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To demonstrate the prevalence and risk factors for overactive bladder symptoms associated with artificial urinary sphincter implantation, we investigated the patients who underwent primary artificial urinary sphincter implantation with severe urinary stress incontinence. Forty-eight patients who completely answered the questionnaires of the overactive bladder symptom score before surgery were included. Patient characteristics, urinary status at pre and 1, 3, 6, and 12 months post-device activation, and predictive factors for overactive bladder symptoms were examined. Sixty percent of the patients had preoperative overactive bladder symptoms. Until 12 months after device activation, 35-40% of all patients had overactive bladder symptoms. The rate of persistent and de novo postoperative overactive bladder symptoms was 44.8% and 26.3%, respectively. Daily pad use was not different between patients w/wo overactive bladder symptoms. The only risk factor for postoperative overactive bladder symptoms was a max cystometoric capacity < 200 mL measured by a preoperative urodynamic study. Attention must be given to both persistent and de novo overactive bladder symptoms associated with artificial urinary sphincter implantation for patients with stress incontinence. Counsel should equally be provided for preoperative overactive bladder symptoms, especially in cases with a cystometric capacity < 200 mL., (© 2024. The Author(s).)

Purpose: Cognitive ability and manual dexterity sufficient to operate an artificial urinary sphincter (AUS) are critical for device function and safety. We aimed to define the incidence of cognitive and/or dexterity disorders among men after AUS. We secondarily aimed to assess for association between these disorders and postimplant complications., Materials and Methods: This is a retrospective cohort study using the SEER (Surveillance, Epidemiology, and End Results)-Medicare linked database (2000-2018). We included men ≥ 66 years diagnosed with prostate cancer between 2001 to 2015 who subsequently underwent AUS placement. We excluded patients with < 1-year continuous fee-for-service Medicare enrollment or cognitive and/or manual dexterity disorder diagnoses prior to AUS implant. Subsequent cognitive/dexterity disorders and implant-related complications were queried using appropriate ICD (International Classification of Diseases)-9/10 and/or CPT (Current Procedural Terminology) codes. Associations between cognitive/dexterity disorders and postimplant complications were assessed using extended Cox proportional hazards modeling. Secondary analysis focused on serious complications (device revision/removal, Fournier's gangrene, urethral erosion)., Results: We identified 1560 men who underwent AUS who met inclusion criteria. Median age was 73.0 (IQR 70-77) years. Cumulative incidence function analysis estimated 44% and 17% incidence of cognitive and manual dexterity disorder, respectively, at 15 years post-AUS. Presence of cognitive with/without manual dexterity disorder was associated with increased hazard of any, but not serious, complication during follow-up., Conclusions: A significant proportion of patients develop cognitive and/or manual dexterity disorders following AUS. These data support the need for close longitudinal monitoring after implant.

Introduction: Postoperative opioid prescriptions are associated with an increased risk of opioid dependance. While studies on no-opioid discharge strategies have been assessed following many urologic procedures, the effect of no-opioid discharges on health care utilization following artificial urinary sphincter placement is unknown. We performed a single-surgeon retrospective comparison of health care system interactions following artificial urinary sphincter implantation between patients who received an opioid prescription on discharge to those who did not., Methods: We identified 101 male patients who underwent 3-piece artificial urinary sphincter placement or revision by 1 provider between 2015 and 2022. All patients were discharged with acetaminophen and ibuprofen; none received intraoperative local anesthetic. Demographic information, preprocedural opioid use, opioid prescriptions following the procedure, postoperative office communications, unplanned office visits, and emergency department (ED) visits were recorded for each patient for 90 days., Results: Forty-five patients (45%) were discharged without an opioid prescription and 56 patients (55%) were discharged with an opioid prescription. No differences in age, race, BMI, operative time, or presence of a preoperative opioid prescription were observed. Discharge without an opioid did not significantly increase the number of office communications (55% vs 40%, P = .11), unplanned office visits (36% vs 23%, P = .19), or ED visits (20 vs 12, P = .41) within 90 days of implantation/revision., Conclusions: Opioids can be omitted from the discharge analgesic regimen following artificial urinary sphincter placement without increasing burden to surgical office staff or local EDs. Providers should consider no-opioid discharges for patients undergoing uncomplicated sphincter placement to limit risk of opioid-related morbidity.

Introduction and Objectives: Artificial urinary sphincter (AUS) is a treatment option for women with stress urinary incontinence (SUI) after failure of previous surgery or as a primary procedure in severe intrinsic sphincter deficiency (ISD). The aim of the study was to assess the long-term efficacy and risk factors for surgical revision and definitive explantation of AUS laparoscopic implantation in female patients., Methods: A retrospective review of all women submitted to AUS implantation between April 2005 and March 2023 was conducted. The AUS was implanted via transperitoneal laparoscopic approach, by two experienced surgeons. The primary endpoint was postoperative continence. Continence was defined as no leakage and no pad usage or leakage and/or pad usage with no impact on social life and failure as leakage and/or pad usage impacting social life. As secondary outcomes, clinical predictive factors for AUS revision and definitive explantation were evaluated., Results: In the last 18 years, females with a mean age of 68±12 years-old were submitted to laparoscopic implantation of AUS. Early overall complication rate was 16%, but only one case was Clavien-Dindo ≥3. After a median follow-up of 67 months, 22.2% of the patients needed a device revision, the majority due to mechanical device dysfunction. AUS definitive explantation was performed in 16%, mainly due to urethral/vaginal erosion (9.9%) and infection (6.2%). Patients with age ≥70 years and follow-up ≥10 years significantly predisposed for device revision. At the time of the last follow-up, 72% of the patients were keeping the urinary continency., Conclusions: Laparoscopic AUS implantation in females is an effective treatment for SUI due to ISD. Meanwhile, adequate patient selection, multidisciplinary evaluation and careful expectation management are essential to achieving good results, concerning their significant complication rate.

Purpose: Neurogenic stress urinary incontinence (N-SUI) is a condition with serious impact on the quality of life. There are several treatment modalities of which the artificial urinary sphincter (AUS) stands out as the most suitable technique for addressing sphincter insufficiency. In this article, the purpose is to describe practical considerations, outcomes, and complications of the artificial urinary sphincter in neurological sphincter deficiency in both males and females., Methods: A narrative review of the current literature., Results: The outcomes of AUS are reasonably good in patients with NLUTD, the surgical technique is discussed as well as the limitations and special considerations in this complex and heterogeneous patient population., Conclusion: The available evidence suggests that its efficacy and functional durability may be lower in patients with neurogenic lower urinary tract dysfunction (NLUTD) compared to those without neurological deficits. However, studies have shown that AUS can still provide effective and safe continence outcomes in both male and female patients, with long-term device survival rates ranging from several years to over a decade., (© 2024. The Author(s).)

