Artificial Urinary Sphincter Implantation Research Articles

Eighteen years of experience in laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency

Introduction and objectives: Artificial urinary sphincter (AUS) is a treatment option for women with stress urinary incontinence (SUI) after failure of previous surgery or as a primary procedure in severe intrinsic sphincter deficiency (ISD). The aim of the study was to assess the long-term efficacy and risk factors for surgical revision and definitive explantation of AUS laparoscopic implantation in female patients.Methods: A retrospective review of all women submitted to AUS implantation between April 2005 and March 2023 was conducted. The AUS was implanted via transperitoneal laparoscopic approach, by two experienced surgeons. The primary endpoint was postoperative continence. Continence was defined as no leakage and no pad usage or leakage and/or pad usage with no impact on social life and failure as leakage and/or pad usage impacting social life. As secondary outcomes, clinical predictive factors for AUS revision and definitive explantation were evaluated.Results: In the last 18 years, females with a mean age of 68±12 years-old were submitted to laparoscopic implantation of AUS. Early overall complication rate was 16%, but only one case was Clavien-Dindo ≥3. After a median follow-up of 67 months, 22.2% of the patients needed a device revision, the majority due to mechanical device dysfunction. AUS definitive explantation was performed in 16%, mainly due to urethral/vaginal erosion (9.9%) and infection (6.2%). Patients with age ≥70 years and follow-up ≥10 years significantly predisposed for device revision. At the time of the last follow-up, 72% of the patients were keeping the urinary continency.Conclusions: Laparoscopic AUS implantation in females is an effective treatment for SUI due to ISD. Meanwhile, adequate patient selection, multidisciplinary evaluation and careful expectation management are essential to achieving good results, concerning their significant complication rate.

No-Opioid Discharge Following Artificial Urinary Sphincter Placement Does Not Significantly Increase Health Care System Burden.

Postoperative opioid prescriptions are associated with an increased risk of opioid dependance. While studies on no-opioid discharge strategies have been assessed following many urologic procedures, the effect of no-opioid discharges on health care utilization following artificial urinary sphincter placement is unknown. We performed a single-surgeon retrospective comparison of health care system interactions following artificial urinary sphincter implantation between patients who received an opioid prescription on discharge to those who did not. We identified 101 male patients who underwent 3-piece artificial urinary sphincter placement or revision by 1 provider between 2015 and 2022. All patients were discharged with acetaminophen and ibuprofen; none received intraoperative local anesthetic. Demographic information, preprocedural opioid use, opioid prescriptions following the procedure, postoperative office communications, unplanned office visits, and emergency department (ED) visits were recorded for each patient for 90 days. Forty-five patients (45%) were discharged without an opioid prescription and 56 patients (55%) were discharged with an opioid prescription. No differences in age, race, BMI, operative time, or presence of a preoperative opioid prescription were observed. Discharge without an opioid did not significantly increase the number of office communications (55% vs 40%, P = .11), unplanned office visits (36% vs 23%, P = .19), or ED visits (20 vs 12, P = .41) within 90 days of implantation/revision. Opioids can be omitted from the discharge analgesic regimen following artificial urinary sphincter placement without increasing burden to surgical office staff or local EDs. Providers should consider no-opioid discharges for patients undergoing uncomplicated sphincter placement to limit risk of opioid-related morbidity.

Robotic-assisted laparoscopic surgeries in functional and reconstructive urology

The adoption of robotic-assisted laparoscopic surgery in urology is becoming increasingly frequent. Initially, its use was essentially limited to oncological surgery, such as radical prostatectomy. Its success lies in the enhanced dexterity, the three-dimensional vision, and the ability to easily suture intracorporeally. All these advantages have enabled many pioneer surgeons to develop techniques in the field of functional surgery, such as artificial urinary sphincter implantation and sacrocolpopexy, and as for reconstructive surgery, ureteral reconstructions and enterocystoplasties. This article provides a brief yet rich review of the recently innovated techniques and the now minimally invasive feasibility of previously highly complex procedures in conventional laparoscopy.

Longitudinal deterioration in lower urinary tract symptoms after artificial urinary sphincter implantation in patients with a history of pelvic radiation therapy.

To evaluate longitudinal changes in lower urinary tract symptoms (LUTS) after artificial urinary sphincter (AUS) implantation in patients undergoing radiation therapy (RT) in comparison to those in non-irradiated patients. This retrospective study included 20 and 51 patients with and without a history of pelvic RT (RT and non-RT group, respectively) who were treated with primary AUS implantation for post-radical prostatectomy incontinence between 2010 and 2020. Longitudinal changes in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the International Prostate Symptom Score (IPSS), and the Overactive Bladder Symptom Score (OABSS) were calculated with a linear mixed model. In the RT and non-RT group, 18 (90%) and 48 (94%) patients achieved social continence, defined as daily pad use ≤1 at 1 month after activation of AUS, respectively (p = .555). During the mean follow-up of 38 months, ICIQ-SF, IPSS, and OABSS significantly improved after AUS implantation in both the RT and non-RT groups. In the RT group, ICIQ-SF, IPSS, and OABSS subsequently deteriorated with a slope of 0.62/year (p = .010), 0.55/year (p = .025), and 0.30/year (p = .007), respectively. In the non-RT group, no significant longitudinal changes in subsequent IPSS and OABSS were observed, although ICIQ-SF significantly deteriorated (0.43/year, p = .006). Comparing between the groups, the slopes of IPSS and OABSS were significantly greater in the RT group than in the non-RT group (p < .001, and .015, respectively). Longitudinal deterioration in LUTS that improved immediately after AUS implantation was observed in patients with a history of pelvic RT, but not in patients without a history of pelvic RT.

Immediate and Long-term Outcomes of Lateral Retroperitoneal Pressure Regulating Balloon Placement During Artificial Urinary Sphincter Implantation

ObjectiveTo describe immediate and long-term outcomes of pressure regulating balloon (PRB) placement, exchange, and extraction from the lateral retroperitoneum (LR) in male patients receiving an artificial urinary sphincter (AUS). MethodsA retrospective chart review was performed on all patients that underwent primary AUS placement between 2006 to 2021. All patients had the PRB placed in the LR during the study period. Intraoperative complications during PRB placement, exchange, or removal, and indications for PRB revision, such as infection, erosion, or mechanical failures were analyzed. Results541 patients were included in the study. All patients underwent primary implantation with no intraoperative complications including no incidents of bowel or vascular injury during PRB placement. In addition, there were no instances of intraoperative injury during PRB removal (with or without PRB replacement). After mean follow-up of 54.8 months (range: 1 – 181 months), 9 patients (1.7%) developed a reservoir-specific complication with infection (5 patients, 0.9%) being the most common issue found. The second most common type or reservoir issue was a palpable or herniated reservoir. There were 2 patients (0.4%) who herniated their reservoirs and one patient with a non-bothersome, but palpable reservoir. Lastly, there were 2 incidents (0.4%) of mechanical failure caused by a leak in the PRB. ConclusionDue to the ease and safety of placing and removing PRBs from this location and exceedingly low rates of PRB-related complications in long term follow-up, the LR should be considered as an ideal location for PRB placement in male patients receiving an AUS.

International multicenter retrospective study on high-risk patients who underwent artificial urinary sphincter (AUS) Implantation with Transcorporal versus Standard technique

International multicenter retrospective study on high-risk patients who underwent artificial urinary sphincter (AUS) Implantation with Transcorporal versus Standard technique

Urinary deversion as a last resort in patients with failed artificial urinary sphincter implantation

Urinary deversion as a last resort in patients with failed artificial urinary sphincter implantation

Robot-assisted Periprostatic Artificial Urinary Sphincter Implantation in Men with Neurogenic Stress Urinary Incontinence: Description of the Surgical Technique and Comparison of Long-term Functional Outcomes with the Open Approach

