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Also known as
Cuff erosion, urethral erosion, AUS erosion, urethral cuff erosion, device erosion, sphincter erosion, prosthesis erosion
Definition
Device Extrusion (AUS) is a serious complication of Artificial Urinary Sphincter implantation where device components, most commonly the urethral cuff, erode through surrounding tissue and become exposed1. This process typically involves the cuff eroding through the urethral wall, compromising the integrity of both the device and urethral tissue2. The erosion usually occurs on the ventral aspect of the urethra and secondarily on the lateral aspects, with dorsal erosion being less common3. Device extrusion can lead to device infection, urinary tract infection, and ultimately device failure requiring explantation4. This complication represents one of the most significant adverse events associated with AUS implantation, with reported rates between 3.8–10% in published literature5.
Clinical Context
Device Extrusion (AUS) occurs in the clinical setting of male stress urinary incontinence treatment with Artificial Urinary Sphincter implantation. Several patient factors increase the risk of this complication, including previous radiation therapy (“fragile urethras”), previous urethroplasty surgery, hypogonadism with low testosterone levels, older age (greater than 80 years), diabetes, need for anticoagulation, and history of stroke or coronary artery disease1,4.
Perioperative factors that may contribute to device extrusion include urinary retention in the acute postoperative phase, prolonged urinary catheterization (>48 hours), and endoscopic manipulation with an activated AUS2. Device-specific considerations include cuff size, with smaller cuffs (3.5 cm) potentially increasing the risk of erosion3. Pelvic radiation has been shown to increase the risk of erosion by 41.1% compared to non-radiated patients5.
Patients with device extrusion may present with a spectrum of symptoms ranging from minor changes in urinary symptoms to sepsis2. Common presenting symptoms include scrotal inflammatory signs (tenderness, erythema, swelling), obstructive voiding symptoms, and worsening incontinence2. Some patients may be asymptomatic, with erosion discovered during routine follow-up cystoscopy4.
Diagnosis is primarily made through cystoscopy, with retrograde urethrogram serving as an adjunct study2. Management requires device explantation, with timing varying based on patient condition. In septic patients with obvious signs of infection, urgent explant is necessary, while stable patients without concerning infectious symptoms can undergo explant on an outpatient basis2. Various surgical approaches have been developed to prevent recurrence, including transcorporal cuff placement, rectus fascial wrapping, and in-situ urethroplasty at the time of explant3,5.
After explantation, a period of urethral rest is necessary before considering reimplantation. Patients must be counseled about the higher risk of recurrent erosion with secondary implantation (up to 4 times higher)4. Despite these challenges, many patients ultimately achieve satisfactory continence with appropriate management and surgical technique1.