Stress urinary incontinence (SUI) is an unfortunate and common comorbidity associated with the treatment of prostate cancer. With the use of primary or adjuvant radiation therapy, men can develop debilitating SUI that significantly impacts their quality of life. The Artificial urinary sphincter (AUS) is the gold standard surgical intervention for severe SUI in men with a history of radiation therapy. In this study, we aimed to evaluate our institution’s experience with AUS placement after radiation therapy.

A retrospective chart review was completed of patients with a history of radiation therapy who underwent AUS placement from 2003-2019. Baseline characteristics included demographics, type of radiation, history of radical prostatectomy, number of pads used, history of stricture disease, and history of prior incontinence procedure. Post-surgical outcomes included continence status measured by pads per day, post-operative complications, and activation of AUS per protocol. Additionally, need for future procedures such as urethral dilation and redo/removal of AUS was evaluated.

130 men with a history of radiation therapy underwent AUS placement at our institution from 2003-2019 for urinary incontinence. The mean follow up was 10.7 months (IQR 0.25-63.4). Patient demographic characteristics included a mean age of 71.8 years, median American Society of Anesthesiologists class of 2, and a median BMI of 30.13 kg/m2. In regards to radiation therapy, 108 (83.1%) had external beam radiation therapy, 1 (0.8%) had proton beam therapy, 6 (4.6%) had both brachytherapy and external beam therapy. 111 (85.4%) had previously undergone radical prostatectomy and 59 (45.4%) had a history of urethral stricture disease, with the majority of these patients requiring dilation. 38 (29.2%) had a previous incontinence procedure. Of these patients, 20 (52.6%) had previous sling, 17 (44.7%) had previous AUS, and 1 (2.6%) had prior sling and AUS placed. Mean pads per day pre-operatively was 6.2 (IQR 1-20).  Post-operatively, mean pads per day was 1.7 (IRQ 0-20). Post-operative complications included hematoma formation (n=4, 3.1%), infection (n=6, 4.6%), and urinary retention (n=11, 8.5%). Additional procedures were required in 51 patients and included further dilation (n=20, 15%) and AUS removal or revision (n=28, 22%).

Based upon the study results, it is evident that AUS placement after radiation therapy can significantly improve SUI as demonstrated by a mean 4.5 pads per day improvement in pad usage. AUS placement can be completed with minimal post-operative complications, as 21 patients experienced a complication within 30 days of surgery which resolved without further surgical intervention. However, patients should be counseled regarding the potential for reoperation, as 22% of patients required revision or removal of the AUS during our follow up period.

We present the largest prospective series to date of men undergoing AUS placement after radiation therapy, which remains the gold standard surgical intervention for management of SUI in this patient population. Our study demonstrates that men can have significant improvement with SUI with AUS placement. However, patients need to be counseled on the potential for reoperation.