BackgroundPeriprostatic artificial urinary sphincter implantation (pAUSi) is a rare yet relevant indication for male neurogenic stress urinary incontinence (SUI). ObjectiveTo describe the surgical technique of robot-assisted pAUSi (RApAUSi) and compare the long-term functional results with the open pAUSi (OpAUSi). Design, setting, and participantsData of 65 consecutive men with neurogenic SUI undergoing pAUSi between 2000 and 2022 in a tertiary centre were collected retrospectively. Surgical procedureThirty-three patients underwent OpAUSi and 32 underwent RApAUSi. OpAUSi cases were performed by a single surgeon, experienced in functional urology and prosthetic surgery. RApAUSi cases were performed by the same surgeon together with a second surgeon, experienced in robotic surgery. MeasurementsOutcome measures were achievement of complete urinary continence, intra- and postoperative complications, and surgical revision–free survival (SRFS). Results and limitationsRApAUSi showed superior results to OpAUSi in terms of median (interquartile range) operative time (RApAUSi: 170 [150–210] min vs OpAUSi: 245 [228–300] min; p < 0.001), estimated blood loss (RApAUSi: 20 [0–50] ml vs OpAUSi: 500 [350-700] ml; p < 0.001), and median length of hospital stay (LOS; RApAUSi: 5 [4–6] d vs OpAUSi: 11 [10–14] d; p < 0.001). Clavien-Dindo grade ≥3a complications occurred more frequently after OpAUSi (RApAUSi: 1/32 [3%] vs OpAUSi: 10/33 [30%]; p = 0.014). Achievement of complete urinary continence (zero pads) was comparable between the groups (RApAUSi: 24/32 [75%] vs OpAUSi: 24/33 [73%]; p = 0.500). The median follow-up periods were 118 (50–183) and 56 (25–84) mo for OpAUSi and RApAUSi, respectively (p < 0.001). A tendency towards longer SRFS was observed in the RApAUSi group (p = 0.076). The main study limitation was its retrospective nature. ConclusionsRApAUSi is an efficient alternative to OpAUSi, resulting in shorter operative times, less blood loss, fewer severe complications, and a shorter LOS with similar functional results and need for revision surgery. Patient summaryCompared with open periprostatic artificial urinary sphincter implantation (pAUSi), robot-assisted pAUSi leads to faster recovery and similar functional results, with fewer postoperative complications.

Urinary Artificial Sphincter in Male Stress Urinary Incontinence: Where Are We Today? A Narrative Review

Introduction: Urinary incontinence is a prevalent condition, especially in elderly men, with stress urinary incontinence (SUI) being a common cause after radical prostatectomy. The artificial urinary sphincter (AUS), particularly the AMS 800™ device, has been the gold-standard treatment for moderate-severe male SUI for decades. Despite some technical advancements and alternative devices like ZSI-375, Victo, and BR-SL-AS 904 being introduced, there is limited literature comparing their effectiveness to the AMS 800™. Methods: This literature review compares the AMS 800™ to the newer technologies in the management of SUI. We reviewed the current literature on urinary sphincter implant in male stress incontinence, including AMS 800™, ZSI-375, Victo, and BR-SL-AS 904. Findings: The AMS 800™ is a sophisticated system consisting of an inflatable cuff, a pressure-regulating balloon, and a control pump. Studies show continence rates ranging from 61% to 100% with AMS 800™ implants, with low infection rates and significant improvement in patients’ quality of life. The ZSI-375 sphincter is a unique single-piece cuff without an abdominal reservoir, simplifying implantation. Preliminary data show a social continence rate of 73% at six months, with lower complication rates than the AMS 800™. The VICTO® device offers adjustable pressure and a stress relief mechanism, providing conditional occlusion of the urethra. Early studies report a satisfaction rate of up to 94.2% and a complication rate of 17.6%. BR-SL-AS 904 is a newly proposed urinary sphincter, but due to the limited number of cases and a single study, its efficacy and complication rates remain uncertain. Conclusions: Overall, AMS 800™ remains the gold-standard treatment for SUI after radical prostatectomy. Alternative devices like ZSI-375 and VICTO® show promising results, but longer studies and more data are needed to establish their effectiveness and safety compared with the AMS 800™. Further research and ongoing monitoring are essential to address mechanical issues associated with AUS implants.

Using a stress reservoir to improve urine leakage after artificial urinary sphincter implantation.

