Near‐Obliterative Bulbar Urethral Stricture 12 Years After Artificial Urinary Sphincter Implantation: A Case Report

ABSTRACT

Introduction

Artificial urinary sphincter implantation is guideline‐supported for post‐prostatectomy stress urinary incontinence; however, ultra‐late urethral deterioration remains poorly characterized.

Case Presentation

A 66‐year‐old man underwent radical retropubic prostatectomy in December 2006, followed by salvage radiotherapy in April 2007. Twelve years after artificial urinary sphincter implantation, intraluminal cuff exposure was incidentally detected on cystoscopy before urethral catheterization for orthopedic surgery. Urinalysis at diagnosis and pre‐explant urine culture were unremarkable. Explantation was delayed for 5 months because of patient preference after counseling about infection and urethral injury risks. At explantation, the bulbar urethra showed near‐obliterative circumferential collapse with loss of architecture, requiring excision and primary anastomosis urethroplasty (EPA). Obstructive symptoms recurred within 2 months, and recurrent stricture was confirmed endoscopically; suprapubic cystostomy was required at 3 months.

Conclusion

This case demonstrates ultra‐late advanced urethral deterioration beyond focal cuff erosion or simple atrophy. In high‐risk radiated patients, explantation may not restore urethral integrity.

Keynote Message

Artificial urinary sphincter implantation may be associated with severe urethral deterioration more than a decade after placement, particularly in patients with prior pelvic radiotherapy. This case showed diffuse circumferential urethral collapse rather than a small focal erosion. Immediate EPA failed rapidly, and long‐term suprapubic urinary diversion was required. Lifelong surveillance, clear transfer documentation, and careful evaluation before urethral catheterization may help high‐risk patients avoid delayed recognition of serious urethral injury.

1. Introduction

Artificial urinary sphincter (AUS) implantation is a standard surgical option for male post‐prostatectomy stress urinary incontinence. AUA/GURS/SUFU and EAU guidance support AUS use in selected men, while emphasizing counseling regarding erosion, infection, failure, and reintervention [1, 2]. AUS cuff erosion may lead to urethral stricture, fistula, and compromised future continence surgery [1, 3, 4, 5]. We report near‐obliterative circumferential urethral collapse 12 years after AUS implantation in a radiated patient.

2. Case Presentation

A 66‐year‐old man underwent open radical retropubic prostatectomy for localized prostate cancer in December 2006. He had no diabetes mellitus at that time. Four months later, postoperative PSA recurrence was detected, and salvage three‐dimensional conformal external‐beam radiotherapy was initiated in April 2007. A total dose of 70.4 Gy was delivered in 32 fractions, 2.2 Gy per fraction over 7 weeks. After a subsequent PSA rise, oral bicalutamide monotherapy was initiated in September 2008. No concomitant LHRH agonist or antagonist was administered. Serum testosterone levels were not available.

Seven years after prostatectomy, an AMS 800 AUS was implanted at our institution. The urethral circumference was 3.5 cm, and a 4.0 cm cuff was selected. Standard bulbar cuff placement was performed; transcorporal placement was not performed and was not explicitly documented as considered. Retrospective review suggested that the cuff was slightly more distal than the typical proximal bulbar location, but the operative record did not provide a rationale.

The early postoperative course was uneventful, and continence improved. After follow‐up at our institution, structured AUS‐specific follow‐up was interrupted, and the patient continued care elsewhere mainly for prostate cancer surveillance; routine cystoscopic AUS surveillance was not documented.

Twelve years after AUS implantation, orthopedic surgery was planned, and perioperative urethral catheterization was requested. Cystoscopy was performed at the outside institution to assess the AMS 800 before catheter placement. This revealed intraluminal cuff exposure, and the patient was referred back to our institution.

At diagnosis, urinalysis was normal and showed no pyuria. During outside follow‐up, no obstructive symptoms, dysuria, hematuria, recurrent urinary tract infection, or related antibiotic treatment were documented. Before explantation, urinalysis and urine culture were unremarkable. The cystoscopy record did not describe luminal narrowing in detail; mild or moderate stricture could not be excluded retrospectively, but near‐obliterative stricture was not documented.

Timely explantation was recommended because of infection and urethral injury risk; however, the patient wished to defer surgery for personal and logistical reasons. Explantation was performed approximately 5 months after diagnosis.