Background: Periprostatic artificial urinary sphincter implantation (pAUSi) is a rare yet relevant indication for male neurogenic stress urinary incontinence (SUI)., Objective: To describe the surgical technique of robot-assisted pAUSi (RApAUSi) and compare the long-term functional results with the open pAUSi (OpAUSi)., Design, Setting, and Participants: Data of 65 consecutive men with neurogenic SUI undergoing pAUSi between 2000 and 2022 in a tertiary centre were collected retrospectively., Surgical Procedure: Thirty-three patients underwent OpAUSi and 32 underwent RApAUSi. OpAUSi cases were performed by a single surgeon, experienced in functional urology and prosthetic surgery. RApAUSi cases were performed by the same surgeon together with a second surgeon, experienced in robotic surgery., Measurements: Outcome measures were achievement of complete urinary continence, intra- and postoperative complications, and surgical revision-free survival (SRFS)., Results and Limitations: RApAUSi showed superior results to OpAUSi in terms of median (interquartile range) operative time (RApAUSi: 170 [150-210] min vs OpAUSi: 245 [228-300] min; p < 0.001), estimated blood loss (RApAUSi: 20 [0-50] ml vs OpAUSi: 500 [350-700] ml; p < 0.001), and median length of hospital stay (LOS; RApAUSi: 5 [4-6] d vs OpAUSi: 11 [10-14] d; p < 0.001). Clavien-Dindo grade ≥3a complications occurred more frequently after OpAUSi (RApAUSi: 1/32 [3%] vs OpAUSi: 10/33 [30%]; p = 0.014). Achievement of complete urinary continence (zero pads) was comparable between the groups (RApAUSi: 24/32 [75%] vs OpAUSi: 24/33 [73%]; p = 0.500). The median follow-up periods were 118 (50-183) and 56 (25-84) mo for OpAUSi and RApAUSi, respectively (p < 0.001). A tendency towards longer SRFS was observed in the RApAUSi group (p = 0.076). The main study limitation was its retrospective nature., Conclusions: RApAUSi is an efficient alternative to OpAUSi, resulting in shorter operative times, less blood loss, fewer severe complications, and a shorter LOS with similar functional results and need for revision surgery., Patient Summary: Compared with open periprostatic artificial urinary sphincter implantation (pAUSi), robot-assisted pAUSi leads to faster recovery and similar functional results, with fewer postoperative complications., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To determine the role of androgens in penile and urethral health, we sought to understand what impact hypogonadism may have on artificial urinary sphincter (AUS) and inflatable penile prosthesis (IPP) outcomes. We hypothesize that patients with hypogonadism are at increased risk of reinterventions, complications, and infections., Methods: We queried the TriNetX Global Database in March 2023 for patients receiving an AUS or IPP, looking at lifetime reintervention, complication, and infection rates. We conducted multiple comparisons: (1) eugonadal patients against hypogonadal patients, (2) hypogonadal patients on testosterone replacement therapy (TRT) against hypogonadal patients not on TRT, and (3) hypogonadal patients on TRT against eugonadal patients., Results: Hypogonadal patients undergoing AUS had more complications (33.5% vs 28.3%), higher reintervention rates (27.7% vs 24.3%) and higher infection rates (7.3% vs 6.8%), albeit none reaching significance. Hypogonadal patients undergoing IPP had significantly higher infection rates (6.3% vs 4.4%, RR 1.5 (1.04, 2.04)) and reintervention rates (14.9% vs 11.9%, RR 1.3 (1.04, 1.61)), but not complication rates (21.9% vs 18.9%). When comparing patients with hypogonadism on TRT vs off TRT, there was not a significant difference in reinterventions, or complications, in AUS and IPP patients, but there were significantly more infections in IPP patients (7.0% vs 3.9%, RR 1.9 (1.002, 3.5))., Conclusion: Hypogonadal patients have more reinterventions, complications, and infections following urologic implant surgery, to varying levels of significance. TRT may not be completely protective to improve tissue health but with many limitations that should be explored in further research., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To describe the role and long-term outcomes of using the 51-60cm H 2 O pressure regulating balloon (PRB) in male patients with an artificial urinary sphincter (AUS)., Methods: From 2005-2021, 90 patients with a variety of urethral risk factors underwent AUS placement with use of the low-pressure 51-60 cm H 2 O PRB to treat stress incontinence. Patient demographics, indication for use of the 51-60 cm H 2 O PRB, perioperative data, and postoperative outcomes were examined and Pearson's chi squared test and Wilcoxon rank sum test were used to identify associations with future revisions, erosion, and mechanical failure., Results: Ninety patients were included in the study. After median follow-up of 46.6months (range: 6-146months), 4 (4.44%) patients developed an erosion-related complication that required device removal, 4 developed an infection, and 3 underwent surgery for pump relocation. One patient had a reported mechanical failure of unknown source. Thirty patients underwent revision surgery to reduce incontinence. Of the 4 patients with erosion, 1 was due to iatrogenic catheterization. The remaining 3 had numerous urethral risk factors. Univariate analysis was performed to identify predictors of cuff erosion, infection, and revision in patients with a 51-60 cm H 2 O PRB. No significant associations were found including prior pelvic radiation, age at AUS placement, presence of inflatable penile prosthesis (IPP), prior AUS erosion, or previous urethroplasty., Conclusion: The low-pressure 51-60 cm H 2 O PRB can be used in high-risk male patients with urinary incontinence with low rates of complications including erosion, infection, and mechanical failure. While patients may choose to undergo future revisional surgery to improve continence, the 51-60 cm H 2 O PRB should be considered as the initial PRB in patients with urethral risk factors., Competing Interests: Declaration of Competing Interest Jeffrey C. Loh-Doyle Paid Consultant to Boston Scientific. David Ginsberg Paid Consultant to Caldera Medical, Laborie, Medtronic. Stuart Boyd Paid Consultant to Boston Scientific. Emily Markarian no conflict., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To describe immediate and long-term outcomes of pressure regulating balloon (PRB) placement, exchange, and extraction from the lateral retroperitoneum (LR) in male patients receiving an artificial urinary sphincter (AUS)., Methods: A retrospective chart review was performed on all patients that underwent primary AUS placement between 2006 and 2021. All patients had the PRB placed in the LR during the study period. Intraoperative complications during PRB placement, exchange, or removal, and indications for PRB revision, such as infection, erosion, or mechanical failures were analyzed., Results: Five hundred forty-one patients were included in the study. All patients underwent primary implantation with no intraoperative complications including no incidents of bowel or vascular injury during PRB placement. In addition, there were no instances of intraoperative injury during PRB removal (with or without PRB replacement). After mean follow-up of 54.8months (range: 1-181months), 9 patients (1.7%) developed a reservoir-specific complication with infection (5 patients, 0.9%) being the most common issue found. The second most common type or reservoir issue was a palpable or herniated reservoir. There were 2 patients (0.4%) who herniated their reservoirs and one patient with a nonbothersome, but palpable reservoir. Lastly, there were 2 incidents (0.4%) of mechanical failure caused by a leak in the PRB., Conclusion: Due to the ease and safety of placing and removing PRBs from this location and exceedingly low rates of PRB-related complications in long-term follow-up, the LR should be considered as an ideal location for PRB placement in male patients receiving an AUS., Competing Interests: Declaration of Competing Interest Jeffrey Loh-Doyle Paid Consultant to Boston Scientific. Emily Markarian no conflict. Stuart Boyd Paid Consultant to Boston Scientific., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Although the longest efficacy record, some patients report about urinary leakage during higher intra-abdominal pressure after Artificial Urinary Sphincter (AUS) implantation. To improve the continent results, we placed in addition to the occluding cuff and the pressure regulating balloon, in a second procedure a stress-relief reservoir in lower abdomen, for additional passive pressure transmission to the occluding cuff., Methods: In this retrospective monocentric data analysis between 2011 and 2018, 80 patients with persistence incontinence after AUS implantation were included. Stress-relief reservoir was indicated in 12 patients with involuntary leakage of urine, that occurred when intra-abdominal pressure raised., Results: In all 12 cases, the stress reservoir was easily implanted and there were no intraoperative complications. In a mean follow-up time of 53 months, the pad per day usage (p/d) improved from 3 (± 1.2) to 1.7 (± 1.5) (p = 0.001). Two patients with multiple previous abdominal surgeries used an equal number of pads after SRR; however, an improvement during physical exertion was reported. Continence situation was evaluated with a questionnaire and was rated as "excellent", "good", or "satisfactory" by 11 (92%) patients., Conclusion: The persistence of urinary incontinence after AUS is a challenging topic. Implantation of a stress reservoir in carefully selected patients with urinary leakage during higher intra-abdominal pressure is minimally invasive and offers new options to improve the proven long-term record of AUS. Certainly, more investigations are needed to determine the clinical relevance of this approach., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Treatments for benign and malignant pathologies of the prostate can compromise urine control. Urinary incontinence (UI) affects the quality of life of patients and limits their ability to carry out usual activities. The degree of impact of UI is variable and the associated discomforts make patients seek treatment for it. At the center of the management of urinary incontinence in men are surgical interventions that seek to replace the affected sphincter function through implants. The artificial urinary sphincter since its development in the 1970s has been considered the standard of treatment for UI in men. More recently artificial sphincter and slings have been shown to be effective in a selected group of incontinent men. The goals of surgical treatment of incontinence include the preservation of bladder function, the ability to improve the strength of the urinary sphincter, and to reduce or eliminate urine leakage, and thereby improve the quality of life. The aim of the article is to present various implants for the correction of male urinary incontinence., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: Persistence or recurrence of stress urinary incontinence (prSUI) after artificial urinary sphincter (AUS) implantation may be secondary to non-mechanical failure (NOMECA). It have for long been assumed to result from urethral atrophy. Its existence is now debated. As the pathophysiology of NOMECA is not elucidated, the most appropriate management remains unclear. We aimed to compare the several revision techniques for NOMECA of AUS in men., Methods: NOMECA was defined as prSUI, with normally functioning device, no erosion, infection or fluid loss. Exclusion criteria were neurogenic SUI, revision or explantation for other causes. From 1991 to 2022, 143 AUS revisions for NOMECA, including 99 cuff DOWNSIZING, 10 cuff repositioning (RELOC), 13 TANDEM-CUFF placement, 18 cuff changing (CHANGE), three increasing balloon pressure (BALLOON-UP), were performed in 10 centers. BALLOON-UP patients weren't included in comparative analysis due to small sample size. All components could be changed during the revision. Patients were also categorized in COMPLETE-CHANGE vs. PARTIAL-CHANGE of the device., Results: The three-months complete continence rate was 70.8% with a significant difference between RELOC and DOWNSIZING groups (p = 0.04). COMPLETE CHANGE was significantly associated with complete continence status at three months in multivariate analysis (83.3% vs. 63.3%, OR = 2.7; CI 95% [1.1-7.1], p = 0.03). Estimated five-year reoperation-free and explantation-free survival were respectively 63.4% and 75.9% (p = 0.16; p = 0.30). Those were significantly longer in COMPLETE-CHANGE vs PARTIAL-CHANGE (82.2% vs. 69.6%, p = 0.03); (71.2% vs. 58.2%, p = 0.047)., Conclusions: AUS revision for prSUI due to NOMECA yields satisfactory outcomes regardless of the technique used. We observed better functional outcomes when repositioning the new cuff. COMPLETE-CHANGE may improve functional outcomes, explantation-free and reoperation-free survivals., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose of Review: Stress urinary incontinence after prostatectomy is a common and debilitating side effect. Immediate post-prostatectomy management emphasizes pelvic floor muscle exercises. Per American Urologic Association guidelines, if incontinence persists for more than 12 months postoperatively, surgical interventions are the mainstay of treatment. Treatment decisions depend on a multitude of factors. The goal of this paper is to review recent literature updates regarding the diagnosis of male SUI to better guide surgical treatment decision-making., Recent Findings: Patient history is a critical component in guiding surgical decision making with severity and bother being primary factors driving treatment decisions. Recent studies indicate that a history of pelvic radiation continues to impact the overall duration and complication rate associated with artificial urinary sphincters (AUS). Cystoscopy should be done on every patient preparing to undergo surgical SUI treatment. Urodynamics and standing cough stress tests are additional diagnostic testing options; these tests may augment the diagnosis of SUI and better delineate which patients may benefit from a male sling versus AUS. Treatment of SUI after prostatectomy can improve health-related quality of life. A patient history focused on severity and degree of bother in addition to the use of ancillary office testing can help guide surgical treatment decisions to optimize patient continence goals., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction and Objective: Perioperative antimicrobial prophylaxis is crucial for prevention of prosthesis and patient morbidity after artificial urinary sphincter (AUS) placement. While antibiotic guidelines exist for many urologic procedures, adoption patterns for AUS surgery are unclear. We aimed to assess trends in antibiotic prophylaxis for AUS and outcomes relative to American Urological Association (AUA) Best Practice guidelines., Methods: The Premier Healthcare Database was queried from 2000 to 2020. Encounters involving AUS insertion, revision/removal, and associated complications were identified via ICD and CPT codes. Premier charge codes were used to identify antibiotics used during the insertion encounter. AUS-related complication events were found using patient hospital identifiers. Univariable analysis between hospital/patient characteristics and use of guideline-adherent antibiotics was done via chi-squared and Kruskal-Wallis tests. A multivariable logistic mixed effects model was used to assess factors related to the odds of complication, specifically the use of guideline-adherent versus nonadherent regimens., Results: Of 9775 patients with primary AUS surgery, 4310 (44.1%) received guideline-adherent antibiotics. The odds of guideline-adherent regimen use increased 7.7% per year with 53.0% (830/1565) receiving guideline-adherent antibiotics by the end of the study period. Patients with guideline-adherent regimens had a decreased risk of any complication (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.74-0.93) and surgical revision (OR: 0.85, 95% CI: 0.74-0.96) within 3 months; however, no significant difference in infection within was noted (OR: 0.89, 95% CI: 0.68-1.17) within 3 months., Conclusions: Adherence to AUA antimicrobial guidelines for AUS surgery appears to have increased over the last two decades. While guideline-adherent regimens were associated with decreased risk of any complication and surgical intervention, no significant association was found with risk of infection. Surgeons appear to be increasingly following AUA recommendations for antimicrobial prophylaxis for AUS surgery, however, further level 1 evidence should be obtained to demonstrate conclusive benefit of these regimens., (© 2023 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Purpose: There is insufficient evidence for postoperative outcomes of artificial urinary sphincter (AUS) implantation for postprostatectomy incontinence (PPI) with detrusor underactivity (DU). Thus, we assessed the impact of preoperative DU on the outcomes of AUS implantation for PPI., Materials and Methods: Medical records of men who underwent AUS implantation for PPI were reviewed. Patients who had bladder outlet obstruction surgery before radical prostatectomy or AUS-related complications that required revision of AUS within three months were excluded. Patients were divided into two groups based on the preoperative urodynamic study including pressure flow study, a DU group, and a non-DU group. DU was defined as a bladder contractility index less than 100. The primary outcome was postoperative postvoid residual urine volume (PVR). The secondary outcomes included maximum flow rate (Qmax), postoperative satisfaction, and international prostate symptom score (IPSS)., Results: A total of 78 patients with PPI were assessed. The DU group consisted of 55 patients (70.5%) and the non-DU group comprised 23 patients (29.5%). Qmax was lower in the DU group than in the non-DU group and PVR was higher in the DU group as per a urodynamic study before AUS implantation. There was no significant difference in postoperative PVR between the two groups, although the Qmax after AUS implantation was significantly lower in the DU group. While the DU group showed significant improvements in Qmax, PVR, IPSS total score, IPSS storage subscore, and IPSS quality of life (QoL) score after AUS implantation, the non-DU group showed postoperative improvement in IPSS QoL score., Conclusion: There was no clinically significant impact of preoperative DU on the outcome of AUS implantation for PPI; thus, surgery can be safely performed in patients with PPI and DU.