Although the longest efficacy record, some patients report about urinary leakage during higher intra-abdominal pressure after Artificial Urinary Sphincter (AUS) implantation. To improve the continent results, we placed in addition to the occluding cuff and the pressure regulating balloon, in a second procedure a stress-relief reservoir in lower abdomen, for additional passive pressure transmission to the occluding cuff. In this retrospective monocentric data analysis between 2011 and 2018, 80 patients with persistence incontinence after AUS implantation were included. Stress-relief reservoir was indicated in 12 patients with involuntary leakage of urine, that occurred when intra-abdominal pressure raised. In all 12 cases, the stress reservoir was easily implanted and there were no intraoperative complications. In a mean follow-up time of 53months, the pad per day usage (p/d) improved from 3 (± 1.2) to 1.7 (± 1.5) (p = 0.001). Two patients with multiple previous abdominal surgeries used an equal number of pads after SRR; however, an improvement during physical exertion was reported. Continence situation was evaluated with a questionnaire and was rated as "excellent", "good", or "satisfactory" by 11 (92%) patients. The persistence of urinary incontinence after AUS is a challenging topic. Implantation of a stress reservoir in carefully selected patients with urinary leakage during higher intra-abdominal pressure is minimally invasive and offers new options to improve the proven long-term record of AUS. Certainly, more investigations are needed to determine the clinical relevance of this approach.

Outcomes of Artificial Urinary Sphincter Implantation in Patients with Detrusor Underactivity and Postprostatectomy Incontinence.

There is insufficient evidence for postoperative outcomes of artificial urinary sphincter (AUS) implantation for postprostatectomy incontinence (PPI) with detrusor underactivity (DU). Thus, we assessed the impact of preoperative DU on the outcomes of AUS implantation for PPI. Medical records of men who underwent AUS implantation for PPI were reviewed. Patients who had bladder outlet obstruction surgery before radical prostatectomy or AUS-related complications that required revision of AUS within three months were excluded. Patients were divided into two groups based on the preoperative urodynamic study including pressure flow study, a DU group, and a non-DU group. DU was defined as a bladder contractility index less than 100. The primary outcome was postoperative postvoid residual urine volume (PVR). The secondary outcomes included maximum flow rate (Qmax), postoperative satisfaction, and international prostate symptom score (IPSS). A total of 78 patients with PPI were assessed. The DU group consisted of 55 patients (70.5%) and the non-DU group comprised 23 patients (29.5%). Qmax was lower in the DU group than in the non-DU group and PVR was higher in the DU group as per a urodynamic study before AUS implantation. There was no significant difference in postoperative PVR between the two groups, although the Qmax after AUS implantation was significantly lower in the DU group. While the DU group showed significant improvements in Qmax, PVR, IPSS total score, IPSS storage subscore, and IPSS quality of life (QoL) score after AUS implantation, the non-DU group showed postoperative improvement in IPSS QoL score. There was no clinically significant impact of preoperative DU on the outcome of AUS implantation for PPI; thus, surgery can be safely performed in patients with PPI and DU.

Ambulatory peri-bulbar implantation, revision and replacement of Artificial Urinary Sphincter in neurogenic and non-neurogenic male patients: A preliminary feasibility study over a one-year experience.

Our goal was to determine the rate of complications, early revision and removal after full ambulatory implantation of bulbar AUS in men; secondly, to describe satisfaction and short-term continence rate. Between April 2018 and April 2019, 28 consecutive patients underwent AUS implantation in a newly organised ambulatory setting. A prospective database of all included patients was established with comprehensive data collected on medical history, aetiology and severity of SUI, surgical procedures, postoperative complications and patient satisfaction. Twenty-eight patients were included (30 consecutive procedures: 22 primary AUS placement, 6 complete revisions, 2 partial revisions), with a mean follow up of 223±220.5 days. Fourteen patients had prior radiotherapy. Readmission rate was 6.7% in the first 30 days after surgery. Both revision and removal rates were 6.7%. Complications were reported in 26.7% of procedures, mainly Clavien-Dindo I. Patient satisfaction of ambulatory surgery organisation and experience was high (87/5% satisfied or very satisfied). Full continence & social continence were achieved for, respectively, 55.6% and 88.9% of procedures. Ambulatory placement of AUS is safe and can be performed successfully. Larger patient cohorts and randomised trials are crucial to improve knowledge on non-indications for full ambulatory AUS implantation in men.

Outcomes and Complication Rates of Cuff Downsizing in the Treatment of Worsening or Persistent Incontinence After Artificial Urinary Sphincter Implantation.

This study investigated the functional outcomes and complication rates of cuff downsizing for the treatment of recurrent or persistent stress urinary incontinence (SUI) in men after the implantation of an artificial urinary sphincter (AUS). Data from our institutional AUS database spanning the period from 2009 to 2020 were retrospectively analyzed. The number of pads per day was determined, a standardized quality of life (QoL) questionnaire and the International Consultation on Incontinence Questionnaire (ICIQ) were administered, and postoperative complications according to the Clavien-Dindo classification were analyzed. Out of 477 patients who received AUS implantation during the study period, 25 (5.2%) underwent cuff downsizing (median age, 77 years; interquartile range [IQR], 74-81 years; median follow-up, 4.4 years; IQR, 3-6.9 years). Before downsizing, SUI was very severe (ICIQ score 19-21) or severe (ICQ score 13-18) in 80% of patients, moderate (ICIQ score 6-12) in 12%, and slight (ICIQ score 1-5) in 8%. After downsizing, 52% showed an improvement of >5 out of 21 points. However, 28% still had very severe or severe SUI, 48% had moderate SUI, and 20% had slight SUI. One patient no longer had SUI. In 52% of patients, the use of pads per day was reduced by ≥50%. QoL improved by >2 out of 6 points in 56% of patients. Complications (infections/urethral erosions) requiring device explantation occurred in 36% of patients, with a median time to event of 14.5 months. Although cuff downsizing carries a risk of AUS explantation, it can be a valuable treatment option for selected patients with persistent or recurrent SUI after AUS implantation. Over half of patients experienced improvements in symptoms, satisfaction, ICIQ scores, and pad use. It is important to inform patients about the potential risks and benefits of AUS to manage their expectations and assess individual risks.

(499) Exploring Risk Factors for Re-Operation Following Male Artificial Urinary Sphincter and Urethral Sling Implantation in a Multiethnic, Diverse Academic Center

Abstract Introduction New onset stress urinary incontinence (SUI) is the second most common complication following a prostatectomy, significantly affecting an estimated 10-20% of patients. Severe cases of SUI are often managed surgically by artificial urinary sphincter (AUS) or urethral sling implantation, depending on patient preference and incontinence severity. However, despite a large portion of these patients requiring surgical revision, there is a lack of information regarding the risk factors associated with reoperation, particularly in diverse populations. Thus, in this study, we analyzed the impact of demographic and intraoperative characteristics on reoperation risk following sling and AUS device implantation. Objective To identify risk factors for reoperation following primary AUS and urethral sling implantation. Secondarily, we aim to see if there was a difference in reoperation rates between the two procedures. Methods We performed a retrospective review of primary AUS and urethral slings implanted at a single academic center from July 2015 to May 2022. Demographic data, SUI severity (measured in pads per day), intraoperative characteristics, and 30-day safety outcomes were collected. Baseline characteristics were analyzed using a two-sample t-test, chi-square, or Mann-Whitney U test depending on distribution normality. Reoperation risk factors were analyzed utilizing Cox proportional hazard models for univariate and multivariate analysis, and a Kaplan Meier curve was used to depict re-operation time between sling and AUS. Results A total of 116 patients were included, 72 (62.1%) of which underwent urethral sling placement and 44 (37.9%) AUS implantation. The reoperation rate was 19.4% for urethral slings and 34.1% for AUS (p=0.077). Baseline characteristics between slings and sphincters differed in mean age (64.0 [7.1] vs 67.2 [7.5], p=0.024), median preoperative pads per day (2 [1-3] vs 3 [2-5], p&amp;lt;0.001), and history of XRT (11.1% vs 29.5%, p=0.012). After controlling for factors significant on univariate analysis (age, cardiovascular disease, and hyperlipidemia), multivariate analysis revealed that higher pads per day (OR=1.71, p=0.027) significantly increased the likelihood of sling reoperation, while age (OR=1.17, p=0.005) significantly increased the likelihood of AUS reoperation. Cardiovascular disease (CVD) (OR=0.10, p=0.003) and former smoking status (OR=0.17, p=0.018) were protective of AUS reoperation. There was no difference between sling and AUS reoperation on a log rank test (p=0.21). Conclusions A greater number of preoperative pads per day is associated with increased rates of reoperation following sling implantation, while age, CVD, and former smoking status are associated with AUS reoperation. Further research is warranted to identify patient-specific risk factors, particularly to clarify the effects of CVD and former smoking status on reoperation. Disclosure No

(446) Synchronous Surgical Management of Erectile Dysfunction and Stress Urinary Incontinence: A Systematic Review and Meta-analysis of Reoperation Rates

