Urinary Diversion as Last Option After Failed Artificial Urinary Sphincter and Iatrogenic Devastated Bladder Outlet

To describe functional outcomes and identify risk factors for artificial urinary sphincter (AUS) failure and need for urinary diversion (UD) in patients with iatrogenic devastated bladder outlet (DBO). Our hypothesis was that pelvic radiation or ablative therapy (RT/AT) increases the risk of complications compared to surgery alone.

Multicenter, retrospective study of patients with complications from previous treatments, subsequent AUS failure and unsalvageable DBO, ultimately requiring UD between 2008 and 2020. Demographics, comorbidities, prior treatments, reconstructive attempts, and type of UD ± extirpative procedures were reviewed. The patients were divided into two groups according to their primary treatment: G1 (RT/AT±surgery) and G2 (surgery alone).

We identified 34 patients with DBO requiring UD after AUS failure. Primary diagnoses were prostate cancer (88.2%), anal cancer (2.9%), and benign prostatic obstruction (8.8%). Primary treatments were RT/AT±surgery in 27 (G1) and surgery alone in seven (G2). Complications included bladder outlet obstruction, fistulae, and urinary incontinence. Number of AUS implantations (range 1-4) and failed reconstructive attempts before UD (range 1-12) were more prevalent in G2. Time from completion of primary treatment to first complication was longer in G1, while from first complication to UD shorter in G1. Details regarding UD, extirpative procedures, and further complications are described.

Exposure to pelvic RT/AT and complexity of primary surgical treatments combined with AUS complications and repeated failed attempts at surgical reconstruction can generate a high-risk patient profile associated with an unsalvageable DBO leading patients to ultimately opt for UD as a trade-off for QoL.