The fate of the urethra after artificial urinary sphincter cuff erosion: a review of 98 patients

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Background: Cuff erosion following artificial urinary sphincter (AUS) implantation, can have devastating downstream sequelae. As there is a paucity of literature regarding outcomes following AUS removal due to erosion, we aim to report rates of urinary fistulae (UF) and urethral stricture (US) complications after AUS removal in patients presenting with AUS cuff erosion. Methods: A retrospective chart review was performed on all patients who underwent AUS explant due to erosion from July 2009 to December 2020 at University of Southern California/Norris Comprehensive Cancer Center. All patients were managed with a standardized approach that involves prompt device explantation, suture urethrorraphy, and continual urethral catheter drainage. Patient demographic data, hypothesized cause of erosion, and post-operative outcomes were collated. Results: A total of 98 patients underwent AUS removal due to erosion. No intraoperative complications occurred during AUS explantation. The median age at AUS erosion was 79.4 years old [interquartile range (IQR), 72.7–83.1 years] with 45 (45.9%) of age 80 or greater. The median follow-up after AUS removal was 19.8 months (IQR, 7.0–49.2 months). Of these patients, 86 (87.8%) had a “fragile” urethra (history of pelvic radiotherapy, urethroplasty, or prior AUS failure or erosion) with 28 (28.6%) having two or more risk factors prior to AUS erosion at our institution. Fifty-three (54.1%) patients had history of pelvic radiation, 14 (14.3%) had a previous erosion, 6 (6.1%) had previous cuff relocation unrelated to erosion, and 6 (6.1%) had dual cuffs, 18 (18.4%) had a previous history of a posterior transecting urethroplasty, and 2 (2.0%) had a previous anterior urethroplasty. Of the 98 patients, 6 (6.1%) developed a de novo urethrocutaneous fistula (UCF) with median time to fistula resolution of 3.8 months. A total of 18 (18.4%) patients developed a US after AUS explantation, while 7 (7.1%) of those patients required urethral dilation and 2 required urethroplasty (2.0%). Notably, in patients with a penile prosthesis (PP) in situ (n=28), no infectious or erosive complications arose subsequent to AUS removal and catheterization. Prior erosions and posterior urethroplasty were found to be significantly associated with the development of UCF and US. Conclusions: In a contemporary cohort of patients presenting with AUS cuff erosion, rates of UCF and US are low. Due to the increassed risk of these complications after prior erosions, strategies to prevent initial erosion events should be further explored.

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