Cuff Erosion Research Articles

Primary and revision artificial urinary sphincter for stress urinary incontinence post-radical prostatectomy: a surgery with high rewards but high risks?

To evaluate the efficacy of artificial urinary sphincter (AUS) implantation in men with stress urinary incontinence post-radical prostatectomy and the complication burden with a focus on identifying potential risk factors for reoperation as well as determining the fate of revision surgeries. Retrospective analysis of consecutive patients undergoing primary AUS (pAUS) and revision AUS (rAUS) implantation at a tertiary centre. Logistic regression was employed to identify risk factors for reoperation associated with non-mechanical failures. Kaplan Meier method was applied to generate implant patency curves. Over 11-years, 108 and 28 patients underwent pAUS and rAUS, respectively. Amongst the former group, a 30-day complication rate of 20.4% was found with a complete (zero pad) dryness rate at follow-up of 49.1%. Post-operative infection was the commonest occurring complication in 7.4%. After pAUS, 27.8% underwent reoperation with cuff erosion being the top indication in 46.7%. Diabetes was a significant predictor for reoperation with an associated 3.6-fold increased risk. The 3-year and 5-year device survival rates without reoperation for pAUS were 80% and 76%, respectively. For rAUS, complete dryness rates achieved were lower at 32.1%. The rate of reoperation was higher at 42.9% with a significantly worse survival probability compared to pAUS (p = 0.024). Whilst men may achieve complete dryness after pAUS, the potential complication burden and risk of reoperation are not low, and patients need to be counselled regarding this. Chances of continence success are lower when revision surgery is performed with a worse implant survival probability.

Vessel-sparing Non-transecting Anastomotic Reconstruction of the Posterior Urethra: Single Center Experience with Long-term Follow-up

OBJECTIVETo discuss the long-term results of our vessel-sparing non-transecting approach (vspEPA) to perform anastomotic urethroplasty at the posterior urethra. We avoid transecting the bulbar arteries to preserve the antegrade vascularization of the urethra. We hypothesize that vspEPA is feasible, safe and not inferior to the traditional transecting technique. Additionally, it may provide benefits if an artificial urinary sphincter (AUS) implantation be required in the future. METHODSThe bulbar urethra was elevated from the corpus cavernosum, released distally, retracted laterally, and approached dorsally at the bulbo-membranous junction. This exposure allows removal of the scar and perform the anastomotic reconstruction as in the standard transecting technique, while avoiding division of the bulbar arteries. RESULTS127 patients, median age 58 years (IQR 35-67), were reconstructed since 2008. Etiology of the stenosis was BPH surgery (n=48), pelvic fracture urethral injury (PFUI) (n=61), prostate cancer treatment (n=14) and instrumentation (n=4). With a median follow-up of 43 months (IQR 17-74) stenosis repair success was observed in 121 patients (95%). High grade complications (Clavien ≥III) occurred in 6 (5%) of cases and overall stress incontinence was observed in 24 (19%) of patients. 14 patients subsequently received an AUS and notably none of them suffered cuff erosion after a median follow up of 36 months, CONCLUSIONSparing of the bulbar arteries during anastomotic reconstruction of the posterior urethra is feasible and safe. Although slightly more elaborated, it will not compromise the surgical results and may be instrumental to avoid AUS cuff-related erosion in the future.

Outcomes of transperineal reanastomosis as a salvage treatment for recurrent vesicourethral anastomosis stenosis after radical prostatectomy.

To evaluate transperineal reanastomosis (TRPA) combined with incontinence surgery as a complex treatment for recurring vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy (RP). Retrospective analysis of 8 patients who underwent TRPA for recurring VUAS. Detailed preoperative and follow up data were assessed. Mean follow up lasted 47 months (range 17-77) with mean age being 63.4 years (range 61-70). All patients achieved patency and 87.5% (7/8) maintained it to the end of follow up. However, four of them required additional procedures to retain patency. Six underwent incontinence surgery - artificial urinary sphincter (AUS) implantation - after which one cuff erosion occurred. In the end 62.5% (5/8) of patients achieved patent urethra and continence. TRPA combined with incontinence surgery is a reasonable treatment for patients with recurrent VUAS. Nonetheless, this is a set of difficult surgeries that may ultimately end in failure, i.e. the inability to restore urethral patency, urinary incontinence or urinary diversion, hence they should be performed by experienced surgeons.

Artificial urinary sphincter and stricture disease: surgical principles in management.

Iatrogenic stress urinary incontinence (SUI) is the most common complication of surgical treatment of prostate cancer, regardless of operative approach, and has a major impact on patients' quality of life. Although SUI can occur after surgical treatment of benign prostatic hyperplasia, specifically transurethral prostate resection, laser enucleation of the prostate, and simple open prostatectomy, these therapeutic modalities play a much less significant role in the etiology of SUI. Artificial urethral sphincter (AUS) implantation is considered the standard treatment modality providing high success rates, including durable efficacy, and optimal patient satisfaction for moderate to severe urinary incontinence resulting mainly from radical prostatectomy. However, although complication rates are generally acceptably low, revision and/or explantation may be required due to mechanical failure and non-mechanical problems, specifically urethral atrophy/cuff deficient occlusion, infection, and cuff erosion. Several risk factors for AUS failure associated with a fragile, compromised urethra have been identified and these play a critical role in device cuff erosion and subsequent removal of the device. Among others, apparently the most impacting factors are irradiation, urethral stent placement, a previous AUS placement, and importantly presence of urethral stricture or prior urethroplasty. Generally, any clinical situation leading to a diseased urethra or lack of urethral integrity is associated with impaired local blood perfusion, and consequently lower success rates. The present review aims to evaluate the impact of the presence of prior urethral strictures and urethroplasty on the outcomes of AUS implantation on one hand, and vice-versa, the influence of AUS placement on later urethral stricture surgery, particularly following cuff erosion.

Delayed healing is common in in‐situ urethroplasty patients after artificial sphincter cuff erosion

AbstractIntroductionUrethral erosion is a known complication of artificial urinary sphincter (AUS) surgery. We performed an in‐situ urethroplasty (ISU) to reduce the healing time and time to reimplantation of the AUS. We sought to assess urethral integrity one month after ISU and to identify factors associated with delayed healing in our high‐volume tertiary referral center experience.MethodsA retrospective review of our AUS database from 2009 to 2023 was conducted to identify all ISU cases. Patients were stratified as healed or non‐healed based on the absence of extravasation on voiding cystourethrogram (VCUG) obtained 4 weeks postoperatively. Background characteristics were evaluated including age, body mass index, diabetes, hypogonadism and smoking history. Operative variables included degree of erosion, location of defect, and the number of stitches required for repair.ResultsAmong 98 patients undergoing an ISU, 61 underwent VCUG at one month. Of these, 34.4% (21/61) had evidence of delayed healing on VCUG requiring prolonged catheterization. Although a higher average number of repair sutures were used in ISU, this was not significant (p = 0.381). The most common complication in both groups was urinary tract infection (UTI). Non‐healed patients had a higher rate of UTI, without significant predilection towards fistula, stricture or diverticulum. No other patient or operative characteristic was significantly different between groups.ConclusionDespite an aggressive approach to management via ISU, many patients still require prolonged catheterization after AUS erosion to ensure complete healing of the defect.

