteristics were included in multivariable cox proportional hazard models, to identify predictors for device survival. We also analyzed factors impacting the time to revision or explantation from initial AUS implantation and prostatectomy. RESULTS 841 men underwent AUS placement at a median 23 months (IQR:15-40.6) after prostatectomy. 236 (28%) men ultimately required revision or explantation. There were no differences in age, race or hospital setting for those undergoing reoperation vs. not (p≥0.2). Patients who underwent reoperation were more likely to have had higher clinical stage cancer, undergone open prostatectomy, or had prior sling placement (p<0.01). There were no differences in rates of diabetes, smoking status, prior radiation therapy, or Charlson Comorbidity Index scores between those requiring reoperation vs. not (all p >0.15). Patients with delayed AUS placement (29%), defined as >3 years after prostatectomy, experienced prolonged device survival (Figure). Delayed patients were significantly more likely to have received radiation therapy [36.5% vs. 10.5% (p<0.001)]. Nonetheless, delayed repair was confirmed to be protective on multivariate analysis, after controlling for patient and disease characteristics including radiation history [HR:0.44 (95% CI: 0.32-0.62); p<0.01]. Factors independently associated with a shorter interval time until reoperation included history of radiation [HR: 1.69 (95% CI: 1.16-2.44);p<0.01] and history of prior sling [HR:1.88 (95% CI: 1.19-2.97); p<0.01]. CONCLUSIONS Delayed AUS implantation in the Medicare population is associated with prolonged device survival, while radiation exposure and prior urethral sling surgery predict for early reoperation. Further work is required to identify patient specific factors which may explain variability in timing for AUS after prostatectomy and how such factors contribute to device longevity. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e473 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Andrew Cohen More articles by this author Kristine Kuchta More articles by this author Sangtae Park More articles by this author Jaclyn Corrine Milose More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Artificial Urinary Sphincter Mechanical Failures—Is it Better to Replace the Entire Device or Just the Malfunctioning Component?

We evaluate the characteristics of artificial urinary sphincter mechanical failures and compare outcomes based on the surgical revision strategy, replacing only the failed component or the entire device. A total of 1,802 male patients with stress urinary incontinence underwent artificial urinary sphincter procedures from 1983 to 2011 at our institution, of which 1,082 were primary placements. Of these patients 125experienced mechanical device malfunction. Multiple clinical and surgical variables were evaluated for a potential association with device malfunction. In addition, we evaluated for predictors of failure of the revised device, including time from primary artificial urinary sphincter to revision surgery and surgical revision strategy (single component vs entire device), with failure defined as any tertiary surgery. At a median followup of 4.2 years (IQR 0.8, 7.9) 125 patients experienced device malfunction. The urethral cuff was the most common component failure (46.1%), followed by abdominal reservoir (22.6%), tubing (21.7%) and pump (9.6%). There was no association of time from primary surgery to revision for mechanical failure (HR 0.89, p=0.33) or revision strategy (HR 0.47, p=0.15) withthe risk of tertiary surgery. Additionally, as there was no significant interaction between these variables (HR 1.11, p=0.39), no cutoff could be identified at which one revision technique produced significantly improved device survival compared to another. However, there was a trend toward improved 3-year device survival after replacement of the entire device vs a single component (76% vs 60%, p=0.11). No cutoff in time to mechanical failure could be identified to guidedecision making in the management of mechanical artificial urinary sphincter failure. Likewise, it is unclear if replacing the entire device, rather than the single malfunctioning component, alters device survival. As such, further studies are needed. However, given the current trend toward improved overall device survival, the limited additional risk and the lack of adequate clinical predictors fortertiary surgery, we would advocate for replacement of the entire device whenpossible.

Risk factors for artificial urinary sphincter failure.

To analyze revision rates and risk factors for artificial urinary sphincter failure. Eighty-four patients underwent implantation of an artificial urinary sphincter in one reference center. Continence rates were defined by daily pad usage. Influence of predefined risk factors for device explantation, revision, differences in preoperative pad usage, and device survival was analyzed using Chi-squared test, Wilcoxon signed-rank test, and Kaplan-Meier analysis. A multivariate analysis was performed using a logistic regression model. A p value below 0.05 was considered statistically significant. After a mean follow-up of 39.7 months, the device was still in situ in 64 patients. In univariate analysis, perioperative need of anticoagulation led to a significant increase in urethral erosion (6 vs. 30 %; p = 0.002) and explantation rate (15 vs. 34 %; p = 0.047). Pelvic irradiation increased postoperative infection rates significantly (0 vs. 10 %; p = 0.018). Penoscrotal approach led to significant increase in urethral erosion rate (0 vs. 21 %; p = 0.015). Implantation of a double cuff led to a significant increase in explantation rate (58 vs. 24 %; p = 0.014), revision rate (75 vs. 38 %; p = 0.017), and infection rate (17 vs. 1 %; p = 0.008). When using cuff size of 3.5 cm, revision rate (20 vs. 50 %; p = 0.026) as well as incontinence rates (40 vs. 82 %; p = 0.014) was significantly lower. In multivariate analysis, only perioperative anticoagulation and double-cuff placement were independent predictors of artificial urinary sphincter failure. Our findings highlight the influence of perioperative anticoagulative therapy. In addition, the current study provides further evidence that double-cuff implantation should be performed only with caution during primary implantation.