What happens when the artificial urinary sphincter fails?

The identified risk factors for reintervention are previous urethroplasty, radiotherapy, smoking, and diabetes (2). When a new sphincter is inserted, the perioperative complication rates seem similar to their primary insertion (3). However, repeat AUS carries a higher risk of infection or urethral erosion (4). Social continence rates (defined as less than a pad per day) decrease from 90% to 82% after one and 71% after two revision (5).

Unsurprisingly, patient enthusiasm for revision is waning. In our cohort, only a quarter attempted salvage re-implantation, with the majority opting for conservative treatment or urinary diversion. Of those who proceeded with re-implantation, half ultimately required re-explantation (6).

The erosion/infection risk factors reported in studies relate to tissue quality, for example radiotherapy and cardiovascular factors. Testosterone levels are rarely reported, however their importance in maintaining urethral tissue quality has been documented for urethral strictures (7). A recent small retrospective study showed that men with low testosterone were three times more likely to suffer AUS erosion than men with normal testosterone (8). We note that radiotherapy is not only a generally accepted risk factor for AUS complications, but it is also more commonly associated with androgen deprivation therapy compared to prostatectomy.

While continuing to focus on urethral tissue vascularity and health, deactivation of the device at night has been proposed to limit ischaemia (9). It would be interesting to see if patients doing this regularly increases the risk of mechanical failure. 

We suggest addressing cardiovascular risk factors, offering testosterone replacement, and considering nocturnal sphincter deactivation as potential preventive strategies for selected higher risk patients with a previous AUS.

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