Management of urethral atrophy after implantation of artificial urinary sphincter: what are the weaknesses?

Abstract

The use of artificial urinary sphincter (AUS) for the treatment of stress urinary incontinence has become more prevalent, especially in the "prostate-specific antigen (PSA)-era", when more patients are treated for localized prostate cancer. The first widely accepted device was the AMS 800, but since then, other devices have also entered the market. While efficacy has increased with improvements in technology and technique, and patient satisfaction is high, AUS implantation still has inherent risks and complications of any implant surgery, in addition to the unique challenges of urethral complications that may be associated with the cuff. Furthermore, the unique nature of the AUS, with a control pump, reservoir, balloon cuff, and connecting tubing, means that mechanical complications can also arise from these individual parts. This article aims to present and summarize the current literature on the management of complications of AUS, especially urethral atrophy. We conducted a literature search on PubMed from January 1990 to December 2018 on AUS complications and their management. We review the various potential complications and their management. AUS complications are either mechanical or nonmechanical complications. Mechanical complications usually involve malfunction of the AUS. Nonmechanical complications include infection, urethral atrophy, cuff erosion, and stricture. Challenges exist especially in the management of urethral atrophy, with both tandem implants, transcorporal cuffs, and cuff downsizing all postulated as potential remedies. Although complications from AUS implants are not common, knowledge of the management of these issues are crucial to ensure care for patients with these implants. Further studies are needed to further evaluate these techniques.

Keywords: artificial urinary sphincter; artificial urinary sphincter complications; tandem cuffs; transcorporal cuffs; urethral atrophy.

Figure 1

(a) AMS 800 (Boston Scientific, Marlborough, MA, USA), image reproduced with permission from Boston Scientific. (b) ZSI 375 (ZEPHYR Surgical Implants, Geneva, Switzerland). (c) FlowSecure (Sphinx Medical, Bellshill, North Lanarkshire, United Kingdom). (d) Periurethral Constrictor (Silimed, Rio de Janeiro, Brazil).

Figure 2

(a) Single transcorporal cuff on distal bulbar urethra placed in tandem with existing periurethral cuff on proximal bulbar urethra. (b) Two transcorporal cuffs placed on the proximal and distal bulbar urethra. (Images reproduced with permission from Dr. Daniel Elliott, Mayo Clinic, MN, USA).