Introduction: Our goal was to determine the rate of complications, early revision and removal after full ambulatory implantation of bulbar AUS in men; secondly, to describe satisfaction and short-term continence rate., Material and Methods: Between April 2018 and April 2019, 28 consecutive patients underwent AUS implantation in a newly organised ambulatory setting. A prospective database of all included patients was established with comprehensive data collected on medical history, aetiology and severity of SUI, surgical procedures, postoperative complications and patient satisfaction., Results: Twenty-eight patients were included (30 consecutive procedures: 22 primary AUS placement, 6 complete revisions, 2 partial revisions), with a mean follow up of 223±220.5 days. Fourteen patients had prior radiotherapy. Readmission rate was 6.7% in the first 30 days after surgery. Both revision and removal rates were 6.7%. Complications were reported in 26.7% of procedures, mainly Clavien-Dindo I. Patient satisfaction of ambulatory surgery organisation and experience was high (87/5% satisfied or very satisfied). Full continence & social continence were achieved for, respectively, 55.6% and 88.9% of procedures., Conclusion: Ambulatory placement of AUS is safe and can be performed successfully. Larger patient cohorts and randomised trials are crucial to improve knowledge on non-indications for full ambulatory AUS implantation in men., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Purpose: Reported rates of urethral stricture development after artificial urinary sphincter erosion are highly variable. We hypothesized that the risk of stricture is commensurate with the degree of erosion., Materials and Methods: We reviewed our prospectively maintained quality improvement database for all patients with artificial urinary sphincter erosion from 2011 to 2022. The incidence of postoperative stricture development was compared to the severity of erosion using a graded scale: 1, <25% circumference; 2, 25%-50% circumference; 3, >50% and <100% circumference; and 4, 100% circumference. From 862 artificial urinary sphincter surgeries, 102 erosion cases were identified, and 63 with documented erosion severity were included for analysis. Additional analysis was performed on 28 cases without documented erosion severity for validation., Results: Within the main cohort, urethral stricture developed in 22 (34.9%) patients. The incidence of stricture did not vary by grade of erosion ( P = .73) and was not significantly higher in men with grade 4 erosion vs lower-grade erosions (32.7% vs 50.0%, P = .34). Radiation exposure was associated with a 41.1% higher incidence of stricture ( P < .01) and nearly every stricture occurred in the setting of prior radiation (21 of 22; 95.5%). In the validation group, 10 (35.7%) developed stricture, mostly in the setting of radiation (8 of 10; 80%). Overall, 29 of 32 (90.6%) cases of stricture involved a history of radiation., Conclusions: Artificial urinary sphincter erosion does not lead to urethral stricture formation in most cases and is not associated with degree of erosion. Those who develop strictures nearly always have a history of pelvic radiation.