Abstract Introduction The efficacy, safety, and postoperative outcomes of synchronous surgery for concomitant erectile dysfunction (ED) and stress urinary incontinence (SUI) remain unclear. Objective We performed a systematic review and meta-analysis to evaluate the available synchronous surgical approaches for concomitant ED and SUI and to assess the reoperation rates compared to asynchronous surgery and surgery only for ED or SUI. Methods We searched PubMed, Cochrane Library, and Embase databases until June 2022 for relevant studies. Based on data availability, we performed a meta-analysis of odds ratios (ORs) comparing reoperation rates after synchronous surgery in patients with concomitant ED and SUI versus asynchronous surgery, as well as surgery solely for ED or SUI (PROSPERO: CRD42022326941). Results We included 18 studies in the systematic review (16,517 patients) and 5 in the meta-analysis. Comparing synchronous implantation of penile prosthesis and artificial urinary sphincter (AUS) versus asynchronous surgery, no statistically significant differences were observed in the reoperation rates [OR:0.98, 95% confidence interval (CI): 0.52-1.84, I2:0%). Comparing synchronous implantation of both penile prosthesis and AUS versus implantation of only a penile prosthesis or an AUS, combined surgery was associated with higher reoperation rates (OR:2.02, 95%CI: 1.29-3.16, I2:36% and OR:1.7, 95%CI: 1.25-2.32, I2:0%, respectively). Synchronous surgery led to high satisfaction rates and significant improvement in ED and SUI. Evidence for the combination of penile prosthesis with a male sling or the ProACT device is low, but data suggests it may be safe and effective. The synchronous placement of a Mini-Jupette sling and penile prosthesis represents a promising treatment modality for the correction of ED and mild SUI and/or climacturia. Conclusions Synchronous penile prosthesis and AUS implantation appears safe and effective in patients with severe ED and SUI. Further high-quality studies are mandatory to strengthen the current scarce evidence for synchronous surgery in patients with ED and SUI. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Cynosure, Coloplast, Clarus Therapeutics, Antares Pharma, Acerus

(403) Artificial Urinary Sphincter Implantation for Severe Post-Prostatectomy Incontinence in Setting of Salvage Radiotherapy and Prior Inflatable Penile Prosthesis

Abstract Introduction Artificial urinary sphincter (AUS) implantation is one of the most common treatment options for individuals with severe stress urinary incontinence (SUI), which is a common complication after radical prostatectomy (RP). The modern AUS consists of a urethral cuff, pump, and reservoir, which serves as a replacement for the native incompetent sphincter. There are various surgical approaches for AUS insertion, including transperineal, transscrotal, and abdominal approaches. Objective This video covers the surgical technique for the implantation of an AUS for management of SUI. Notably, this patient underwent RP followed by salvage radiotherapy (XRT) for biochemical recurrence of prostate cancer and had prior inflatable penile prosthesis (IPP) placement. Methods A standard step-by-step surgical technique for placement of an AUS through a perineal incision and additional counter incision to allow for high submuscular placement of the pressure-regulating balloon is demonstrated in this unique case of a patient with prior IPP placement and salvage XRT. Results We highlight a meticulous dissection around the urethra in a case that had a challenging urethral dissection secondary to prior radiotherapy and a prior IPP in the proximal corpora. The AUS pump was successfully placed in the subdartos pouch of the scrotum on the contralateral side to avoid the patient’s prior IPP pump. At the conclusion, a flexible cystourethroscopy showed adequate AUS cuff coaptation and cycling. Conclusions This video covers the step-by-step technique for insertion of an AUS with a transperineal approach in the unique context of a patient with prior IPP placement and XRT. Preoperative counseling, evaluation, and careful intraoperative dissection of key parts of the procedure are critical for successful placement of the AUS, especially in patients who are at high-risk for complications, such as in this case. Disclosure No

(312) Area Deprivation Index in Men Undergoing AUS Placement– Community Resource Limitations Do Not Correlate with Poorer Device or Satisfaction Outcomes