The 51-60 cm H2O Artificial Urinary Sphincter Pressure Regulating Balloon: Indications and Outcomes

To describe the role and long-term outcomes of using the 51-60 cm H2O pressure regulating balloon (PRB) in male patients with an artificial urinary sphincter (AUS). From 2005 to 2021, 90 patients with a variety of urethral risk factors underwent AUS placement with use of the low pressure 51-60 cm H2O PRB to treat stress incontinence. Patient demographics, indication for use of the 51-60 cm H2O PRB, perioperative data, and postoperative outcomes were examined and Pearson's chi squared test and Wilcoxon rank sum test were used to identify associations with future revisions, erosion, and mechanical failure. 90 patients were included in the study. After median follow-up of 46.6 months (range: 6 - 146 months), 4 (4.44%) patients developed an erosion-related complication that required device removal, 4 developed an infection, and 3 underwent surgery for pump relocation. One patient had a reported mechanical failure of unknown source. 30 patients underwent revision surgery to reduce incontinence. Of the 4 patients with erosion, 1 was due to iatrogenic catheterization. The remaining 3 had numerous urethral risk factors. Univariate analysis was performed to identify predictors of cuff erosion, infection, and revision in patients with a 51-60 cm H2O PRB. No significant associations were found including prior pelvic radiation, age at AUS placement, presence of IPP, prior AUS erosion, or previous urethroplasty. The low pressure 51-60 cm H2O PRB can be used in high-risk male patients with urinary incontinence with low rates of complications including erosion, infection, and mechanical failure. While patients may choose to undergo future revisional surgery to improve continence, the 51-60 cm H2O PRB should be considered as the initial PRB in patients with urethral risk factors.

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 ...

MP71-02 ASSESSING THE IMPACT OF HYPOGONADISM ON SURGICAL OUTCOMES FOLLOWING ARTIFICIAL URINARY SPHINCTER PLACEMENT

You have accessJournal of UrologyCME1 Apr 2023MP71-02 ASSESSING THE IMPACT OF HYPOGONADISM ON SURGICAL OUTCOMES FOLLOWING ARTIFICIAL URINARY SPHINCTER PLACEMENT Andrew Gabrielson, Logan Galansky, Una Choi, and Andrew Cohen Andrew GabrielsonAndrew Gabrielson More articles by this author , Logan GalanskyLogan Galansky More articles by this author , Una ChoiUna Choi More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003339.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retrospective series suggest a link between hypogonadism and complications following artificial urinary sphincter (AUS) placement. We sought to confirm this finding and evaluate whether testosterone replacement therapy (TRT) in hypogonadal patients prior to AUS placement mitigates this risk. METHODS: A retrospective cohort study was conducted using the TriNetX research network between 2006-2022. We defined 4 groups: 1) Eugonadal patients undergoing AUS, 2) Hypogonadal patients (>1 confirmatory T level <300 ng/dL) with and without TRT, 3) Hypogonadal patients who received TRT prior to AUS, 4) Hypogonadal patients who did not receive TRT prior to AUS. Propensity-score matching was used in comparing baseline differences in comorbidities of the eugonadal and hypogonadal arms. Outcomes included 5-year all-cause revision (cuff erosion, mechanical, infectious), 5-year device complication (mechanical, infectious only), and 90-day surgical site infection (SSI) rate. RESULTS: We included 4,520 eugonadal and 514 hypogonadal patients (19% with TRT, 81% without TRT) undergoing AUS (Table 1). Compared to eugonadal patients, the hypogonadal cohort had a significantly higher 5-year device complication (17% vs 13%, p=0.03) and 90-day SSI rate (2% vs 0.8%, p<0.01), but no difference in 5-year revision rate (26% vs 24%, p=0.21). When comparing hypogonadal patients who received TRT prior to AUS versus hypogonadal patients who did not receive TRT, we found no difference in 5-year revision (32% vs 26%, p=0.19), 5-year device complication (23% vs. 16%, p=0.10), or 90-day SSI (1.1% vs. 1.9%, p=0.48) rates. Hypogonadal patients receiving TRT before AUS were more likely to have pre-existing erectile dysfunction and penile implant surgery, but had similar rates of radical prostatectomy. Post-AUS, only 22 (5.3%) patients in the non-TRT arm received new TRT, suggesting minimal crossover. There was no difference in 5-year revision between eugonadal and hypogonadal patients not receiving TRT. CONCLUSIONS: Pre-existing hypogonadism may impact early SSI rates and long-term mechanical or infectious complications but was not associated with higher rates of all-cause revision likely due to similar rates of cuff erosion. TRT does not appear to impact surgical outcomes among hypogonadal patients undergoing AUS placement. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1013 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Gabrielson More articles by this author Logan Galansky More articles by this author Una Choi More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF downloadLoading ...

