Transcorporal approach for artificial urinary sphincter (AUS) implantation has been developed to lower the risk of urethral erosion. To date, its safety remains poorly known. The aim of our study was to compare transcorporal vs bulbar AUS implantation in men with fragile urethra and to investigate the risk factors of AUS explantation in this patient population.

The charts of all male patients who had an AUS implantation between 2004 and 2020 in 16 centers were reviewed retrospectively. . Only patients with a fragile urethra were included in the present analysis. Fragile urethra was defined as a urethra carrying a high risk of cuff erosion because of prior radiotherapy and/or history of AUS explantation and/or history of urethral stricture surgery. The patients were divided in two groups according to the implantation site: bulbar vs transcorporal. The primary endpoint was device explantation-free survival. Explantation was defined as any surgical intervention requiring complete removal of the AUS without immediate reimplantation (infection, erosion, decreased bladder capacity/compliance). Another study’s endpoint was reoperation-free survival. Reoperation was defined as explantation and/or revision. Revision was defined as any surgical intervention consisting in replacing one or more components of the device.

Out of 1363 male patients who underwent an AUS implantation over the study period, 464 patients were included for analysis. Eighty-eight patients underwent a transcorporal AUS implantation and 376 underwent a bulbar AUS implantation. The proportion of patients who experienced at least one post-operative complications was comparable in both groups (13.5% vs. 17.7%; p=0.33). The explantation-free survival in the transcorporal group paralleled the one of the bulbar group (estimated 5-year explantation-free survival rates 55.3% vs. 58.4%; p=0.98). The reoperation-free survivals did not differ significantly between both groups (estimated 5-year reoperation-free survival rates: 44.6% vs. 42%; p=0.51). In the subgroup of patients with an history of previous AUS explantation, patients of the transcorporal group tended to have a longer explantation-free survival (2-year explantation-free survival: 61.9% vs. 58.2%; p=0.096). In multivariate Cox regression analysis, the only risk factor of shorter explantation free survival was the history of previous AUS explantation (HR=2.65; p=0.01)

In the present multicenter cohort, transcorporal AUS implantation was not associated with longer explantation-free nor reoperation-free survival in male patients with fragile urethras compared to bulbar implantation. Transcorporal and bulbar AUS implantation brought similar functional and perioperative outcomes. History of previous AUS explantation was the only risk factor associated with shorter explantation-free survival in the transcorporal group. In other subgroups (e.g. irradiated patients, history of urethroplasty) in the light of our findings and given that transcorporal implantation after failure of a bulbar AUS has been proven feasible but not the opposite, transcorporal AUS might be regarded solely as a back-up plan when bulbar dissection appears technically impossible intraoperatively.

Transcorporal AUS does not lower the risk of urethral erosion in men with fragile urethras. However, patients with history of previous AUS explantation might draw benefits from this approach. Further studies are needed to elucidate the exact benefits of transcorporal approach for each subgroup of patients with fragile urethras.