Purpose: To identify trends, costs, and predictors in the use of different surgical procedures for post-radical prostatectomy incontinence (PPI)., Materials and Methods: We identified 21,589 men who were diagnosed with localized prostate cancer (PCa) and treated with radical prostatectomy (RP) from 2003 to 2017. The primary outcome was the incontinence procedure performances. Optum's de-identified Clinformatics ® Data Mart Database was queried to define the cohort of interest. The average costs of the different incontinence procedures were obtained and compared. Also, demographic, and clinical predictors of incontinence surgery were evaluated by multivariable regression analysis., Results: Of the 21,589 men with localized PCa treated with RP, 740 (3.43%) underwent at least one incontinence procedure during a median of 5 years of follow-up. In total, there were 844 unique incontinence procedures. Male slings were the most common procedure (47.5%), had an intermediate cost compared to the other treatment options, and was the first-choice treatment for the majority of patients (50%). The use of an artificial urinary sphincter (AUS) was the second most common (35.3%), but also was the most expensive treatment and was first-choice-treatment for 32.3% of patients. On multivariable analysis, metabolic syndrome related disorders, adjuvant/salvage radiation therapy as well as a history of neurological comorbidities were independently associated with an increased likelihood of incontinence surgery., Conclusions: The receipt of male slings increased and then subsequently decreased, while AUS utilization was stable, and the use of urethral bulking agents was uncommon. From a cost standpoint, AUS was the most expensive option. Finally, patient's comorbidity history and RP related factors were found to influence the choice for primary or subsequent PPI interventions., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: Simultaneous performance of artificial urinary sphincter (AUS) placement and bladder augmentation (BA) in patients with neuropathic bladder is currently controversial., Objective: The aim of this study is to describe our very long-term results after a median follow-up of 17 years., Study Design: A retrospective single-center case-control study was performed in patients with neuropathic bladder treated in our institution between 1994 and 2020, in whom AUS placement and BA were performed simultaneously (SIM group) or sequentially at different times (SEQ group). Demographic variables, hospital length of stay (LOS), long-term outcomes and postoperative complications were compared between both groups., Results: A total of 39 patients (21 males, 18 females) were included, with a median age of 14.3 years. BA and AUS were performed simultaneously at the same intervention in 27 patients, and sequentially in different interventions in 12 cases, with a median of 18 months between both surgeries. No demographics differences were observed. SIM group had a shorter median LOS when compared to SEQ group, considering the two sequential procedures (10 vs. 15 days; p = 0.032). Median follow-up was 17.2 years (interquartile range 10.3-23.9). Four postoperative complications were reported, 3 patients in SIM group and 1 case in SEQ group, with no statistically significant differences between them (p = 0.758). Adequate urinary continence was achieved in more than 90% of patients in both groups., Discussion: There are scarce recent studies comparing the combined performance of simultaneous or sequential AUS and BA in children with neuropathic bladder. The results of our study show a much lower postoperative infection rate than previously reported in the literature. It is a single-center analysis with a relatively small sample of patients although it is among the largest series published so far, and presents the longest long-term follow-up with more than 17 years of median follow-up time., Conclusion: Simultaneous BA and AUS placement appears safe and efficacious in children with neuropathic bladder, with shorter LOS and no differences in postoperative complications or long-term outcomes when compared to performing the two procedures sequentially at different times., Competing Interests: Conflicts of interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Patients with artificial urinary eventually need surgical revision. Unfortunately, in women, this requires another invasive abdominal intervention. Robotic-assisted revision may provide a less invasive and more acceptable approach for sphincter revision in women. We wanted to determinate the continence status after robotic-assisted artificial urinary sphincter revision among women with stress incontinence. We also examined postoperative complications and the safety of the procedure., Methods: The chart of the 31 women with stress urinary incontinence who underwent robotic-assisted AUS revision at our referral center from January 2015 to January 2022 were reviewed retrospectively. All patients underwent a robotic-assisted artificial urinary sphincter revision by one of our two expert surgeons. The primary outcome was to determinate the continence rate after revision and the secondary outcome aimed to evaluate the safety and feasibility of the procedure., Results: Mean patients age was 65 years old, and the mean time between the sphincter revision and previous implantation was 98 months. After a mean follow-up of 35 months, 75% of the patients were fully continent (0-pad). Moreover, 71% of the women were back to the same continence status as with the previously functional sphincter, while 14% even have an improved continence status. Clavien-Dindo grade [Formula: see text] 3 and overall complications occurred in 9% and 20.5% of our patients, respectively. This study is mainly limited by its retrospective design., Conclusion: Robotic-assisted AUS revision carries satisfying outcome in terms of continence and safety., (© 2023. Crown.)

Background: Urinary incontinence (UI) is a common worldwide rising health issue among women with a prevalence of 5 to 70%. Stress urinary incontinence (SUI) is the most common subtype of UI. There are different treatments for UI, including AUS (artificial urinary sphincter) implantation, as one of the surgical options for treating SUI. The aim of this study was to determine the complication rate of AUS, exclusively in female patients with SUI, which resulted from ISD (intrinsic sphincter deficiency). We also compared the complication rate between minimally invasive (laparoscopic or robotic surgery) and open approaches., Methods: Scopus, PubMed, Web of Science, Embase, and Google Scholar were searched for studies regarding complications in AUS implantation surgery, from the beginning of the project to March 2022. After screening and reviewing of full text, the general characteristics of the study and study population including follow-up time, type of surgery, and the number of complications that occurred such as necrosis, atrophy, erosion, infection, mechanical failure, revision, and leak, were extracted., Results: We found that atrophy occurred in 1 of 188 (0.53%) patients treated with minimally invasive surgery and in 1 of 669 (0.15%) patients treated with open surgery. None of the 17 included studies reported the occurrence of necrosis in the patients under study. Erosion occurred in 9 of 188 (4.78%) patients treated with minimally invasive surgery and in 41 of 669 (6.12%) patients treated with open surgery. Infection occurred in 12 of 188 (6.38%) patients treated with minimally invasive surgery and in 22 of 669 (3.2%) patients treated with open surgery. The mechanical failure occurred in 1 of 188 (0.53%) patients treated with minimally invasive surgery and in 55 of 669 (8.22%) patients treated with open surgery. Reconstructive surgery occurred in 7 of 188 (3.72%) patients treated with minimally invasive surgery and in 95 of 669 (14.2%) patients treated with open surgery. Leaks occurred in 4 of 188 (2.12%) patients treated with minimally invasive surgery and in 6 of 669 (0.89%) patients treated with open surgery. The type of surgery was associated with a statistically significant increase in mechanical failure (p-value = 0.067) and infection (p-value = 0.021), and reconstructive surgery (p-value = 0.049). Out of the 857 participats in the study,469 were studied for less than five years and 388 were studied for more than five years.21 of 469 (4.4%) (p-value = 0.08) patients and 81 of 388 (20.8%) (p-value = 0.001) patients required reconstructive surgery. Erosion occurred in 23 of 469 (4.9%) (p-value = 0.01)patients with following time less than five years and in 27 of 388 (6.9%) (p-value = 0.001) patients with following time more than five years., Conclusion: The use of artificial urinary sphincters in the treatment of UI causes complications such as atrophy, erosion, and infection; the amount of which is influenced by the surgical method and the duration of using the artificial urinary sphincter. It seems that the use of new surgical methods, such as laparoscopic surgery, is useful in reducing the incidence of complications., (© 2023. The Author(s).)

Purpose: For male cancer survivors, the combination of stress urinary incontinence and recurrent bladder neck contracture presents a management dilemma with poor consensus. Our objective was to assess the impact of artificial urinary sphincter placement on bladder neck contracture recurrence among prostate cancer survivors with stress urinary incontinence and bladder neck contracture., Materials and Methods: Men electing artificial urinary sphincter placement at our institution undergo synchronous bladder neck contracture treatment if indicated. An institutional database was queried for men with stress urinary incontinence and ≥1 intervention for bladder neck contracture. Records were divided according to whether an artificial urinary sphincter was ever placed. The impact of artificial urinary sphincter placement on bladder neck contracture recurrence was assessed using a multivariable conditional survival analysis, with survival defined as the recurrence-free interval following bladder neck contracture intervention. The proportional hazards assumption was assessed on the basis of Schoenfeld residuals., Results: The analytic cohort consisted of 118 in the artificial urinary sphincter group and 88 in the non-artificial urinary sphincter group. Patients in both groups underwent a median of 2 (range 1-8) bladder neck contracture interventions over the entire course of their care, encompassing 445 total bladder neck contracture interventions. The artificial urinary sphincter group was on average 2.6 years younger ( P = .02) and had a higher pack-year smoking history ( P < .01). The presence of an artificial urinary sphincter was associated with a 61% lower bladder neck contracture re-intervention rate (HR 0.39, P < .01, CI 0.30-0.50) at any time when accounting for number of prior bladder neck contracture interventions and bladder neck contracture risk factors., Conclusions: Artificial urinary sphincter placement is associated with a lower rate of bladder neck contracture re-intervention. Artificial urinary sphincter placement should not be delayed or avoided due to the presence of bladder neck contracture.

Objective: To understand whether patients taking sodium-glucose co-transporter 2 inhibitors (SGLT2i) would be at a similar risk of genitourinary device infection or failure as patients not taking these medications., Methods: We queried the TriNetX database for all adult male patients undergoing artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) and compared patients taking SGLT2i against those not. Cohorts and outcomes were defined using current procedural terminology and International Classification of Diseases (ICD-10) codes. We used Age, body mass index, diabetes, smoking history and history of prostatectomy to generate propensity score matching. Our primary outcome was need for reintervention after implantation based on current procedural terminology codes. Secondary outcomes included infection rate and overall complication rate based on ICD-10 codes. Analytics were performed via TriNetX which calculated risk ratios., Results: Analyses were run on November 28, 2022. After propensity score matching, there were 319 and 83 patients in each IPP and AUS cohort and comorbidity profiles were similar. Patients with an IPP on an SGLT2i were at a lower risk of overall complication (10.6% vs 16.1%, RR 0.66, P = .049). There was similar rates for AUS and risk of complication and for either implant on risk of infection or reintervention., Conclusion: Patients taking SGLT2is may be safely offered urologic implants. Patients taking an SGLT2 had a lower risk of complication for IPP, and there were similar rates of infection and reintervention for both IPP and AUS., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The artificial urinary sphincter (AUS) is the "gold standard" surgical treatment for severe stress urinary incontinence.  However, a subset of patients with frail urethras may require technical adjuncts to ensure optimal cuff function.  Our objective is to provide a detailed tutorial of our institution's method for performing urethral bulking with native tissue in patients with frail urethras during AUS surgery. We have found that urethral bulking with native tissue provides a cost-efficient and durable technique for improved AUS cuff coaptation.  Our experience demonstrates adequate short and intermediate term efficacy with limited complications.  These techniques equip surgeons with an alternative surgical approach for appropriate patients receiving AUS surgery who have been previously exposed to pelvic radiation and/or significant surgical morbidity resulting in frail urethral tissue.

