AUA 2019: Artificial Urinary Sphincter Implantation As a Safe Procedure with Low Complication Rates Even in the Elderly and Comorbid Population

Chicago, Illinois (UroToday.com) During this podium session there were a variety of studies presented taking an intensive look at the treatment options for male patients with urinary incontinence. Male urinary incontinence, although commonly encountered following radical prostatectomy, has a very strong correlation with age. Simultaneously as our male patients age, there is an increased incidence of chronic medical conditions and frailty which may translate into a unique set of challenges when establishing a treatment plan. This applies particularly to urologists as surgeons offering procedures to patients that may be at an increased risk for perioperative complications or prolonged recovery. There is a possibility that this may contribute to the underutilization of this surgical procedure. The authors of this study were interested to determine the validity of the perceived dangers of operating on this patient cohort, specifically treating urinary incontinence with an artificial urinary sphincter (AUS) implantation. They hypothesized that even high-risk patients can safely have this surgical procedure.

This was a retrospective review of the National Surgical Quality Improvement Program (NSQIP) data, by identifying patients with CPT codes for AUS implantation from 2007 to 2015. They identified 1370 and then used ICD-9 codes to establish a Charleston Comorbidity Index (CCI) and Frailty Index (FI) for each of these patients. They then queried the NSQIP data for complications and converted them Clavien-Dindo classifications. Following this, they completed a weighted logistic regression to determine if there is a correlation between CCI and FI, with overall complication rates and subdivisions of Clavien grade I and grade III after controlling for age and anesthesia type.

In the data analysis, the average age of patients was 70 (+/- 9.6 years), BMI 29.6. 77% of the patients were Caucasian, and 96% received general anesthesia. Average CCI was 4.0 (+/-1.4) and of the patients identified, 47% had 1 FI condition and 25% had 2 or more FI conditions. For these patients, there was a 3% incidence of NSQIP complications reported. They did not find any correlation between CCI and Grade I complication risk (OR=1.11, 95% CI [0.89, 1.38], p=0.36), Grade III complication risk (OR=1.09, 95% [ 0.88, 1.35], p=0.45), and overall complication rates (OR=1.10 95% CI [0.93, 1.29], p=0.26). They reported they had similar results when looking at FI.
AUA 2019 Complication Rates

The conclusion that these authors had in regards to this information is that there is a low risk of complications in an elderly cohort with co-morbidities.  The aim of this study is valid to make sure that treating urologists do not discount older patients’ ability to tolerate surgical procedures. However, there are weaknesses to this study being that it was a retrospective review of NSQIP data, which may have reporting or selection biases, though this data did adjust for age and it could be applied to counseling patients with similar CCI and/or FI. In addition, NSQIP data is only looking at short-term perioperative complications, and much of the concern with complications with AUS implantation may be delayed as the patients become more elderly and unhealthy, such as improper use of the sphincter or cuff erosion. Prospective studies, or retrospective studies with longer-term follow-up, would add confidence to these conclusions.   


Presented by: Brian M. Inouye, MD, Duke Surgery, Duke School of Medicine 

Written by: Ross Moskowitz, MD, Assistant Clinical Professor of Urology, University of California Irvine Medical Center, Twitter: @rossmosk1 at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois