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JU INSIGHT Urethral Stricture After Artificial Urinary Sphincter Cuff Erosion Is Uncommon Without Pelvic Radiation

By: Kevin Krughoff, MD, Oregon Urology Institute, Springfield; Thomas Dvergsten, BA, Duke University Hospital, Durham, North Carolina; Jordan R. Foreman, MD, Duke University Hospital, Durham, North Carolina; Andrew C. Peterson, MD, MPH, Duke University Hospital, Durham, North Carolina | Posted on: 20 Jul 2023

Krughoff K, Dvergsten T, Foreman JR, Peterson AC. Urethral stricture formation after artificial urinary sphincter cuff erosion is uncommon in the absence of pelvic radiation. J Urol. 2023;210(1):136-142.

Study Need and Importance

Erosion and infection comprise the most morbid artificial urinary sphincter (AUS) complications. The presentation of cuff erosion is highly variable, and the risk of subsequent stricture development is poorly understood.

What We Found

Our standard management approach for AUS erosion consists of reapproximating the fibrous pseudocapsule to facilitate more rapid healing of the damaged urethra and spongiosum. A urethral catheter is left in place, a peri-catheter retrograde urethrogram (RUG) is performed 3 weeks later, and a cystoscopy is performed after 3 months. We reviewed all erosion cases over a 10-year period and categorized each case on the basis of erosion severity (see Figure). We did not find an association between stricture development and severity of erosion as we had hypothesized. Instead, post-erosion strictures occurred almost exclusively (95.5%) in the setting of prior radiation. Similarly, strictures almost never developed in the absence of radiation regardless of erosion severity. For those with a history of radiation, extravasation on post-erosion RUG was strongly associated with stricture development.

Figure. Erosion severity grades. Top left: grade 1, <25% circumferential erosion. Top right: grade 2, 25%-50% circumferential erosion. Bottom left: grade 3, 51%-99% circumferential erosion. Bottom right: grade 4, 100% erosion.

Limitations

The proportion of high-grade erosions was outnumbered considerably by the number of low-grade erosions. Comparisons to other studies are limited due to variable follow-up patterns and stricture definitions. In some cases strictures take years to develop and likely not all were captured.

Interpretation for Patient Care

Erosion of the AUS cuff into the urethra does not lead to urethral stricture formation in most cases and is not associated with degree of erosion at time of presentation. Those who develop strictures nearly always have a history of pelvic radiation. Post-erosion RUG may help risk-stratify patients for follow-up purposes and treatment expectations.

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