Artificial urinary sphincter in patients following major pelvic surgery and/or radiotherapy: are they less favorable candidates?

Between January 1988 and December 1992 the AMS800* artificial urinary sphincter was inserted in 81 men with urinary incontinence due to major pelvic surgery and/or radiation therapy. Radical retropubic prostatectomy had been performed in 38 men, radical retropubic prostatectomy with adjuvant radiation in 28, definitive radiation therapy for prostatic carcinoma in 5, abdominoperineal resection with adjuvant radiation in 1 and radical cystectomy with orthotopic urinary diversion in 8, while 1 suffered major pelvic trauma with urethral rupture. A bulbar urethral cuff was used exclusively, with pressure regulating balloons of 51 to 60 and 61 to 70 cm. water. The interval for primary activation ranged from 4 to 12 weeks (mean 7.7), with all irradiated patients waiting 12 weeks. Surgical revision was required in 38% of the patients totaling 43 operations. Inadequate cuff compression after presumed urethral atrophy secondary to hypovascularity accounted for 74% of the procedures, whereas infection with or without erosion necessitated 8 revisions, mostly attributable to improper placement elsewhere of an indwelling catheter after the artificial urinary sphincter had been activated. Mechanical malfunction was responsible for 7% of the revisions. Overall, socially acceptable continence was achieved in 91% of the study population. Despite a significantly greater need for revision in this high risk group (38% versus 22% in the literature for low risk groups) with meticulous surgical and sterile techniques as well as diligent followup, the long-term outcome in terms of continence and device survival may be excellent regardless of the underlying etiology. We conclude that use of the AMS800 artificial sphincter for significant male urinary incontinence is undoubtedly the most efficacious treatment currently available for which even the most adverse candidate should not necessarily be excluded.