Introduction and Hypothesis: To assess the effectiveness, safety and risk factors of failure and complications associated with Adjustable Continence Therapy (ACT®) balloons as a treatment for female stress urinary incontinence (SUI)., Methods: In the present multicentric retrospective study, all women implanted with ACT® balloons between 2000 and 2018 were considered eligible. Effectiveness and safety were assessed at 1 year, and risk factors for failure and complications were sought. The effectiveness was categorized into three distinct groups: Success = maximum 1 pad/day and patient's impression of improvement using a numerical rating scale (NRS) ≥ 8/10; Improvement = decrease of daily pad use and NRS ≥ 5/10; Failure = increase or stability of daily pad use or NRS < 5/10. The intra- and postoperative surgical complications were collected., Results: Over the study period, 281 women were included. Among them, 104 (37.0%), 94 (33.5%) and 83 (29.5%) were categorized as success, improvement, and failure, respectively. Intra-, early and late postoperative complications occurred in 13 (4.6%), 35 (12.5%) and 75 (26.7%) women, respectively. Most early surgical complications were minor according to the Dindo-Clavien classification. Of women that presented a late postoperative surgical complication, 64 (22.8%) underwent an explantation performed under local or general anesthesia without associated sequalae., Conclusions: The short-term effectiveness associated with ACT® balloons, their minimally invasive implantation and the frequent but easily manageable and sequelae-free complications suggest that they should be part of the therapeutic arsenal for female SUI., (© 2022. The International Urogynecological Association.)

Purpose: To assess the incidence of artificial urinary sphincter (AUS) explant in high-risk patients and to evaluate the relationship between transcorporal cuff (TCC) placement and explant risk in this population., Methods: We retrospectively reviewed all AUS insertions performed on high-risk patients by a single surgeon from 2010 to 2020. "High-risk" was defined as having ≥ 1 urethral risk factor: pelvic radiation, urethroplasty, recalcitrant urethral/bladder neck stenosis, urethral stenting, or previous AUS erosion/infection. Patients with ≥ 2 factors were "ultra-high-risk." Time-to-event analyses were used to assess all-cause-, infection/erosion-related-, and mechanical failure-related explant-free survival. Subgroup analyses were performed for patients with a history of radiation and urethral dissection., Results: The final cohort included 68 men, mean age of 67 years (SD 11), and 77 AUS cuffs. Mean follow-up was 32 months (IQR 6-50). 29% of cuffs (n = 22) were transcorporal. 32 cuffs (42%) were explanted. All-cause explant-free survival was 64% at 1 year and 52% at 2 years. Classification as "ultra-high-risk" was not associated with explant risk (all p-values > 0.05). TCC placement was associated with an increased risk of explant for infection/erosion across all patients (HR 2.74, p = 0.03) and in radiated patients (n = 50; HR 4.1, p = 0.04), but not in patients with prior urethral dissection (n = 52; HR 1.98, p = 0.21)., Conclusion: High-risk patients have a high rate of AUS explant and TCC placement may not be protective in this population. TCC placement was associated with an increased risk of infection/erosion in radiated patients, but not in those with a history of open urethral surgery., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Urethral sphincter dysfunction is an important cause of stress urinary incontinence (SUI). The most effective treatment is the insertion of an artificial urethral sphincter (AUS), which relies to a large extent on the surgeon's experience. However, there is no quantitative standard for cuff tightness, resulting in frequent postoperative complications. This study aimed to investigate the effect of internal and external sphincter dyssynergia on urodynamic parameters in the lower urinary tract. A geometric model of male lower urinary tract tissue was constructed from collodion slices, accounting for the active behavior of the internal and external sphincters. Normal and dyssynergic internal and external sphincters (active sphincter behavior was individually injured by 25%, 50%, 75%, or 100%) were simulated with fluid-structure interactions and changes in urethral stress, displacement, and urine flow rate were detected. We found that when the internal sphincter was injured by 25%, 50%, 75%, and 100%, urethral stress near the internal sphincter decreased by 8.3%, 15.6%, 24.3%, and 35.7%, respectively. Additionally, when the external sphincter was injured by 25%, 50%, 75%, and 100%, urethral stress near the external sphincter was reduced by 13.3%, 24.3%, 38.6%, and 46.6%, respectively. Internal sphincter injury primarily affects positions near the internal sphincter and prostate, while external sphincter injury affects the area between the prostate and urethral outlet. These data could facilitate the standardized evaluation of internal and external sphincter dysfunction and lead to novel methods of preoperative assessment for AUS surgery., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: In this study, we aimed at evaluating the long-term adjustable peri-urethral balloons (PUB) durability in both male and female with neurogenic or non-neurogenic stress urinary incontinence., Material and Methods: Each consecutive patient who underwent surgery for PUB placement before 2008 was included in this study. A PUB was proposed for patients with refractory to perineal reeducation stress urinary incontinence (SUI) caused by intrinsic sphincter deficiency. There were no exclusion criteria. Demographic, clinical and perioperative data were collected retrospectively from our clinical follow-up notes., Results: A total of 177 patients were included in the study. Median [IQR] follow-up was 5 years [1.8-11.2]. The 3 main causes of SUI were radical prostatectomy (n=82, 46.3%), idiopathic intrinsic sphincter deficiency (n=55, 31.1%) and neurogenic sphincter deficiency (n=32, 18.1%). Complete continence (no pad necessary) was achieved for 109 patients (61.6%). At the end of the follow-up, the PUB global survival rate was 47.5% (Fig. 1). Median [IQR] PUB survival without removal was 57.8 months [42.3-81.7]. PUB survival without failure rate was 68.4% accounting for a median [IQR] survival duration of 116.9 months [86.2-176.9] CONCLUSION: In this study, we evidenced acceptable long-term efficiency and survival of PUB in the management of SUI in both neurogenic and non-neurogenic population. Given those results it could be a good alternative to AUS on unfit or unwilling population., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: To determine whether larger artificial urinary sphincters (AUS) cuff sizes of ≥ 5.0 cm have an impact on urinary incontinence after AUS implantation as compared to cuff sizes ≤ 4.5 cm., Materials and Methods: A retrospective chart review of AUS implants performed at our institution from 1991 to 2021. Medical records were reviewed for demographics including body mass index (BMI), cause of incontinence, pelvic radiation, valsalva leak point pressure (VLPP), degree of leakage preoperatively and at 1-year post-AUS surgery, AUS revisions, erosion rate and the need for adjunct medication postoperatively., Results: A total of 110 patients were included in the analysis. Of these, 44 patients had an AUS cuff size of ≥ 5.0 cm and 66 patients had a cuff size ≤ 4.5 cm. After AUS implantation at 1 year both groups had a median pad use of 1 pad per day. Lastly, the erosion rate was higher in the ≤ 4.5 cm cuff group (7.7% vs. 2.4%) but this was not statically significant. In all cases (6 patients) of cuff erosion, each patient had been radiated., Conclusion: AUS cuff sizes of ≥ 5.0 cm do not appear to have a negative impact on the degree of incontinence at 1-year post AUS as compared to those with cuff sizes ≤ 4.5 cm. The erosion rate was higher in those with cuffs ≤ 4.5 cm but was not statistically significant. This would suggest that at AUS implantation, the surgeon should choose a larger cuff if there is any doubt especially in those with radiation.

Objective: To investigate the effectiveness and safety of robot-assisted artificial urinary sphincter (AUS) implantation surgery for female patients with severe stress urinary incontinences (SUI) by performing a systematic literature review., Methods: A comprehensive search was carried out across multiple databases, including PubMed, EMBASE, Web of Science Clarivate, Cochrane library, Medicine and clinicaltrials.gov between inception to March 2022. Studies were included if they met the inclusion criteria and were evaluated by different quality evaluation methods according to study types. P value and 95% confidence intervals (CI) of outcome measures mainly including continence rates, intraoperative and postoperative complication rates were pooled to present the efficacy and safety., Results: A total of 9 studies with 157 participants were finally included. Eight retrospective and 1 prospective study met the inclusion criteria with moderate and high evidence levels. The pooled results showed that patients with robot-assisted AUS implantation treatment, presented great continence rate (P = .83, 95%CI:0.76-0.89) but high complication rate (Intraoperation: 0.21 95%CI:0.11-0.34; Postoperation: 0.20 95%CI: 0.12-0.29). In addition, subgroup analysis of 2 approaches showed that compared with the posterior approach, the traditional surgical approach had better efficacy and safety., Conclusion: The results of this study indicated that robot-assisted AUS implantation surgery improved SUI patients' urinary continence, but the complication rates were high, which mainly included intraoperative vaginal and bladder injury and postoperative acute urinary retention. More evidence from prospective studies is needed to provide guidance for clinical practice., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The artificial urinary sphincter is the reference treatment for stress urinary incontinence in men, but it remains rarely used in women. This study aimed to compare long-term device survival between women and men, after the first implantation of an AMS800™ artificial urinary sphincter (Boston Scientific) for the treatment of a non-neurogenic stress urinary incontinence., Materials and Methods: This retrospective cohort study included all patients with nonneurogenic stress urinary incontinence who underwent surgery in a large-volume university hospital between 2000 and 2013. The primary outcome was the overall survival of the device, defined as the absence of any repeated surgery (revision or explantation) during follow-up. Men and women were matched 3:1 according to age and year of implantation. Differences were analyzed using a Cox model accounting for matching and applying time intervals because hazards were not proportional over time. Sensitivity analyzes were performed, excluding firstly a population with a history of radiotherapy and secondly a population with more than one previous surgery for urinary incontinence., Results: A total of 107 women were matched to 316 men. Median follow-up was 6.0 years (Q1-Q3 1.8-9.4): 7.0 years (Q1-Q3 3.1-10.3) for women and 5.1 years (Q1-Q3 1.3-9.1) for men. During the follow-up, 56 patients had an explantation of the device: 44 men (13.9%) and 12 women (11.2%), and 113 had a revision: 85 men (26.9%) and 28 women (26.1%). Men have a significantly higher risk of explantation or revision than women between 6 months and 8 years after implantation (hazard ratio 2.12 [1.29-3.48]). Before 6 months and after 8 years, there were no significant differences. Both sensitivity analyses found consistent results., Conclusions: This study suggests that device survival seems better in women after the first 6 months., (© 2022 Wiley Periodicals LLC.)