Abstract Introduction Outcomes following artificial urinary sphincter (AUS) placement have been associated with non-urologic health metrics including hemoglobin A1c and BMI, as well as with health literacy and frailty. Concerns about these patient factors may lead urologic prosthetic surgeons to alter their recommendations for stress urinary incontinence treatment to avoid poor patient outcomes. The Area Deprivation Index (ADI) is a ranking system to measure socioeconomic disadvantage between neighborhoods and correlates with rates of chronic medical conditions such as diabetes and cardiovascular disease, as well as healthcare service utilization and death. This ranking system includes a composite score of patient income, education level, employment status and housing quality. Evaluating socioeconomic disadvantage may help implanters tailor their patient counseling and improve patient pre- and postoperative education. Objective We sought to characterize variability in functional, subjective, and objective outcomes following AUS placement according to ADI. Methods Patients were identified by CPT codes for AUS insertion, removal/replacement, and revision from 2014 to 2022 at our institution. National percentile ADI was obtained using the Neighborhood Atlas® (Madison, WI) based on patient home address. Higher ADI scores indicate greater socioeconomic disadvantage. Associations of ADI with post-AUS satisfaction, device survival, and complications including (I) any Clavien-Dindo complication and (II) complications requiring surgical intervention. Patient satisfaction was assessed on a 1-5 Likert scale based on telephone interviews. Results 284 patients met inclusion criteria with 232 having data available regarding complications. Median ADI scores in our cohort was 59 (41-75), and we divided the cohort according to high (&amp;gt;58) and low socioeconomic deprivation groups based on this cutoff. Of these, 53 (22.8%) experienced any complication following AUS procedure, over a median of 6.3 months follow up. Device survival at last follow up was similar between low (88.8%) and high ADI groups (92%, P=0.41). Patients with low and high ADI scores had similar overall complication rates (21.6% vs. 24.4%; P=0.64) of any Clavien-Dindo score. Device survival was high at last follow up regardless of ADI score (88.8% vs. 92.0%; P=0.41) with total follow up also being similar between groups (5.64 mo vs. 8.01 mo; P=0.23). Time from prostatectomy to AUS implantation was also similar between high and low ADI groups (4.23 years vs. 4.17 years, P=0.70) Finally, patient satisfaction was very high in both the low and high ADI groups (5 vs. 5; P=0.41). Conclusions ADI was not associated with time to sphincter implantation, postoperative complications, patient satisfaction or device survival. Despite ADI capturing several factors that potentially impact a patient’s ability to optimally access medical care-including income, education and housing quality, we found no evidence that socioeconomic disadvantage by ADI scores was predictive of poorer outcomes, satisfaction, or suboptimal follow up. Disclosure No

(543) Antibiotic Prophylaxis for Artificial Urinary Sphincter Surgery - Trends in AUA Best Practices Guideline Adherence

Abstract Introduction Infections involving an artificial urinary sphincter (AUS) can be devastating and costly. Antibiotic use during implantation is a mainstay in preserving the implant as well as reducing morbidity for patients. While antibiotic guidelines regarding urologic procedures have been published, it remains unclear how widespread these recommendations adoption or use is in practice especially with regards to AUS implantation. Objective Using the premier healthcare database (PHD), a large national database, we assessed trends in antibiotic prophylaxis for AUS in conjunction with the AUA Best Practice Guidelines on urologic procedures and antimicrobial prophylaxis. Methods The premier healthcare database (PHD) was queried from Q1 of year 2000 to Q1 of 2020. Encounters involving AUS insertion, removal, and/or associated complications were identified via ICD diagnosis, ICD procedure, and CPT codes. Premier charge codes were used to identify antibiotics administered during the insertion encounter. Antibiotics were grouped into categories based on antibiotic classification. Information pertaining to the day a particular item was billed was used to identify whether administration was ‘guidelines based’ or not. Antibiotic administration was considered guidelines based if they consisted of either Aminoglycosides and 1st/2nd generation Cephalosporin or Monobactam (Aztreonam) and 1st/2nd generation Cephalosporin. Removal or complications associated with AUS were identified on subsequent encounters and linked via the patients’ hospital identifier. Differences in removal and complication rates between patients with guidelines-based antibiotic administration at insertion were assessed via chi-squared tests. The association of guidelines-based administration with other categorical variables was also assessed via chi-squared tests. Differences between groups in continuous variables were assessed via Mann-Whitney U tests. Results A total of 9,976 patients having undergone AUS surgery were identified between 2000 and 2020, of which 1548 (16%) received AUA-adherent antibiotics. Six thousand six hundred and twenty six (66%) encounters were isolated since 2011. Mean age was 69.8 with 7485 (75%) Caucasian, 7158 (71%) utilizing Medicare. Mean length of hospital stay (LOS) was 0.4 days overall and 0.2 days compared to 0.5 (p&amp;lt;0.001) for patients receiving AUA-adherent to AUA non-adherent antibiotics. Patients receiving AUA-adherent antibiotic regimens (359 [23%]) had fewer complications than those receiving non-adherent regimens (2335 [28%]) (p&amp;lt;0.001) however no statistically significant reduction in encounters for removal or repair were noted (AUA-adherent 307 [20%]) to AUA-non-adherent 1826 [22%]) (p=0.11). No statistical significance was noted with regards to the decade of encounter, age, or race of the patient, or if the patient had received AUS teaching. Only 4.95% of patients received antibiotic therapy beyond the recommended 24-hour prophylactic recommendations. Conclusions Adherence to AUA-recommended, best practice antimicrobial guidlines, with regards to AUS implantation appears low. This is likely multifactorial and dependent on individual surgeon preferences, local antibiograms and resistance patterns as well as individual patient sensitivities and tolerances. Disclosure No

