Presenting signs and symptoms of artificial urinary sphincter cuff erosion

Treatment strategies for revision surgery of artificial urinary sphincter: A review

Artificial urinary sphincters (AUS) are an effective treatment for male stress urinary incontinence (SUI). However, infection, erosion, mechanical failure, atrophy, and balloon deterioration cause device malfunction in approximately half of patients by 10 years after implantation. Many patients desire to regain urinary continence and require revision surgery (RS), including device removal and simultaneous or delayed implantation. Patients for whom RS is considered should be examined physically and by interview for signs of infection. Urethral erosion should be assessed using cystoscopy. If there is infection or erosion, all devices should be removed first, and a new device should be implanted several months later. During the RS, after strong adhesion around the urethra, transcorporal cuff implantation is a safe choice. Device removal and simultaneous implantation can be performed in the absence of infection or erosion. If a long time has passed since device implantation, the entire device should be replaced due to device aging and deterioration; however, if the time is short, only the defective component need be replaced. Intraoperative assessment of urethral health is necessary for device removal and implantation. If the urethra is healthy, a new cuff can be placed in the same position as the old cuff was removed from; however, if the urethra is unhealthy, the cuff can be implanted in a more proximal/distal position, or a transcorporal cuff implant may be chosen. This article reviews the literature on diagnostic and treatment strategies for recurrent SUI in male patients with AUS and proposes a flowchart for AUS revision.

Artificial urinary sphincter erosion and infection: a contemporary review of perioperative considerations and management

Surgical treatment options have long been a part of the treatment armamentarium in the field of male stress urinary incontinence (SUI) and will continue to play an important role moving forward given the dramatic improvement they can have on a patient's quality of life and urinary tract function and control. The artificial urinary sphincter (AUS) is widely considered the gold standard treatment option for male SUI given its breadth of effectiveness in mild, moderate, and severe cases of SUI. As with any surgery, there are potential perioperative risks and complications that all patients must be aware of when weighing the pros and cons of different treatment options. Two of the most dreaded complications of AUS surgery are urethral cuff erosion and device infection, both necessitating a subsequent surgery for device explant. The goal of this clinical practice review article is to examine and discuss the perioperative factors and management of these complications. Effectively treating these complications is of utmost importance, not just to address the acute clinical problem for patient health and safety, but also to provide the patient with the best chance of pursuing AUS replacement surgery in the future, given that the vast majority of these patients will develop recurrent bothersome SUI after the eroded and/or infected device is removed. By reviewing pertinent patient factors, preoperative and postoperative considerations, device-specific characteristics, surgical techniques, and patient counseling, this article serves as a thorough and practical clinical review guide for practicing urologists who perform male incontinence surgery.

Surgical Management of Male Stress Incontinence: Techniques, Indications, and Pearls for Success

Purpose

Male stress urinary incontinence (SUI) has detrimental and long-lasting effects on patients. Management of this condition is an evolving field with multiple options for surgical treatment. We sought to review the pre-operative evaluation, intra-operative considerations, post-operative care, and future directions for treatment of male SUI.

Methods

A literature review was performed using the PubMed platform to identify peer-reviewed, English-language articles published within the last 5 years pertaining to management of male stress urinary incontinence with an emphasis on devices currently on the market in the United States including the artificial urinary sphincter (AUS), male urethral slings, and the ProACT^TM system. Patient selection criteria, success rates, and complications were compared between the studies.

Results

Twenty articles were included in the final contemporary review. Pre-operative workup most commonly included demonstration of incontinence, PPD, and cystoscopy. Definition of success varied by study; the most common definition used was social continence (0-1 pads per day). Reported rates of success were higher for the AUS than for male urethral slings (73-93% vs 70-90%, respectively). Complications for these procedures include urinary retention, erosions, infections, and device malfunction. Newer treatment options including adjustable balloon systems and adjustable slings show promise but lack long-term follow-up.

Conclusion

Patient selection remains the primary consideration for surgical decision-making for management of male SUI. The AUS continues to be the gold standard for moderate-to-severe male SUI but comes with inherent risk of need for revision. Male slings may be a superior option for appropriately selected men with mild incontinence but are inferior to the AUS for moderate and severe incontinence. Ongoing research will shed light on long-term results for newer options such as the ProACT and REMEEX systems.