The re-operation rate for artificial urinary sphincters (AUS) is around 25% in men, and survival rate deteriorates when re-implantation takes place after urethral erosion or infection. Several risk factors for urethral erosion have been identified in the past, and may affect the outcome of re-implantation. The aim of this study was to evaluate the functional and survival outcomes of a third AUS after two previous explantations.

The records of all patients implanted with a third AUS between 2006 and 2023 in 7 French university hospitals were retrospectively reviewed. The different reoperations had to concern at least the cuff (excluding revisions of other AUS components). The primary endpoint was survival of the 3rd AUS. Secondary endpoints were functional outcomes at 6 months, at the last follow-up of the 3rd AUS, and at the last overall follow-up (after possible implantation of a 4th or even a 5th AUS), as well as reoperations.

Seventy-five patients were included. Fifteen patients (20,3%) had radiation therapy, 22 (29,3%) had previous pelvic surgery, 13 (18,3) were taking an anticoagulant, and 16 (25%) smoked. The median cuff size was 45 mm (min-max: 35-80), and implantation was bulbar in 76.1% of cases, with a trans-cavernous approach in 16.9%. Early complications affected 16.7% of patients (11/72), including 5 Clavien 3 complications (6.9%). 
After a median follow-up of 11 months (1-122), 28 explantations were required (37.3%). The 5-year survival rate was 34.8% (see survival curve). The only significant risk factor identified for explantation was smoking, but BMI and ASA score>2 were close to significance.
At 6 months, 66.2% of patients were socially continent (0-1 protection per day), 10.8% were improved, and failure rate was 23%. At the last follow-up of the 3rd AUS, these results were 40%, 5.3% and 54.7% respectively. However, at last overall follow-up (median 12 months, 1-183), the results improved to 54.8%, 9.6% and 35.6 for social continence, improvement and failure respectively, with 23 patients implanted with a 4th or 5th AUS.

The outcomes of a 3rd AUS are clearly inferior to those of a primary implantation: their survival and efficacy on incontinence are about half as good as described in the literature. The risk factors we have identified relate only to the patients, not to the surgery itself.

A third AUS may be acceptable for motivated patients who have run out of therapeutic options. Selecting the right candidates and providing appropriate counseling will be the main challenge.

Continence 12S (2024) 101482
DOI: 10.1016/j.cont.2024.101482