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Single Surgeon Outcomes with Artificial Urinary Sphincter (AUS) implants in High-Risk Patient Population.
Wesley H. Chou, BA, Ajay K. Singla, MD.
Massachusetts General Hospital, Boston, MA.

BACKGROUND: Artificial urinary sphincter (AUS) implant is the gold standard treatment for stress urinary incontinence following management of prostate cancer, with post-prostatectomy incontinence (PPI) being the most common indication. Complications include device infection, urethral erosion, urethral atrophy, and device malfunction. Although certain factors have been linked to higher rates of complication and revision, prior literature has focused more on heterogeneous patient series versus higher-risk patients specifically. Thus, we sought to describe our experience with AUS in a high-risk patient population with regards to complication rates.
METHODS: A retrospective chart review of patients who received AUS procedures over 2.5 years in a single surgeon's practice at a tertiary care center was performed. Inclusion criteria for high-risk patients included any of the following: prior anti-incontinence procedure, prior radiation treatment, history of bladder neck contracture and/or urethral stricture, urethral erosion and/or infection, and/or history of penile implant (prior or concomitant). Patients receiving a “virgin” AUS without meeting above criteria were excluded.
RESULTS: A total of 53 AUS procedures in 43 male patients were initially identified. Of these, 41 AUS procedures in 31 patients met ≥1 inclusion criterion while 12 patients with primary implant and no other risk factors were excluded. Regarding inclusion criteria, 68.3% of cases (28/41) had ≥1 prior anti-incontinence procedure; 61.0% (25/41) had prior radiation treatment; 41.5% (17/41) had a history of bladder neck contracture and/or urethral stricture; 63.4% (26/41) met ≥2 inclusion criteria. Mean age was 71.0 ± 7.6 years, with the oldest patient being 90 years old at procedure time; mean BMI was 28.8 ± 3.3, with 39.0% (16/41) having BMI in the obese range; 65.9% (31/41) had current or former smokers; 7.3% (3/41) carried a diagnosis of coronary artery disease; 14.6% (6/41) carried a diagnosis of diabetes mellitus.
Regarding case type, 56.1% (23/41) were insertions, 24.4% (10/41) were revisions, 12.2% (5/41) were removal and replacements, and 7.3% (3/41) were removals; the number of AUS re-operations undergone by patients is summarized in Table 1. Mean operating time was 118.2 ± 32.5 min, and salvage procedure using dermal grafts were used in 17.1% (7/41). Mean length of post-procedure follow-up was 345 ± 252 days. Urethral atrophy was the most common complication in 22.0% (9/41), with a mean onset time of 400.6 ± 227 days. There were 4.9% of cases (2/41) with device infection/urethral erosion and 2.4% of cases (1/41) with device failure. Where listed, chart review showed that 45.5% of cases (15/33) were described as using one or fewer pads per day in postoperative follow-up.

Table 1. Number of AUS reoperations undergone by patients
Number of reoperationsNumber of patients (%)
024/31 (77.4)
15/31 (16.1)
21/31 (3.2)
31/31 (3.2)

CONCLUSIONS: Complication rates are comparable to those of prior literature, showing the feasibility of salvaging AUS in a highly complex patient cohort with a greater risk of complication and recurrent incontinence. Further follow-up of this cohort is warranted to better characterize complication rate and quality of life outcomes.

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