A systematic review and meta-analysis of complications of artificial urinary sphincters in female patients with urinary incontinence due to internal sphincter insufficiency

BackgroundUrinary incontinence (UI) is a common worldwide rising health issue among women with a prevalence of 5 to 70%. Stress urinary incontinence (SUI) is the most common subtype of UI. There are different treatments for UI, including AUS (artificial urinary sphincter) implantation, as one of the surgical options for treating SUI. The aim of this study was to determine the complication rate of AUS, exclusively in female patients with SUI, which resulted from ISD (intrinsic sphincter deficiency). We also compared the complication rate between minimally invasive (laparoscopic or robotic surgery) and open approaches.MethodsScopus, PubMed, Web of Science, Embase, and Google Scholar were searched for studies regarding complications in AUS implantation surgery, from the beginning of the project to March 2022. After screening and reviewing of full text, the general characteristics of the study and study population including follow-up time, type of surgery, and the number of complications that occurred such as necrosis, atrophy, erosion, infection, mechanical failure, revision, and leak, were extracted.ResultsWe found that atrophy occurred in 1 of 188 (0.53%) patients treated with minimally invasive surgery and in 1 of 669 (0.15%) patients treated with open surgery. None of the 17 included studies reported the occurrence of necrosis in the patients under study. Erosion occurred in 9 of 188 (4.78%) patients treated with minimally invasive surgery and in 41 of 669 (6.12%) patients treated with open surgery. Infection occurred in 12 of 188 (6.38%) patients treated with minimally invasive surgery and in 22 of 669 (3.2%) patients treated with open surgery. The mechanical failure occurred in 1 of 188 (0.53%) patients treated with minimally invasive surgery and in 55 of 669 (8.22%) patients treated with open surgery. Reconstructive surgery occurred in 7 of 188 (3.72%) patients treated with minimally invasive surgery and in 95 of 669 (14.2%) patients treated with open surgery. Leaks occurred in 4 of 188 (2.12%) patients treated with minimally invasive surgery and in 6 of 669 (0.89%) patients treated with open surgery. The type of surgery was associated with a statistically significant increase in mechanical failure (p-value = 0.067) and infection (p-value = 0.021), and reconstructive surgery (p-value = 0.049). Out of the 857 participats in the study,469 were studied for less than five years and 388 were studied for more than five years.21 of 469 (4.4%) (p-value = 0.08) patients and 81 of 388 (20.8%) (p-value = 0.001) patients required reconstructive surgery. Erosion occurred in 23 of 469 (4.9%) (p-value = 0.01)patients with following time less than five years and in 27 of 388 (6.9%) (p-value = 0.001) patients with following time more than five years.ConclusionThe use of artificial urinary sphincters in the treatment of UI causes complications such as atrophy, erosion, and infection; the amount of which is influenced by the surgical method and the duration of using the artificial urinary sphincter. It seems that the use of new surgical methods, such as laparoscopic surgery, is useful in reducing the incidence of complications.

Totally intracorporeal robot-assisted supratrigonal cystectomy and ileal augmentation cystoplasty with periprostatic artificial urinary sphincter implantation for male neurogenic mixed urinary incontinence.

Totally intracorporeal robot-assisted supratrigonal cystectomy and ileal augmentation cystoplasty with periprostatic artificial urinary sphincter implantation for male neurogenic mixed urinary incontinence.