Management of male stress urinary incontinence in high-risk patients: a narrative review

BACKGROUND AND OBJECTIVE: The artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence (SUI). However, highly complex patients such as those with bulbar urethral compromise, bladder pathology, and lower urinary complications pose a particular challenge for the surgeon. In this article, we will address critical risk factors and synthesize existent data across relevant disease states to support surgeons in successful management of SUI in high-risk patients. METHODS: A comprehensive review of current literature was performed utilizing the search term “artificial urinary sphincter” in conjunction with any of the following additional terms: “radiation”, “urethral stricture”, “posterior urethral stenosis”, “vesicourethral anastomotic stenosis”, “bladder neck contracture”, “pelvic fracture urethral injury”, “penile revascularization”, “inflatable penile prosthesis”, and “erosion”. Guidance is provided based upon expert opinion where existing literature was sparse or nonexistent. KEY CONTENT AND FINDINGS: Several known patient risk factors are associated with AUS failure and can ultimately lead to device explantation. Each risk factor requires careful consideration and investigation, or intervention as appropriate, prior to device placement. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients. Several surgical strategies to decrease device complications can be considered: optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation. CONCLUSIONS: A number of patient risk factors are associated with AUS failure and can ultimately lead to device explantation. We present an algorithm for management of high-risk patients. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients.