Reoperative Anti-incontinence Surgery

Repeat anti-incontinence surgery presents a challenging clinical entity due to altered anatomy and potentially impaired tissue health due to previous dissection, radiation, or infection. This document seeks to explore the etiologies leading to recurrent incontinence after primary intervention, outline a systematic approach to the evaluation of such patients, and explore our approach to the management of the most common scenarios. For patients with a prior artificial urinary sphincter (AUS), repeat surgery may be required due to atrophy, mechanical malfunction, or infection/erosion. We use a transcorporal technique for added tissue bulk in the setting of revision for urethral atrophy, a technique which was found to have significantly lower revision and cuff erosion rates while preserving erectile function. Recent studies demonstrate that both cuff downsizing and repositioning are associated with incontinence failure and downsizing has an additional statistically significant risk of mechanical failure. New strategies seeking to avoid such surgical revisions pursue urethral capsulotomy to restore urethral caliber. In the case of atrophy and mechanical malfunction, complete device exchange is typically performed if the initial implantation was performed within 3 years. When erosion is encountered, explantation of all components is performed, with consideration for a delayed reimplantation which can be technically challenging. In patients with persistent or recurrent urinary incontinence after male urethral sling placement, limited data is available. From the series available, AUS placement after a sling provides excellent outcomes.