The artificial urinary sphincter (AUS) is still the standard treatment of male stress urinary incontinence (SUI) caused by sphincter deficiency and offers good outcomes and patient’s satisfaction. As expected with any other prosthetic device, complications including mechanical failure, infection or erosion are reported. The most studies recommend an explanation of the entire device in case of erosion(1,2,3). However, in case of isolated urethral erosion with negative urinary tract infection (UTI) and if no device malfunction is identified, it can be appropriate to remove only the cuff and to preserve the tubes. 
The aim of this retrospective, single center trial was to report on the impacts of an isolated explantation and possible replacement of the urethral cuff after erosion.

We evaluated clinical outcomes in patients with artificial urinary sphincter after the explantation of the urethral cuff and preserving the remaining components. All cases had sterile urine cultures. We included 13 patients between January 2016 and December 2017. The median age of the patients at the time of the surgery was 74.7 year (mean 75yr). After preparation of the urethra, the tubes were clipped, the cuff was removed, and the previously separated parts of the tubes were left in situ. A transurethral catheter was left in place for 4-6 weeks to allow the urethra to heal. The cuff explantation was performed in 17 cases (3 patients with recurrent erosions). The remaining components of the device were sealed using the AMS 800 Repair Kit. The explantation of the cuff was performed in an average time of 45.4 months (median=21) after initial AUS-implantation. All the explanted components were completely unremarkable. There were no intra- or postoperative complications and the mean operation time was 27.9 minutes.

After an average observation period of 52.6 months (median 32.9) no explantation of the remaning components was performed in 12 cases. In one case a supravesical urinary diversion with ileum conduit was indicated, consequently the AUS was no longer needed. 11 patients received a cuff replacement within a median of 4.4 months (range 2.8-64.7). A distal cuff location was used as an alternative for 2 challenging cases, both transcorporal cuffs were placed easily and no recurrent erosion was reported. In one case a cuff replacement was not performed at the time of collection of the data due to patient’s state of health.  
Secondary surgeries due to recurrent erosion were performed in 3 patients, all three had previous radiotherapy and several incontinence surgeries.

By isolated explanation of the cuff after urethral erosion, we preserved 92% of the remaining devices. Additionally, this procedure enables the surgeon to keep the operation time as short as possible, this can be requested in case of patients in poor general condition. A transcoporal cuff placement is associated with a lower rate of recurrent erosion. In this cohort both patients with distal transcorporal cuff placement had no recurrent erosion. Moreover, we were able to replace the urethral cuff in a second procedure in more than 80% of the cases and all the devices were in situ at the time of data collection with no sign of infection or mechanical failure. 
For reasons mentioned above, salvage surgical procedures for artificial urinary sphincter should be performed with preservation the components, whenever it is possible.

Although the success rates and patient satisfaction are high after AUS, revision surgeries are often required. Long-term maintenance of implants should be contemplated whenever AUS revision surgeries are performed. In this cohort, no secondary explantation of the AUS was performed due to infection or mechanical failure. We were able to preserve the AUS in 92% (n= 12) the cases and replace the missing components in 84,6% (n=11). Only in one case we explanted the bland components of the device because the artificial sphincter was no longer indicated. A transcorporal cuff location offers significant advantages in case of revision and should be preferred for challenging cases to reduce the risk of recurrent erosion. This procedure requires a strong indication and should only be performed in patients with sterile urine cultures.

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Linder BJ, de Cogain M, Elliott DS. Long-term device outcomes of artificial urinary sphincter reimplantation following prior explantation for erosion or infection. J Urol. 2014
Kowalczyk JJ, Nelson R, Mulcahy JJ. Successful reinsertion of the artificial urinary sphincter after removal for erosion or infection. Urology. 1996;48:906–8.[PubMed: 8973675] 9. Rozanski AT, Tausch TJ, Ramirez D, Simhan J, Scott JF, Morey AF. Immediate urethral repair during explantation prevents stricture formation after artificial urinary sphincter cuff erosion. J Urol. 2014