Urethral management after artificial urinary sphincter explantation due to cuff erosion.

The artificial urethral sphincter (AUS) is the gold standard treatment in cases of moderate-to-severe stress urinary incontinence in males. Cuff erosions are one of the most important distant complications of AUS implantation. The optimal urethral management has still not been established. Search terms related to 'urethral stricture', 'artificial urinary sphincter', and 'cuff erosion' were used in the PubMed database to identify relevant articles. In this mini review we identified 6 original articles that assessed the urethral management after AUS explantation due to cuff erosion and included urinary diversion by transurethral and/or suprapubic catheterization, urethrorrhaphy, and in situ urethroplasty. We summarized the results of different management methods and their efficacy in terms of preventing urethral stricture formation. We highlight the need for better-quality evidence on this topic. The available data do not provide a clear answer to the question of optimal urethral management during AUS explantation. There is a great need to provide higher-quality evidence on this topic.

Complicated artificial urinary sphincter insertion using the transcorporal cuff: keys to the tunical flap technique.

Urethral sphincter insufficiency following radical prostatectomy (RP) is a common cause of non-neurogenic stress urinary incontinence (SUI). Artificial urinary sphincter (AUS) insertion remains the standard of care for fit patients with SUI refractory to non-operative interventions. The proximal urethra is a common location for uncomplicated AUS placement. However, previous failed AUS, urethroplasty, or pelvic radiotherapy (RT) may compromise urethral tissue requiring technique modifications that optimise outcomes. In these situations, transcorporal cuff (TC) placement has been well described to facilitate continence restoration in men where there is no other feasible option other than urinary diversion or permanent incontinence. In the traditional TC approach, the procedure may be complicated by haematoma due to difficulty in completely closing the corporal defects behind the urethra. This narrated video demonstrates the tunical flap (TF) modification for transcorporal AUS implantation via a perineal and penoscrotal approach in patients with prior failed AUS placements secondary to urethral erosion. The TF technique for transcorporal AUS insertion provides circumferential reinforcement with tunica albuginea from the corpora cavernosa. Here, we show how this technique provides additional urethral support for compromised urethral tissue to help prevent cuff erosion. The TF preserves the corporal volume and does not limit candidacy for future penile prosthesis implantation. In our early results, there have been no postoperative haematoma formation with this technique.

Artificial Urinary Sphincter in a High-Risk Urethra: Transcorporal Gullwing Modification Description of the Technique.

In this report, we describe a modification of transcorporal artificial urinary sphincter place ment known as Gullwing modification. Using a penoscrotal approach, bilateral corpora cavernosa flaps are harvested and sutured in the midline covering the lateral and ventral surfaces of the urethra. Transcorporal cuff placement provides dorsal reinforcement, thus having extra tissue buttressing all the circumference in cases of a fragile urethra due to previous urethral cuff erosion, urethroplasty, or pelvic radiotherapy. After previous urethral cuff erosion, radiotherapy, and urethral reconstruction, our patient complained of severe stress urinary incontinence. Due to the high risk of urethral complications, we proceed to a transcorporal artificial sphincter placement with urethral reinforcement through a bilateral cavernosal flap. The surgery was successfully completed, and after 6 weeks, sphincter was activated with satisfac tory results. Two years after surgery, his continence status is stable without complications. Urethral complications associated with artificial urinary sphincter surgery remain a challenge for the reconstructive surgeon. Reinforcement of the ventral aspect of the urethra through corpora cavernosal flaps may reduce the likelihood of urethral erosion in high-risk cases.

