The “Fragile” Urethra as a Predictor of Early Artificial Urinary Sphincter Erosion

Mann, Rachel; Kasabwala, Khushabu; Buckley, Jill C.; Smith, Thomas G.; Westney, O. Lenaine; Amend, Gregory; Breyer, Benjamin N.; Erickson, Beth; Alsikafi, Nejd F.; Broghammer, A. Joshua; Elliott, Sean P.

doi:10.1016/j.urology.2022.06.023

Cited by 23 publications

(12 citation statements)

References 18 publications

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“…Mann et al demonstrated that the "fragile" urethra (history of urethroplasty, radiation, prior AUS) were strong predictors for earlier erosion with radiation history providing the highest hazard ratio when compared to the other risk factors (HR =2.36; 95% CI: 1.52-3.64; P<0.01). AUS survival rates for "fragile" urethras were also much shorter at 1-year (76.5% vs. 44.1%) and 5-year (50.0% vs. 14.8%) survival when compared to "non-fragile" urethras (P<0.0001) (32). In patients with first replacement AUS, Huang et al also found that a history of pelvic radiation was associated with a shorter time to device failure and was specifically associated with a seven-fold increase risk of device erosion (33).…”

Section: Discussionmentioning

confidence: 91%

Characterizing the biofilm of artificial urinary sphincters (AUS)

Leong¹,

Ancira²,

Bulafka³

et al. 2023

Transl Androl Urol

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Background: There is a paucity of data regarding the bacterial colonization on artificial urinary sphincter (AUS) devices following revision surgery. We aim to evaluate the microbial compositions of explanted AUS devices identified on standard culture at our institution.Methods: Twenty-three AUS devices explanted were included in this study. During revision surgery, aerobic and anaerobic culture swabs are taken from the implant, capsule, fluid surrounding the device, and biofilm, if present. Culture specimens are sent to the hospital laboratory for routine culture evaluation immediately upon case completion. Differences in number of microorganism species detected across samples (richness) against demographic variables were determined through backwards selection of all variables using analysis of variance (ANOVA). We assessed the prevalence (how many times each species occurred) of microbial culture species. Statistical analyses were performed using the statistical package in R (version 4.2.1).Results: Cultures reported positive results in 20 (87%) cases. Coagulase-negative staphylococci were the most commonly identified bacteria among explanted AUS devices (n=16, 80%). Among two of the four infected/eroded implants, more virulent organisms such as Escherichia coli and fungal species such as Candida albicans were identified. The mean number of species identified amongst culture positive devices was 2.15±0.49. The number of unique bacteria identified per sample was not significantly associated with demographic variables including race, ethnicity, age at revision, smoking history, duration of implantation, etiology for explantation, and concomitant medical comorbidities. Conclusions:The majority of AUS devices removed for non-infectious reasons harbor organisms on traditional culture at the time of explantation. The most commonly identified bacteria in this setting is coagulase-negative staphylococci, which may be a result of bacterial colonization introduced at the time of implant. Conversely, infected implants may harbor microorganisms with higher virulence including fungal elements. Bacterial colonization or biofilm formation on implants may not necessarily equate to clinically infected devices. Future studies with more sophisticated technology, such as next-generation sequencing or extended cultures, may evaluate microbial compositions of biofilm at a more granular level to understand its role in device infections.

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Section: Discussionmentioning

confidence: 91%

Characterizing the biofilm of artificial urinary sphincters (AUS)

Leong¹,

Ancira²,

Bulafka³

et al. 2023

Transl Androl Urol

View full text Add to dashboard Cite

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“…Dorsal erosions were least common with 5.1% for standard and 20% for TC-AUS cuffs (29). Larger multiinstitutional studies combine patients with high risk of erosion, or "fragile urethras": history of pelvic radiotherapy, history of AUS explanation, and history of urethroplasty (24,43,102). Extrapolating from that data, transcorporal cuffs tended to have longer explant-free survival.…”

Section: Cuff Size and Transcorporal Placementmentioning

confidence: 94%

“…Furthermore, a more stringent follow-up regimen should be performed as many patients have had multiple insults to the urethra, which compromise urethral health and predispose the patient to device erosion. Mann et al found most device failures occurred within 2 years of implantation in highrisk patients (24). Though we do not perform routine cystoscopy after AUS implantation in high-risk patients, cystoscopy can be used to inspect the quality of the luminal epithelium, evaluate the urethra to ensure patency of the repair, and exclude gross erosion at about 3-6 months.…”

Section: Follow-up For High-risk Patients After Aus Implantationmentioning

confidence: 94%

“…Median stricture length was 3.5 centimeters in the explant group compared to 1.4 in those not requiring explant (P=0.056). Mann et al also found a history of urethroplasty was an independent risk factor for a shorter interval to erosion, with a hazard ratio of 2.12 (24). McGeady et al found that patients with a history of urethroplasty had a higher rate of failure (device malfunction, infection, or erosion) with a hazard ratio of 8.14 when compared to patients without urethral risk factors (11).…”

Section: Prior Pelvic Fracture Urethral Injurymentioning

confidence: 99%

“…Prior studies have examined risk factors associated with AUS cuff erosion, with the vast majority being single-center retrospective studies with small cohorts (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26). Previously described risk factors include diabetes, smoking status, obesity, coronary artery disease, previous urethroplasty, history of radiation, and previous AUS cuff erosion.…”

Section: Bulbar Urethral Compromise Prior Aus Cuff Erosionmentioning

confidence: 99%

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Management of male stress urinary incontinence in high-risk patients: a narrative review

Lin¹,

Skokan²,

Wessells³

et al. 2023

Transl Androl Urol

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Background and Objectives: The artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence (SUI). However, highly complex patients such as those with bulbar urethral compromise, bladder pathology, and lower urinary complications pose a particular challenge for the surgeon. In this article, we will address critical risk factors and synthesize existent data across relevant disease states to support surgeons in successful management of SUI in high-risk patients.Methods: A comprehensive review of current literature was performed utilizing the search term "artificial urinary sphincter" in conjunction with any of the following additional terms: "radiation", "urethral stricture", "posterior urethral stenosis", "vesicourethral anastomotic stenosis", "bladder neck contracture", "pelvic fracture urethral injury", "penile revascularization", "inflatable penile prosthesis", and "erosion". Guidance is provided based upon expert opinion where existing literature was sparse or nonexistent.Key Content and Findings: Several known patient risk factors are associated with AUS failure and can ultimately lead to device explantation. Each risk factor requires careful consideration and investigation, or intervention as appropriate, prior to device placement. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients. Several surgical strategies to decrease device complications can be considered: optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation.Conclusions: A number of patient risk factors are associated with AUS failure and can ultimately lead to device explantation. We present an algorithm for management of high-risk patients. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients.

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

Matz,

Glover,

Krug

et al. 2024

UroPrecision

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IntroductionUrethral 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.

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The “Fragile” Urethra as a Predictor of Early Artificial Urinary Sphincter Erosion

Cited by 23 publications

References 18 publications

Characterizing the biofilm of artificial urinary sphincters (AUS)

Characterizing the biofilm of artificial urinary sphincters (AUS)

Management of male stress urinary incontinence in high-risk patients: a narrative review

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

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