Evaluating the Impact of Centralizing Artificial Urinary Sphincter Implantation Services in France: A National Population-Based Model on Travel Times, Equity, and Patient Outcomes
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Transcorporal Artificial Urinary Sphincter Cuff Placement in a Case Requiring Revision for Urethral Atrophy
Published on: June 16, 2022
Louis Lenfant1, Yoann Taillé2, Emmanuel Chartier-Kastler3
1Department of Urology, Pitié Salpêtrière Academic Hospital, Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Paris, France. louis.lenfant@aphp.fr.
Purpose:
Higher annual center volume for artificial urinary sphincter (AUS) implantation is associated with improved survival without device removal. We assessed the impact of four centralization scenarios on AUS removal rates, patient travel burden, and workload redistribution to inform healthcare policy.
Materials And Methods:
We conducted a national, population-based cohort study using the Observapur database, which includes all men in France treated for prostate cancer or benign prostatic hyperplasia who underwent their first AUS implantation between 2006 and 2018. Patients were identified using reimbursement codes; 7,776 had complete geographic data. We modeled four centralization scenarios: (A) closure of very low-volume centers (<1 AUS procedure/year); (B) closure of low-volume centers (<5 procedures/year); (C) closure of centers performing <10 procedures/year with reallocation to high-volume centers (>20 procedures/year); and (D) closure of centers with the highest AUS removal rates. The primary outcome was the predicted 1- and 2-year AUS removal rate. Secondary outcomes included changes in travel distances and workload redistribution.
Results:
Annual closures ranged from 25 centers (Scenario A) to 138 centers (Scenario C), affecting 381 (Scenario A) to 3,250 (Scenario C) patients. Travel distances increased from -1.8 km (Scenario A) to +43.6 km (Scenario C). AUS removal risk was reduced across all scenarios at 2 years: Scenario A (24.0%), B (25.2%), C (33.8%), and D (19.3%). Workload redistribution was highest in Scenario C, where 65 centers experienced a >50% increase in procedures.
Conclusions:
Centralizing AUS implantation improves patient outcomes by reducing device removal rates, but the impact on additional workload varies. Scenario C offers the greatest survival benefit but imposes the highest travel and workload burden. Moderate centralization (Scenarios A or B) provides a balanced approach, improving outcomes while maintaining accessibility and feasibility.