Objective: To evaluate the functional and surgical impact of CIC protocols in men with a bulbar AUS in place. Stress urinary incontinence (SUI) and poor bladder emptying are both sequelae of prostate cancer treatment, though there is sparse data to guide concomitant management. The safety of intermittent catheterization (CIC) in men with an artificial urinary sphincter (AUS) at the bulbar urethra remains unclear., Methods: We performed a retrospective review of all bulbar urethral AUS procedures at our institution. Inclusion criteria were patients with a history of prostate cancer treatment, AUS placement for SUI, and a history of CIC before and/or after AUS placement. All eligible cases were retrospectively reviewed. Surgical and continence outcomes were analyzed., Results: A total of 57 patients were identified with a history of CIC and AUS placement under the care of two surgeons. Eighteen continued to perform CIC or first initiated CIC after AUS placement and 39 discontinued CIC prior to AUS placement. The incidence of erosion was no different amongst patients who continued or discontinued CIC after AUS placement (17.9% vs 22.2%, P = .79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, P = .41). Both groups experienced improvement in urinary incontinence after placement of an AUS., Conclusion: Bulbar AUS placement in the setting of continuous intermittent catheterization can be considered in patients who are not surgical candidates for definitive treatment of their outlet obstruction., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To compare peri- and postoperative outcomes following artificial urinary sphincter (AUS) insertion using an abdominal versus a sub-inguinal counterincision for pressure regulating balloon (PRB) placement., Methods: This was a retrospective review of all AUS placements by a single surgeon from 2010-2020. Demographic, clinical, and surgical details were obtained from chart review. The cohorts were divided by PRB placement technique (sub-inguinal, abdominal, and attempted sub-inguinal converted intra-operatively to abdominal ["conversion group"])., Results: There were 182 AUS devices placed. The sub-inguinal approach was successfully completed in 132/144 (92%) and converted to abdominal PRB placement in 12/144 (8.3%). The risk of conversion was not increased by prior laparoscopically-assisted robotic prostatectomy (LRP) or radiotherapy (RT). Median operative time was 62, 75, and 77 minutes for sub-inguinal, abdominal, and conversion groups, respectively ( P = 0.30). Time to device activation was 25.0, 32.0, and 37.5 days for abdominal, sub-inguinal, and conversion groups, respectively (P<0.01). There were no bowel or bladder injuries and no PRB herniation in any group; however, there were five instances of pump migration superiorly, all in the sub-inguinal or conversion groups (P = 0.05)., Conclusions: The sub-inguinal approach to PRB placement during AUS is safe and can be successfully completed over 90% of the time. However, it is not faster than the abdominal approach to PRB placement and it is associated with an increased risk of pump migration, though the latter may be confounded by the sub-dartos pouch for pump placement that was used in all sub-inguinal cases., Competing Interests: DECLARATIONS OF INTEREST Dr. Sean P. Elliott is a consultant for Boston Scientific, the manufacturer of the AUS device. He is also the investigator on a study regarding the AUS device which is sponsored by Boston Scientific. None of the other co-authors (AL, KK, SG) have any declarations of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: We report our surgical experience of transperineal bulbovesical anastomosis (BVA) for extensive posterior urethral stenosis (PUS)., Methods: Six male patients who had extensive PUS extending from the bulbomembranous urethra to the bladder neck due to prostatic disease treatment and underwent transperineal BVA between 2014 and 2020 were retrospectively reviewed. BVA was performed according to the elaborate perineal approach for pelvic fracture urethral repair with minor modifications. After confirming the absence of recurrent stenosis 6 months postoperatively, the patients were offered artificial urinary sphincter (AUS) placement for subsequent urinary incontinence (UI)., Results: Median patient age was 68, and the etiology of PUS was radical prostatectomy for prostate cancer in four patients, brachytherapy for prostate cancer in one, and transurethral resection of the prostate for benign prostatic hyperplasia in one. All patients had been previously treated with multiple transurethral procedures such as urethrotomy and dilation. Median operative time and blood loss were 211 min and 154 ml, respectively. Five cases (83.3%) had no recurrent stenosis with a median follow-up of 45 months, but a single direct vision internal urethrotomy was performed in one (16.7%) due to restenosis. Four (66.7%) patients underwent AUS placement via transcorporal approach for subsequent UI, but two had it removed due to urethral erosion., Conclusion: Transperineal BVA could effectively manage extensive PUS after prostatic disease treatment. Staged AUS placement could be a viable option for subsequent UI, but the risk of urethral erosion seemed high., (© 2022 The Japanese Urological Association.)

Objectives: To estimate the surgical and quality-of-life outcomes of artificial urinary sphincter implantation in patients with diabetes mellitus (DM). Subanalyses were performed using the same population as that in our previous multicenter, prospective, observational study., Methods: A total of 135 male patients who underwent primary artificial urinary sphincter implantation were divided into two groups: those with and without DM. The revision-free rates, that is, the percentage of patients who did not require revision surgery, were compared between patients with and without DM. The number of urinary pads required per day, International Consultation on Incontinence Questionnaire-Short Form, and King's Health Questionnaire were used to compare the continence status and quality of life (QOL) between the two groups preoperatively and at 1, 3, and 12 months after surgery., Results: Revision-free rates were significantly lower in the DM group (83.9%, 77.4%, and 67.8% at 1, 2, and 3 years after implantation, respectively) than in the non-DM group (95.5%, 92.5%, and 85.5% at 1, 2, and 3 years after implantation, respectively). Both continence status and QOL, assessed by questionnaires, markedly improved after surgery in patients with and without DM., Conclusions: Despite differences in the durability of the artificial urinary sphincters, patients with DM can obtain as much benefit from artificial urinary sphincter implantation regarding continence and quality-of-life improvement as patients without DM. Therefore, DM was not considered a comorbidity that contraindicated artificial urinary sphincter implantation. Additional large-scale studies are required to verify our findings., (© 2022 The Japanese Urological Association.)

