The artificial urinary sphincter (AUS) is the standard surgical treatment for moderate-to-severe stress urinary incontinence (SUI) in men. (1) Infection and/or erosion occurs in approximately 8.5% of patients within two years after implantation. (2) However, these outcomes are typically reported over extended follow-up periods and often result from hematogenous spread or mechanical factors, rather than intraoperative contamination. Early infection, defined as diagnosis within three months postoperatively, is more likely related to perioperative factors such as antibiotic coverage, sterile technique and tissue handling. Given the absence of standardized guidelines for antibiotic prophylaxis in AUS surgery, significant inter-institutional variability exists. The objective of this study was to determine the incidence of early infection following AUS surgery and to compare perioperative antibiotic protocols across centers, with specific attention to antimicrobial stewardship.

We conducted a retrospective single-center study of 255 AUS surgeries performed between October 2016 and October 2023 in male patients as a treatment for SUI (neurogenic or secondary to prostate surgery or radiotherapy). All implants were AMS 800®. The procedures were performed by one of two experienced surgeons or by a fellow under direct supervision. Early infection was defined as any clinical sign of prosthetic infection requiring explantation within three months. Additionally, we contacted AUS implantation centers across Flanders to assess variability in prophylactic antibiotic protocols.

A total of 255 AUS surgeries were performed on 206 male patients. Of these, 148 (58.0%) were primary implantations, while 107 (42.0%) were reinterventions. The early infection rate was 3.1% (8 out of 255), equally divided between primary implantations and reinterventions. Four of these patients presented with concurrent urethral erosion. All patients received prophylactic antibiotics, most commonly cefazolin alone (53.3%) or combined with amikacin (35.3%), as detailed in table 1. Deviations were based on patient-specific factors or preoperative culture results. Eight out of ten contacted AUS-implantation centers in Flanders provided information on their perioperative antibiotic protocols, revealing substantial heterogeneity (Table 2). Reported regimens ranged from single-dose cefazolin to broad-spectrum combinations, with durations ranging from a single dose to seven days, and in some cases including antifungal agents.

Our current protocol— 24 hours of cefazolin with a single dose of amikacin —was reviewed with the microbiology department and found to provide adequate coverage of identified pathogens. This regime appears sufficient to maintain a low early infection rate and supports avoiding prolonged postoperative antibiotics, in line with antimicrobial stewardship. In contrast, the marked variability observed across centers shows a lack of consensus regarding optimal prophylaxis. The use of broader-spectrum or prolonged regimens in some centers may increase the risk of antimicrobial resistance without clear benefit.

Early infection is a relevant parameter for evaluating perioperative factors such as prophylactic antibiotic protocols. Our low rate of 3.1% supports the use of short-course prophylaxis. Nevertheless, substantial variation in antibiotic protocols was observed across centers, ranging from single-dose cefazolin to seven-day broad-spectrum regimens. This underscores the need for standardized guidelines for infection prevention in urological prosthesis surgery, incorporating local microbiological data and principles of rational use of antibiotics.

Gacci M, Sakalis VI, Karavitakis M, Cornu JN, Gratzke C, Herrmann TRW, et al. European Association of Urology Guidelines on Male Urinary Incontinence. Eur Urol. 2022;82(4):387-98.
Van der Aa F, Drake MJ, Kasyan GR, Petrolekas A, Cornu JN, Group YAUFU. The artificial urinary sphincter after a quarter of a century: a critical systematic review of its use in male non-neurogenic incontinence. Eur Urol. 2013;63(4):681-9.