At explantation, the bulbar urethra showed profound circumferential narrowing with loss of normal architecture. The lesion appeared as a circumferentially collapsed, near‐obliterative segment rather than a discrete focal erosion defect (Figures 1, 2, 3). Because the cuff‐bearing segment appeared severely compromised and stenotic on intraoperative macroscopic assessment, excision and primary anastomosis urethroplasty (EPA) was performed.

FIGURE 1.

Near‐obliterative urethral stricture immediately after removal of the AUS cuff.

FIGURE 2.

Near‐obliterative urethral stricture immediately after removal of the AUS cuff, grasped with forceps.

FIGURE 3.

Intraoperative view after transection of the urethra at the site of the near‐obliterative stricture for EPA.

Postoperative retrograde urethrography before recurrence was unavailable. Obstructive symptoms recurred within 2 months, and severe recurrent stricture was confirmed endoscopically (Figure 4). At 3 months, suprapubic cystostomy was required. AUS reimplantation was not pursued. Diabetes mellitus was absent at prostatectomy; HbA1c was 6.5% at explantation, with no history of sodium‐glucose cotransporter 2 inhibitor use.

FIGURE 4.

Recurrent urethral stricture after EPA. The stenotic segment was impassable with a flexible cystoscope, requiring a flexible ureteroscope to visualize the urethral lumen.

3. Discussion

This case represents extreme AUS‐related urethral morbidity: ultra‐late near‐obliterative circumferential collapse beyond focal erosion or simple atrophy.

Radiotherapy was probably the dominant background risk factor. Radiation‐induced urethral injury is associated with hypovascularity, fibrosis, tissue contraction, and impaired healing [6]. Androgen‐axis manipulation with bicalutamide monotherapy may have contributed, although this remains speculative. Because bicalutamide monotherapy does not necessarily reduce serum testosterone and serum testosterone levels were unavailable, hypogonadism cannot be inferred in this case. Low serum testosterone has been associated with AUS erosion, whereas androgen deprivation therapy exposure has not consistently shown adverse AUS outcomes [7, 8]. Diabetes should be interpreted cautiously: it was absent at prostatectomy, HbA1c was 5.8% in 2014 and 6.5% at explantation, and there was no SGLT2 inhibitor exposure. Thus, diabetes was not considered a primary driver but may have been a late wound‐healing modifier.

A 4.0 cm cuff was selected for a 3.5 cm urethral circumference; therefore, this case should not be attributed simply to cuff undersizing. Although 3.5 cm cuffs have been associated with higher erosion risk in irradiated men, conventionally selected sizing does not necessarily protect a radiated urethra from ultra‐late deterioration [9]. Slightly distal cuff placement may have contributed to chronic local compression, but the operative record did not clarify whether this reflected surgical choice or radiation‐related anatomical constraints. Transcorporal cuff placement may be considered for selected fragile urethras [10, 11]. In current practice, this risk profile would prompt broader counseling regarding alternative cuff strategies and possible diversion.

The 5‐month delay was not the sole cause. No urinary tract infection was documented at diagnosis or before explantation. We hypothesize that chronic subclinical injury from radiation‐related vascular compromise and prolonged cuff compression was accelerated by persistent exposure through mechanical irritation, local inflammation, and ischemia.

Urethral management at AUS explantation is debated. AUA/GURS/SUFU guidance recognizes catheter drainage alone, in situ urethroplasty, and anastomotic urethroplasty as options after eroded AUS removal [1]. Less invasive explantation with urethral rest may be reasonable in many cases, while synchronous repair has been supported in selected series; multicenter data show heterogeneous outcomes [3, 4, 12]. In this case, immediate EPA was not routine management. A staged substitute urethroplasty would have been an alternative strategy; however, the urethra was circumferentially collapsed and appeared severely compromised on intraoperative macroscopic assessment, and simple cuff removal with drainage alone was considered unlikely to restore a functional lumen. EPA was therefore selected as a salvage procedure to reconstitute tubular continuity.

Rapid restenosis within 2 months is atypical after routine AUS explantation. Rather, it likely reflects the biological limitations of reconstruction in a severely compromised radiated urethral bed. Similar high‐risk patients should be counseled that explantation and reconstruction may fail and that staged reconstruction or chronic suprapubic diversion may be necessary.

4. Conclusion

Ultra‐late AUS cuff exposure in a radiated patient may present as near‐obliterative circumferential urethral collapse rather than focal erosion. Even conventionally selected cuff sizing and device explantation may not restore urethral integrity. Lifelong surveillance, clear documentation when follow‐up is transferred between institutions, careful evaluation before urethral catheterization, and counseling regarding reconstruction versus urinary diversion are essential.

Ethics Statement

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.