Objective: To evaluate potential associations between patient risk factors and incontinence related patient-reported outcome measures (PROMs) preandpost artificial urinary sphincter (AUS) implantation. We hypothesize patient risk factors, including prior radiation and diabetes will have a negative association with post AUS PROMs., Methods: A review of prospectively collected preandpostoperative Incontinence Symptom Index [ISI] and Incontinence Impact Questionnaire-7 (IIQ-7)s from multiple institutions in the Trauma and Urologic Reconstruction Network of Surgeons was performed. Changes in preandpost AUS ISI and IIQ-7 scores were compared for the entire cohort then stratified by patients with prior AUS, obesity, diabetes, prior radiation, and mixed urinary incontinence., Results: A total of 145 patients, 67.2 (SD 10.9) years had complete preandpost AUS questionnaires (median follow up 186 days, IQR 136-362). Post AUS ISI and IIQ-7 scores improved significantly for the group at large. Prior radiation was associated with less improvement in total IIQ-7 scores, -25.5 (31.9) vs -39 (33.0), P = .03. Obesity was associated with a greater reduction in incontinence severity -13.6 (SD 9.1) vs -9.2 (SD 8.9), P<0.01, urge -5.2(SD 4.2) vs -2.5(SD 4.5), P <.01, and total ISI score -29.7(SD19.7) vs -21.2 (SD 19.9), P = .02. Prior AUS, diabetes, and mixed incontinence were not associated with post AUS PROMs outcome., Conclusion: Overall, patients reported a significant reduction in incontinence severity, bother, impact, and distress following AUS placement. Prior radiation was associated with less improvement in total IIQ-7 scores. In contrast, obesity demonstrated a greater reduction in ISI severity and urge scores compared to non-obese patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To identify predictors of early artificial sphincter (AUS) erosion among a cohort of men with erosion, who underwent AUS placement by either university or community-based surgeons., Methods: The records of all patients with AUS erosions, including men who underwent AUS placement at outside facilities, were retrospectively reviewed. A Cox proportional-hazards model for time to erosion was performed with the predictors being the components of a fragile urethra (history of radiation, prior AUS, prior urethroplasty), androgen deprivation therapy (ADT), trans-corporal (TC), and 3.5 cm cuff, controlling for other risk factors. Kaplan-Meier survival curves and log-rank test compared "fragile" urethras with "not fragile" urethras. All statistical analysis was done using R version 3.5.2., Results: Of the 156 men included, 36% had undergone AUS placement in the community. Median time to erosion was 16.0 months (1.0-240.0 months), and 122 (78%) met at least one fragility criteria. Radiation (HR 2.36, 95% CI 1.52-3.64) and prior urethroplasty (HR 2.12, 95% CI 1.18-3.80) were independently associated with earlier time to erosion. The Kaplan-Meier estimates demonstrate 1- and 5-year survival rates of 76.5% and 50.0%, respectively, for "non-fragile" and 44.1% and 14.8% for "fragile" urethras (P < .0001)., Conclusion: In a diverse cohort of men with AUS erosion, men with "fragile" urethras eroded sooner. Radiation and prior urethroplasty were independent risk factors for earlier time to erosion, but prior AUS, ADT, TC and 3.5 cm cuff were not., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To assess whether estimated glomerular filtration rate (eGFR) independently predicts adverse outcomes after AUS surgery., Methods: Using a large national database, we identified adult males who underwent AUS surgery between 2005-2019. To calculate eGFR (ml/min/1.73 m 2 ), the Cockroft-Gault equation was utilized. Patients were classified into five different groups: 0-29 (advanced chronic kidney disease [CKD]), 30-59 (Stage III CKD), 60-89 (Stage II CKD), 90-119 (normal), and >120 (hyperfiltration). We investigated 30-day outcomes including any complication, readmission, reoperation, major and minor complications, extended length of stay, and non-home discharge. Multivariable logistic regression analysis (MLRA) was performed to assess eGFR categories as independent predictors for each outcome., Results: A total of 1,910 cases met inclusion criteria. Patients with advanced CKD had a higher frailty burden (5-item modified frailty index ≥2: 39.1% vs. 22.2%), higher American Society of Anesthesiologists score (ASA III or IV: 95.7% vs. 53.5%), and lower BMI (median kg/m²: 29.3 vs. 30.9) compared to patients with normal eGFR. Likewise, patients with advanced CKD had higher rates of any complication, readmission, reoperation, extended length of stay, non-home discharge, as well as major and minor complications, compared to patients with normal eGFR. On MLRA, advanced CKD (0-29) was independently associated with reoperation (OR 5.14; 95% CI 1.06 - 20.84; p = 0.043)., Conclusions: Patients with advanced CKD had a higher likelihood of reoperation when compared to patients with normal eGFR. Patients with advanced CKD should be counseled prior to AUS surgery due to a potential higher risk of 30-day reoperation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Artificial urinary sphincters (AUS) have demonstrated good functional outcomes in pediatric populations. We sought to examine the nationwide short term reoperation rates in pediatric patients after AUS placement., Materials and Methods: An observational cohort study was designed utilizing claims from the Truven MarketScan Commercial Claims and Encounters database from 2007 to 2018. Patients under 18 years of age undergoing an AUS procedure were identified using CPT and ICD9/10 codes. Reoperations included any removal, replacement, or AUS placement codes which occurred after the initially identified placement code. Follow up time was the amount of time between AUS placement and the end of MarketScan enrollment., Results: From 2007-2018, we identified 57 patients under the age of 18 who underwent AUS placement and after excluding 8 for concurrent AUS complication procedure codes and 4 for follow up < 60 days, the final cohort included 45 patients. The median age was 13 years (IQR 9-16 years) at the time of AUS placement, and the median follow up time after AUS placement was 787 days (IQR 442-1562 days), approximately 2.2 years. Total reoperation rate was 22%. Reoperations included 40% device removals (4/10) and 60% replacements (6/10). Neither gender (p = 0.70) nor age (p = 0.23) was associated with need for reoperation. Patients who had a concurrent bladder surgery had a higher rate of undergoing reoperation (50% vs. 12%, p = 0.007)., Conclusions: The rate of reoperation after AUS placement approached 1 in 4 in pediatric patients. These data may be instrumental for providers and parents in counseling and decision-making regarding risks of prosthetic implantation.

Purpose: The artificial urinary sphincter (AUS) is one of the most effective surgical treatments for male urinary incontinence regardless of its severity. Current knowledge comes from high-volume centers, but little is known about the performance of this surgery from community practices. This study aims to report contemporary AUS performance in a nationwide observational study in Colombia., Methods: Male patients who underwent AUS surgery with AMS 800™ between 2000 and 2020 in more than 17 centers and four cities were identified. Pre, intra, and postoperative characteristics were evaluated, mainly addressing patient reported outcomes measurements in the postoperative period. Retrospective and prospective data collection and descriptive analysis were completed. Kaplan-Meier analysis was used to determine AUS survival rate., Results: Out of an initial 667 cases, a total of 215 patients met inclusion and exclusion criteria and were included. Mean age was 67 ± 9.4 years, and mean follow-up was 6.0 ± 4.4 years with maximum range of 14 years. The etiology of urinary incontinence was prostate cancer surgery in 141 (81%) of the cases. The rest of the cases were related to benign prostatic disease or spinal cord injury. It is noteworthy that out of 115 patients, only 59 (51.3%) reported previous formal pelvic floor rehabilitation. Subjective severity of urinary incontinence determined by a visual analog scale showed a decrease in 4.5 points after sphincter implantation. Sphincter removal was required in 50 (23.2%) cases. The main reasons for implant removal were urethral erosion and infection. The sphincter survival rate at 2, 5, 8, 10, and 14 years was 76%, 70%, 60%, 57%, and 17%, respectively. Of the subjects at the last follow-up with the device still in place, 80.7% defined their urinary condition as "does not cause or causes minor discomfort," and 99% would recommend the device to a friend or relative in the same condition., Conclusions: This series from a community-based practice shows the lack of adherence to clinical practice guidelines and the lack of standardized data collection. In contrast, this study provides real-world data on explantation and revision rates, allows physicians to inform patients and to have clear metrics for a shared decision-making process before the procedure., (© 2022 Wiley Periodicals LLC.)

Purpose: To characterize the most common presentation and clinical risk factors for artificial urinary sphincter (AUS) cuff erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these patients., Materials and Methods: We retrospectively reviewed our tertiary center database to identify men who presented with AUS cuff erosion between 2007 - 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for symptom comparison. Risk factors for cuff erosion - pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) - were recorded for each patient. Presenting signs and symptoms of cuff erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (SI)., Results: Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) sustained cuff erosion. Most erosion patients (40/61, 66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling. Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with SI or obstructive symptoms presented significantly earlier than those with worsening incontinence (SI 14 ± 18 vs. obstructive symptoms 15 ± 16 vs. incontinence 37 ± 48 months after AUS insertion, p<0.01). Relative to the non-erosion control group (n=61), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 49%, p=0.02)., Conclusion: AUS cuff erosion most commonly presents as SI symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Background: Artificial urinary sphincter (AUS) is the gold standard for the management of moderate to severe stress urinary incontinence (SUI) in the male population. While outcomes of this device in postprostatectomy incontinence (PPI) are widely described, those obtained for incontinence after benign prostatic obstruction (BPO) surgery remains poorly explored., Objective: To compare continence outcomes after AUS implantation in a PPI population with those obtained in men incontinent after BPO surgery., Design, Setting, and Participants: A retrospective review of all cases of AUS implantation between 2005 and 2020 in 16 different French centers was conducted. Only patients with primary implantation whose indication was moderate to severe SUI after prostatectomy or BPO surgery were included (excluding those with a history of radiation therapy, brachytherapy, cystectomy, high-intensity focused ultrasound therapy, or neurogenic disease)., Outcome Measurements and Statistical Analysis: The primary endpoint was the rate of social continence (zero or one pad per day) at 3 mo. Complications were also noted within 90 d of implantation., Results and Limitations: A total of 417 patients were included in the PPI group and 50 in the BPO surgery group. Social continence rates at 3 mo were similar between the groups (79% vs 72%, p = 0.701). Complication rate was significantly higher in the BPO group (8% vs 18%, p = 0.044). The same was found for the Clavien-Dindo type 2 complication rate (20.6% vs 44.4%, p = 0.026). The retrospective nature and lack of precise definition of incontinence are the main limitations of this study., Conclusions: This multicentric study strengthens the position of AUS as gold standard for SUI after radical prostatectomy. Comparable efficacy results were found for incontinence after BPO surgery, with nevertheless a higher rate of complications., Patient Summary: Artificial urinary sphincter represents the gold standard for the treatment of moderate to severe stress urinary incontinence. Efficacy results are comparable between postprostatectomy incontinence and incontinence after benign prostatic obstruction surgery., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Artificial urinary sphincter has been used to treat urinary incontinence in children with neuropathic bladder, although there are few studies reporting very long-term results. We assess our experience over the last 27 years in the management of artificial urinary sphincter., Methods: A retrospective study was performed in patients with neuropathic bladder in whom an artificial urinary sphincter was placed in our institution between 1994 and 2020. Demographic variables, pre- and post-artificial urinary sphincter implantation urodynamic studies, long-term outcomes, and postoperative complications were collected., Results: An artificial urinary sphincter was implanted in 71 patients (median age 14.5; interquartile range 12.8-15.9), with a median follow-up time of 17.2 years (interquartile range 9.8-23.9 years). Thirty-nine patients underwent enterocystoplasty combined with artificial urinary sphincter placement and 32 underwent artificial urinary sphincter implantation alone, of whom 12 patients (16.9%) eventually required an enterocystoplasty because of unexpected bladder behavior changes, usually within 3 years of artificial urinary sphincter implantation. Adequate urinary continence was reported in 90.1% of patients, nine void their bladders spontaneously, and 62 need clean intermittent catheterization. Eighteen mechanical malfunctions occurred in 15 patients (21.1%), with an average artificial urinary sphincter working life of 15.1 ± 1.3 years. In five patients artificial urinary sphincter was removed due to infection or erosion. In 12 patients (30.8%), a continent catheterizable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterization through the urethra., Conclusion: The very long-term results of this study demonstrate that artificial urinary sphincter is an effective treatment for urinary incontinence in neuropathic bladder patients. Long-term follow-up is important to identify potential unexpected changes in bladder behavior in these patients., (© 2022 The Japanese Urological Association.)

