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JU INSIGHT Artificial Urinary Sphincter Cuff Downsizing Improves Continence Cases of Sub-cuff Atrophy

By: Kevin Krughoff, MD, Oregon Urology Institute, Springfield; Brent D. Nosé, MD, Duke University Medical Center, Durham, North Carolina; Andrew C. Peterson, MD, Duke University Medical Center, Durham, North Carolina | Posted on: 20 Apr 2023

Krughoff K, Nosé B, Peterson AC. Artificial urinary sphincter cuff downsizing improves continence and patient satisfaction in cases of sub-cuff atrophy. J Urol. 2023;209(4):742-751.

Study Need and Importance

The artificial urinary sphincter (AUS) is the reference standard for high-volume stress urinary incontinence (SUI). The need for surgical revision is often required. Sub-cuff atrophy is a commonly attributed indication; however, the workup, management, and theory remain controversial owing to loose definitions and under-reported outcomes.

What We Found

We report continence and satisfaction outcomes when AUS cuff downsizing is performed, using an objective set of criteria for sub-cuff atrophy. We fill the AUS with isotonic contrast solution and obtain baseline radiographs at the activation appointment. In the event of recurrent SUI, sub-cuff atrophy is defined by the appearance of an incompletely coapting cuff on cystoscopy and an increase in cuff fullness on x-ray (see Figure). From 2011-2021, complete data were available for 31 men with post-prostatectomy incontinence and recurrent SUI attributed to sub-cuff atrophy alone. Downsizing took place after a median of 6.1 years. Fifteen (44%) patients had a history of pelvic radiation, and 3.5-cm cuffs were used in 8 (23.5%) cases. Nearly all reported improved continence, with one-quarter completely out of pads. Decreases in American Urological Association Symptom Score bother scores and pad counts were statistically significant. After a median of 3.4 years, 24 (70.6%) of downsized AUSs remained in situ, 2 (5.9%) were further downsized, 2 (5.9%) required replacement for mechanical failure, 4 (11.8%) were removed for erosion, and 2 (5.9%) were replaced for pressure regulating balloon herniation.

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Figure. Baseline after artificial urinary sphincter activation (A), increased cuff fullness 14 months later (B), and baseline activation after cuff downsizing (C).

Limitations

Lack of a continence-focused questionnaire is a weakness of our data, and retrospective cohorts are subject to bias toward more compliant and/or motivated patients who elect to undergo AUS downsizing. The follow-up interval after downsizing was shorter than the typical interval to replacement among native devices.

Interpretation for Patient Care

AUS cuff downsizing restores continence and improves patient satisfaction when cystoscopy and radiography are used to diagnose sub-cuff atrophy.

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