Alternatives When Artificial Urinary Sphincter (AUS) Fails
For patients with failed AUS, the most effective salvage options include AUS revision/replacement, tandem cuff placement, urethral repositioning, or ultimately urinary diversion for refractory cases that significantly impact quality of life. 1
Evaluation of AUS Failure
When an AUS fails, a systematic approach to determine the cause is essential:
History and physical examination to determine:
- Device activation/cycling issues
- Duration since implantation (recent vs. years of function)
- Symptoms suggesting infection or erosion
Diagnostic workup:
- Cystoscopy to evaluate cuff coaptation
- Cross-sectional imaging (ultrasound or CT) to assess for fluid leaks in the system
- Evaluation for urethral atrophy
Salvage Options Based on Failure Mechanism
1. AUS Revision/Replacement
- For mechanical failure: A malfunctioning AUS can be explanted and replaced in the same operative setting if the patient is healthy 1
- For infection: Complete removal of all components is necessary, with a waiting period of 3-6 months before reimplantation at a different urethral location 1
- For erosion: Explant the device and leave a urethral catheter in place for several weeks to allow healing 1
2. Surgical Modifications for Persistent Incontinence
- Cuff repositioning: For distally located cuffs, proximal relocation may improve continence 1
- Cuff downsizing: For larger cuffs, using a smaller size may improve coaptation 1
- Tandem cuff placement: Effective as a salvage procedure for persistent incontinence 1
- Pressure-regulating balloon adjustment: Increasing pressure may improve continence in selected cases
3. Male Sling as an Alternative
- Male slings may be considered in select patients with mild to moderate incontinence 2, 3
- However, evidence suggests lower success rates compared to AUS revision in patients who have already failed an AUS 1
- Bone-anchored slings show cure rates between 58-86%, but with complication rates up to 14.5% 3
4. Adjustable Male Sling Systems
- Adjustable slings (like the Argus system) have shown early success rates of 73% in selected patients 4
- These allow for post-operative tension adjustment to optimize continence
- However, they have higher complication rates (10-22%) than fixed slings 3
5. Urinary Diversion (Last Resort)
- For refractory cases: Urinary diversion with or without cystectomy is an option for patients with multiple device failures, intractable bladder neck contracture, or severe detrusor instability 1
- Options include:
- Ileal conduit
- Continent catheterizable pouch
- This approach should be reserved for patients who cannot obtain long-term satisfactory quality of life with other options 1
Special Considerations
Radiation History
- Patients with history of radiation therapy have higher failure rates with all surgical options
- AUS remains the preferred option over slings in post-radiation patients 1
Bladder Neck Contracture
- Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should have this treated before addressing incontinence 1
- These patients have decreased success rates with male slings, making AUS generally a better option 1
Comorbid Erectile Dysfunction
- In patients with both incontinence and erectile dysfunction, concomitant surgery to address both conditions may be considered 1
- However, patients should be counseled about potentially increased complication risks
Pitfalls and Caveats
- Infection risk: Always evaluate for and treat any urinary tract infection before revision surgery
- Timing: Wait 3-6 months after infection or erosion before reimplantation 1
- Patient expectations: Counsel patients that even revised AUS devices will likely lose effectiveness over time, with failure rates of approximately 24% at 5 years and 50% at 10 years 1
- Urethral atrophy: A common cause of recurrent incontinence that may require cuff downsizing or repositioning
- Device manipulation ability: Ensure patients have adequate dexterity to operate any new device 5
By following this systematic approach to AUS failure, most patients can achieve satisfactory continence outcomes with appropriate salvage procedures tailored to their specific failure mechanism and clinical situation.