Artificial urinary sphincter revision for urethral atrophy: comparing single cuff downsizing and tandem cuff placement

Abstract

Objective To compare outcomes for single urethral cuff downsizing versus tandem cuff placement during artificial urinary sphincter (AUS) revision for urethral atrophy.Materials and Methods We identified 1778 AUS surgeries performed at our institution from 1990-2014. Of these, 406 were first AUS revisions, including 69 revisions for urethral atrophy. Multiple clinical and surgical variables were evaluated for potential association with device outcomes following revision, including surgical revision strategy (downsizing a single urethral cuff versus placing tandem urethral cuffs).Results Of the 69 revision surgeries for urethral atrophy at our institution, 56 (82%) were tandem cuff placements, 12 (18%) were single cuff downsizings and one was relocation of a single cuff. When comparing tandem cuff placements and single cuff downsizings, the cohorts were similar with regard to age (p=0.98), body-mass index (p=0.95), prior pelvic radiation exposure (p=0.73) and length of follow-up (p=0.12). Notably, there was no difference in 3-year overall device survival compared between single cuff and tandem cuff revisions (60% versus 76%, p=0.94). Likewise, no significant difference was identified for tandem cuff placement (ref. single cuff) when evaluating the risk of any tertiary surgery (HR 0.95, 95% CI 0.32-4.12, p=0.94) or urethral erosion/device infection following revision (HR 0.79, 95% CI 0.20-5.22, p=0.77).Conclusions There was no significant difference in overall device survival in patients undergoing single cuff downsizing or tandem cuff placement during AUS revision for urethral atrophy.

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

“…Previous large cohorts have established urethral atrophy as the most frequent cause of recurrent incontinence after AUS placement. Such studies report rates between 8.2% and 14% after primary implantation and attribute up to 52% of device failures to atrophy [3,5,9,10]. However, several recent studies have contested the pervasiveness of urethral atrophy.…”

“…While providing excellent continence outcomes, the device is subject to failure over time, leading to recurrent incontinence. Studies in several large cohorts have revealed device revision/ explant rates >25%; however, these studies have varied results and lack long-term follow up [3,5]. There is controversy regarding the leading causes of AUS device failure.…”

Prevalence and Risk Factors of Artificial Urinary Sphincter Revision in Nonneurological Male Patients

“…In previous studies, the rate of such non-mechanical failure ranged from 8.2 to 14% and accounted for up to 52% of causes of revisions (13)(14)(15)(16). However, several series reported that mechanical failure was the most prevalent cause of male AUS revision (17), but disagreed on which component was responsible of the failure in most cases:…”

Long-term results of the implantation of the AMS 800 artificial sphincter for post-prostatectomy incontinence: a single-center experience

“…In our center, we prefer to implant a tandem cuff in these cases to improve continence status. Linder et al ( 31 ) recently demonstrated that implantation of a second-cuff or downsizing of the cuff are both adequate procedures to treat the recurrence of the UI due to urethral atrophy.…”