Wally Mahfouz

What Is the Evidence Supporting the Implantation of an Artificial Urinary Sphincter (AUS) Before or After Adjuvant Radiotherapy in Patients With Post-Prostatectomy Incontinence?

Dear Editor: Post-prostatectomy incontinence is an important complication after radical prostatectomy in term of impairment of quality of life. It often requires insertion of an artificial urinary sphincter (AUS) as a treatment. Adjuvant radiotherapy is a possible option for local recurrences after radical prostatectomy, and therefore timing of implantation of an AUS in these cases is conflicting; whether prior to or after adjuvant radiotherapy. Success with the AUS for the treatment of PPI is generally excellent, with continence rates between 75% and 90% in most modern series and patient satisfaction rates of 85–95% despite high revisions rate. Infection of the AUS and urethral erosion are often reported together and are usually related. The incidence of infection/erosion ranges from 0% to 25% when reported as a single entity. Previous radiotherapy to the pelvis is not a contraindication for AUS placement in men as the ultimate outcome in term of continence seems to be similar whether or not they have received radiation therapy. However, urethral atrophy, erosion, and infection requiring surgical revision has been reported with a higher incidence rate in irradiated patients compared with those not irradiated (41% vs. 11%). Martins and Boyd used AUS in patients following major pelvic surgery and/or radiotherapy. He categorized the patients into three distinct groups, including those who underwent different types of major pelvic surgery without radiotherapy, those who underwent radiotherapy either as definitive or adjuvant treatment and those with a neobladder. Infection and erosion were more common in the postradiation group compared to those who were not irradiated. Inadequate cuff compression and urethral atrophy were also more common in the post-irradiation group. Radiation therapy was associated with 53% of the revisions for inadequate cuff compression and functional urethral atrophy. Walsh et al. compared the long-term outcome of AUS implantation in patients after prostatectomy, with and without prior history of irradiation. The overall surgical revision was equally common in irradiated (36%) and nonirradiated (24%) patients. Urethral atrophy, infection, and erosion requiring surgical revision weremore common in irradiated patients (41% vs. 11%) Yet 70% of patients reported significant improvement in continence, regardless of previous irradiation. Patient satisfaction remained high with >80% of patients stating they would undergo surgery again or recommend it to others. We cannot find in recent literature mention of the outcome of AUS surgery when the implantation was prior to radiation. With newer and more refined radiation therapy techniques, the anatomical integrity of the bulbar urethra can be spared the deleterious effects of high-dose radiation, thereby anticipating an acceptably low risk for radiation-induced erosion of approximately 13%.