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.

MP52-07 IMPACT OF FRAILTY ON ADVERSE COMPLICATIONS FOLLOWING ARTIFICIAL URINARY SPHINCTER IMPLANTATION

You have accessJournal of UrologyCME1 May 2022MP52-07 IMPACT OF FRAILTY ON ADVERSE COMPLICATIONS FOLLOWING ARTIFICIAL URINARY SPHINCTER IMPLANTATION Rohan Bhalla, Jackson Cabo, Tanya Marvi, Abimbola Ayangbesan, George Koch, Stephen Hill, Douglas Milam, Melissa Kaufman, and Niels Johnsen Rohan BhallaRohan Bhalla More articles by this author , Jackson CaboJackson Cabo More articles by this author , Tanya MarviTanya Marvi More articles by this author , Abimbola AyangbesanAbimbola Ayangbesan More articles by this author , George KochGeorge Koch More articles by this author , Stephen HillStephen Hill More articles by this author , Douglas MilamDouglas Milam More articles by this author , Melissa KaufmanMelissa Kaufman More articles by this author , and Niels JohnsenNiels Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002627.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Frailty is a well-established predictor of postoperative outcomes. We aimed to investigate the association between the modified Frailty Index (mFI) and postoperative complications after artificial urinary sphincter (AUS) surgery. METHODS: Men who underwent AUS surgery at a single institution (1/1/13 – 7/31/2020) were identified and electronic medical records were reviewed. The mFI is a validated measure of predicting patient morbidity and mortality that consists of 11 patient co-morbidities. Each variable is given 1 point with composite scores ranging from 0 (no frailty) to 11 (highest degree of frailty). Operative and non-operative complications were categorized as: mechanical failure, cuff erosion, infection, intractable pain, urinary retention, or other. Multivariable logistic regression was used to identify an association between mFI and postoperative complications. RESULTS: 203 AUS patients met inclusion criteria. The median age was 69.8 years (IQR 65.1-75.0) with 33% (n=67) of patients having a history of radiation and 29.1% (n=59) of patients with a history of diabetes mellitus. The median time from surgery to data collection was 73.4 months (IQR 54.4-89.2). The median cuff size was 4.5cm (IQR 4-5). The complication rate was 26.6% with 18.7% of men requiring a surgical intervention (mechanical failure: n=11, cuff erosion: n=16, infection: n=7, other n=4). The median mFI was 2 (IQR 1-4) for patients with a complication and 2 (IQR 1-3) for those with no complication (Table 1). Multivariable analysis demonstrated no association between mFI and overall complication (OR 1.04, 95% CI 0.83-1.29; p=0.75) or surgical complication (OR 1.04, 95% CI 0.81-1.34; p=0.75). Prior radiation and time since surgery were significantly associated with postoperative complications (Table 2). CONCLUSIONS: The mFI was not associated with an increased risk of AUS complications. However, a prior history of radiation and extended time from surgery were independently associated with complications and the need for surgical intervention. Source of Funding: N/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e888 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rohan Bhalla More articles by this author Jackson Cabo More articles by this author Tanya Marvi More articles by this author Abimbola Ayangbesan More articles by this author George Koch More articles by this author Stephen Hill More articles by this author Douglas Milam More articles by this author Melissa Kaufman More articles by this author Niels Johnsen 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.

Impact of radiation therapy on artificial urinary sphincter implantation in male patients: A multicenter study.

