Artificial Urinary Sphincter Placement in Compromised Urethras and Survival: A Comparison of Virgin, Radiated and Reoperative Cases

Abstract

Purpose Although long-term outcomes after initial placement of artificial urinary sphincters are established, limited data exist comparing sphincter survival in patients with compromised urethras (prior radiation, artificial urinary sphincter placement or urethroplasty). We evaluated artificial urinary sphincter failure in patients with compromised and noncompromised urethras. Materials and Methods We performed a retrospective analysis of 86 sphincters placed at a single institution between December 1997 and September 2012. We assessed patient demographic, comorbid disease and surgical characteristics. All nonfunctioning, eroded or infected devices were considered failures. Results Of the 86 patients reviewed 67 (78%) had compromised urethras and had higher failure rates than the noncompromised group (34% vs 21%, p=0.02). Compared to the noncompromised group, cases of prior radiation therapy (HR 4.78; 95% CI 1.27, 18.04), urethroplasty (HR 8.61; 95% CI 1.27, 58.51) and previous artificial urinary sphincter placement (HR 8.14; 95% CI 1.71, 38.82) had a significantly increased risk of failure. The risk of artificial urinary sphincter failure increased with more prior procedures. An increased risk of failure was observed after 3.5 cm cuff placement (HR 8.62; 95% CI 2.82, 26.36) but not transcorporal placement (HR 1.21; 95% CI 0.49, 2.99). Conclusions Artificial urinary sphincter placement in patients with compromised urethras from prior artificial urinary sphincter placement, radiation or urethroplasty had a statistically significant higher risk of failure than placement in patients with noncompromised urethras. Urethral mobilization and transection performed during posterior urethroplasty surgeries likely compromise urethral blood supply, predisposing patients to failure. Patients with severely compromised urethras from multiple prior procedures may have improved outcomes with transcorporal cuff placement rather than a 3.5 cm cuff.

The Impact of Urethral Risk Factors on Transcorporeal Artificial Urinary Sphincter Erosion Rates and Device Survival

“…13 While there is no randomized trial demonstrating that TC placement impacts cuff erosion and ultimately device survival rates compared with traditional approaches, multiple series have published rates similar to or lower than previously published studies of high-risk population. 10,11,14, 16 We report the largest single institution series of TC AUS placements to date, with a special emphasis on clinical and pre-operative parameters that may impact cuff erosion and device survival.…”

Male urinary incontinence: Artificial sphincter

“…Although there was no difference between the two groups regarding continence rates (83 vs. 80%, NNT = NS), patients with a history of irradiation who underwent 3.5 cm cuff implantation (N = 100) presented a 17% increase in the risk of erosion through the cuff (NNH = 6; 95CI [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] 31 (D) The prosthesis may be filled with isotonic sterile sodium chloride solution or contrast, at the surgeon's discretion. The solution must be isotonic to minimize the transfer of fluid through the semipermeable silicone membrane.…”

“…19 The following are risk factors for complications: pelvic radiotherapy, urethroplasty or any urethral manipulation and antecedent erosion or infection in individuals previously submitted to artificial sphincter implantation. [20][21][22] oBJective The objective of our evaluation is to establish guidelines regarding the most important issues related to artificial urinary sphincter implantation: the best practices in the choice and preparation of the AMS 800 urinary sphincter components, preoperative care for patients with indication of artificial sphincter, the best approach for implantation of the artificial urinary sphincter (perineal or transescrotal), to compare the transcorporal placement of the cuff with the "standard" placement (directly around the urethra), regarding efficacy and safety, to assess the best conduct in the perioperative and postoperative period of artificial urinary sphincter implantation, to assess the best conduct in the management of therapeutic failure (early or late onset urinary incontinence) and to evaluate the best strategy against suspected erosion or extrusion, infection and urethral atrophy, considering primary studies.…”

“…The perineal incision reduced the risk of infection by 1.0% (RRA = 1.0%, 95CI 0.006-0.014; NNT = 100, 95CI 72-161), as well as the risk of cuff erosion by 2% (RRA = 2%, 95CI 0.014-0.024; NNT = 53, 95CI . There was also a reduction in the risk of explantation of 5.7% (ARR = 5.7%, 95CI 0.048-0.066; NNT = 18, 95CI [15][16][17][18][19][20][21] and risk of revision of 2% (ARR = 2%, 95CI 0.12-0.028; NNT = 50, 95CI 36-83). There was no difference between the groups regarding the risk of atrophy.…”

Vyrų šlapimo nelaikymo gydymas implantuojant dirbtinį sfinkterį AMS 800

“…Ilgalaikis manžetės spaudimas sukelia šlaplės atrofiją, o vėliau eroziją. Erozijos rizikos veiksniai yra radiacijos sukeltas endarteritas, buvusios šlaplės, šla-pimo nelaikymo operacijos, koronarinė širdies liga bei sutrikusi šlaplės kraujotaka [52,53]. Todėl labai svarbu prieš operaciją atlikti uretrocistoskopijos tyrimą.…”