Objective: To investigate lower urinary tract symptoms (LUTS) observed after artificial urinary sphincter (AUS) implantation for post-radical prostatectomy urinary incontinence (PRPUI)., Materials and Methods: Cases of AUS for PRPUI were evaluated. Stress urinary incontinence (SUI) was assessed using the Sandvik-incontinence severity index. Other LUTS were evaluated using the overactive bladder symptom score and international prostate symptom score. The prevalence and predictive risk factors for post-AUS LUTS were analyzed., Results: Of 129 patients evaluated (mean follow-up = 42.3 months, mean age = 76.7 years), 8.5% had very severe SUI, 78.4% had moderately to severely symptomatic LUTS (IPSS = 8-35 points), and 45.2% were dissatisfied with their urinary condition. Nocturia was the most prevalent (48.0%). Maximum cystometric capacity (rho = -0.236, P = .007) and involuntary detrusor contraction (P = .002) were significantly related to the severity of post-AUS urgency urinary incontinence (UUI). Multivariable linear regression analysis indicated that involuntary detrusor contraction was more associated with post-AUS urgency (P <.001) and UUI (P = .006) than any other preoperative parameter. Age significantly correlated with the severity of post-AUS urgency (rho = 0.309, P <.001), UUI (rho = 0.196, P = .026), and the need for straining to void (rho = 0.240, P = .007)., Conclusion: Even after successful placement of an AUS, many patients were dissatisfied with various LUTS, ranging from the most frequent nocturia to the need for straining to void. Attention should be paid not only to SUI but also to non-SUI LUTS, which are observed in the general population in this age group and change over time. Counseling to educate patients about expected outcomes and continuous monitoring and treatment for LUTS should be provided for the PRPUI-AUS population., (Copyright © 2022. Published by Elsevier Inc.)

Context: Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI)., Objective: To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management., Evidence Acquisition: A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement., Evidence Synthesis: A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively., Conclusions: The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques., Patient Summary: Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Artificial urethral sphincter (AUS) implantation is the definitive management of male stress urinary incontinence (SUI). Under the long-term pressure of the cuff, recurrence of incontinence caused by urethral atrophy can always be observed in patients. In this situation, distal cuff locations are needed, and new cuff sites should be sought in patients who need to undergo AUS reimplantations. Meanwhile, the circumference of the more distal urethra is often too small to fit with a 4.0 cm cuff. This means that the bulk of the urethra should be added not only for a sufficient urethral circumference but also for better protection. Here, we report a case that required AUS reimplantation because of urethral atrophy. This 73-year-old man had undergone AUS implantation 7 years ago and developed incontinence in the past 3 months. Physical examination and ultrasonography determined that the device still worked, and no obstruction or injury was observed through cystoscopy. Surgery for revision of the AUS was needed. In this operation, a new cuff was implanted transcorporally, which was 2 to 3 cm distal to the original cuff site. During a 6 month short-term follow-up, no stress incontinence, urethral injury, or dysuria was observed. The transcorporal technique offers significant advantages in patients with urethral atrophy: corporal tunica albuginea is added to the urethra, allowing a suitable cuff size and lower risk of erosion. It is worth recommending in the reoperation of AUS implantation.

Purpose: In order to accurately characterize how a history of radiation therapy affects the lifespan of replacement artificial urinary sphincters (AUSs), all possible sources of device failure must be considered. We assessed the competing risks of device failure based on radiation history in men with replacement AUSs., Materials and Methods: We identified men who had a replacement AUS in a single institutional, retrospective database. To assess survival from all-cause device failure based on radiation history and other factors, we conducted Kaplan-Meier, Cox proportional-hazards and competing risks analyses., Results: Among 247 men who had a first replacement AUS, men with a history of radiation had shorter time to all-cause device failure (median 1.4 vs 3.5 years for men with radiation vs without radiation history, p=0.02). On multivariable Cox-proportional hazards analysis, previous radiation was associated with increased risk of all-cause device failure (HR: 2.12, 95% CI: 1.30-3.43, p=0.002) . On multivariable cause-specific hazards analysis, prior radiation was associated with a higher risk of erosion/infection (HR: 7.57, 95% CI: 2.27-25.2, p <0.001), but was not associated with risk of urethral atrophy (p=0.5) or mechanical failure (p=0.15)., Conclusions: Among men with a replacement AUS, a history of pelvic radiation was associated with shorter time to device failure of any cause. Radiation was also specifically associated with a sevenfold increase in the risk of erosion or infection of replacement AUS, but not with urethral atrophy or mechanical failure. Patients with a replacement AUS should be appropriately counseled on how radiation history may impact outcomes of future revisions.

Background: Urethral obstruction secondary to artificial urethral sphincter (AUS) implantation is a recognized complication in dogs. However, urethral obstruction secondary to AUS-associated capsule formation has been described rarely., Hypothesis: Describe clinical and diagnostic findings, management, and outcome in 6 dogs with urethral obstruction secondary to AUS-associated capsule formation., Animals: Six client-owned dogs., Methods: Retrospective study. Medical records between January 1, 2010, and June 30, 2021, were reviewed to identify dogs with urethral obstruction associated with the AUS device., Results: The AUS device was implanted a median of 884 days (range, 20-2457 days) before presentation for urethral obstruction. Median age at time of urethral obstruction was 4.7 years (range, 3.1-8.7 years). Clinical signs at the time of urethral obstruction were stranguria (n = 4), pollakiuria (3), weak urine stream (2), and worsened urinary incontinence (1). In all dogs, the urethra was noted to be stenotic during urethroscopy and positive contrast cystourethrography. All dogs underwent surgery, and a fibrous capsule associated with the AUS was found to be causing urethral stenosis. Resolution of urethral obstruction occurred in all dogs after transection or removal of the capsule. Positive bacterial cultures were obtained from the capsule, AUS, or both in all dogs. Recurrence of urethral obstruction had not occurred in any dog at the time of follow-up., Conclusions and Clinical Importance: Urethral obstruction secondary to capsule formation is an uncommon but clinically important complication associated with use of the AUS. Continued investigation is needed to evaluate this complication more thoroughly, and its possible association with infection., (© 2022 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals LLC on behalf of American College of Veterinary Internal Medicine.)

Introduction: Urinary incontinence after High Intensity Focused ultrasound (HIFU) is a poorly documented issue. To our knowledge, no study has evaluated the outcomes of artificial urinary sphincter (AUS) after HIFU. The aim of this study was to evaluate the functional outcomes of AUS for post-HIFU urinary incontinence., Methods: The charts of all male patients who underwent an AUS implantation between 2004 and 2020 in 13 centers were reviewed retrospectively. Only men with a history of HIFU were included. The primary endpoint was social continence at 3 months defined as wearing 0 to 1 pad per day., Results: Out of 1318 procedures, nine men were implanted with an AUS after HIFU including four men with an history of pelvic irradiation: 3 pelvic radiation therapy and 1 prostatic brachytherapy. The patients were divided into two groups, 5 in the HIFU group without a history of pelvic irradiation, 4 patients in the HIRX group with a history of pelvic irradiation. The median age was 74 years (IQR 71-76). There was no perioperative complication. The median follow-up was 47.5 (IQR 25-85.5) months. Social continence at 3 months was 75% in the total cohort: 80% in the HIFU group and 67% in the HIRX group., Conclusion: AUS implantation may provide satisfactory long-term functional outcomes in the treatment of stress urinary incontinence resulting from HIFU. Larger series are needed to confirm these findings., Level of Evidence: 4., (Copyright © 2021. Published by Elsevier Masson SAS.)