To evaluate the impact of an history of radiation therapy on the outcomes of artificial urinary sphincter (AUS) implantation in male patients. The charts of all patients who underwent AUS implantation for stress urinary incontinence (SUI) after prostate surgery in thirteen centers between 2004 and 2020 were retrospectively reviewed. We excluded patients with neurogenic SUI. Continence rates and incidence of complications, revision and cuff erosion were evaluated. The outcomes in irradiated men were compared to those of non irradiated men. A total of 1277 patients who had an AUS met the inclusion criteria with a median age of 70 years, of which 437 had an history of prior radiotherapy. There was no difference in comorbidities. In irradiated patients, postoperative social continence, urethral atrophy and infection rates were respectively 75.6%, 2.4% and 9.5% and 76.8%, 5.4%, and 5.8% in nonirradiated men (respectively, p = 0.799, p = 0.128, p = 0.148). There were more urethral erosion in irradiated male patients. After a mean follow up of 36.8 months, the explantation free survival was poorer in irradiated patients (p = 0.001). These data suggest that pelvic radiotherapy before AUS adversely affect device survival with and increased greater occurrence of infection-erosion and therefore of explantation.

Long-term lower urinary tract sequelae following AUS cuff erosion.

To examine the rate of lower urinary tract complications (LUTC) and urinary diversion (UD) after artificial urinary sphincter (AUS) explantation with the acute reconstruction of AUS cuff erosion defects. We performed a retrospective study of patients who underwent in-situ urethroplasty (ISU) for AUS cuff erosion from June 2007 to December 2020. Outcomes included LUTC (urethral stricture, diverticulum, fistula), AUS reimplantation, and UD. Defect size was prospectively estimated acutely and a subanalysis was performed to determine the impact of erosion severity (small erosions [<33% circumferential defect] and large erosions [≥33%]) on these outcomes. Kaplan-Meier curves were created to compare survival between the two groups. A total of 40 patients underwent ISU for urethral cuff erosion. The median patient age was 76 years old with a median erosion circumference of 46%. The overall LUTC rate was 30% (12/40) with 35% (14/40) of patients requiring permanent UD. Secondary AUS placement occurred in 24/40 (60%) patients with 11/24 (46%) leading to repeat erosion. On subanalysis, small erosion was associated with improved LUTC-free and UD-free survival but not associated with AUS reimplantation. Lower urinary tract complications are common after AUS cuff erosion and can lead to the need for permanent UD. Patients with larger erosions are more likely to undergo UD and reach this end-stage condition earlier compared to patients with small erosions.

PD04-03 RECONSTRUCTION OF ARTIFICIAL URINARY SPHINCTER CUFF EROSION: DEFECT SIZE PREDICTS PROGNOSIS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I (PD04)1 Sep 2021PD04-03 RECONSTRUCTION OF ARTIFICIAL URINARY SPHINCTER CUFF EROSION: DEFECT SIZE PREDICTS PROGNOSIS Nathan Chertack, Gregory Joice, Kelly Caldwell, Mehraban Kavoussi, Benjamin Dropkin, Nicolas Ortiz, Adam Baumgarten, Nabeel Shakir, Sarah Sanders, Steven Hudak, and Allen Morey Nathan ChertackNathan Chertack More articles by this author , Gregory JoiceGregory Joice More articles by this author , Kelly CaldwellKelly Caldwell More articles by this author , Mehraban KavoussiMehraban Kavoussi More articles by this author , Benjamin DropkinBenjamin Dropkin More articles by this author , Nicolas OrtizNicolas Ortiz More articles by this author , Adam BaumgartenAdam Baumgarten More articles by this author , Nabeel ShakirNabeel Shakir More articles by this author , Sarah SandersSarah Sanders More articles by this author , Steven HudakSteven Hudak More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001968.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: 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. 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 (<33% circumferential defect) and major erosions ( >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). 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). 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. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e50-e50 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Chertack More articles by this author Gregory Joice More articles by this author Kelly Caldwell More articles by this author Mehraban Kavoussi More articles by this author Benjamin Dropkin More articles by this author Nicolas Ortiz More articles by this author Adam Baumgarten More articles by this author Nabeel Shakir More articles by this author Sarah Sanders More articles by this author Steven Hudak More articles by this author Allen Morey More articles by this author Expand All Advertisement Loading ...