Secondary or revision surgeries after AUS implantation are a challenging topic. Multiple salvage techniques has been described for implantation of artificial urinary sphincter in patients with fragile urethra. The transcorporal cuff placement has been used since 1986 in setting of urethral erosion or other compromise conditions, that require suitable surgical approaches. However, the transcorporal approach has also some disadvantages like limited lateral and ventral urethral protection. Using the corpora cavernosa flaps was first described by J. Chouhan et al. and provide a variation of the transcorporal technique for cuff placement to overcome these disadvantages(1). We performed a transcorporal cuff placement adding bilateral tunica albuginea flaps in 5 patients at the highest risk for urethral erosion.

We used a perineal approach, the bilateral tunica albuginea flaps were harvested and sutured in the midline covering ventral and lateral urethra, the dorsal surface was also reinforced as the cuff was placed transcorporally. The aim was to cover the whole circumference of the urethra with extra tissue to provide more protection in case of fragile urethra due to history of urethral cuff erosion or urethroplasty.  
We included the data of 5 patients between Oct. 2022 and Feb. 2023. All the patients had more than 2 previous cuff erosions, in addition 2 had a history of urethroplasty. All patients complained about severe stress urinary incontinence and consequently reduced quality of life. The procedure was performed as a salvage technique after all the patients have been given comprehensive information.

In all cases the surgery was successfully completed, no intra-operative complications were reported. In 2 cases with ≥3 previous urethral cuff erosions, the cuff was placed around the urethra but was left open in situ to not compromise the healing process of the urethra. In these 2 cases the cuff was closed after 4 weeks in a second short procedure. The AUS was activated after 6-8 weeks. The continence results were satisfactory, 3 of 5 were socially dry and the remaining 2 patients reported using 2 pads in 24hours.

This short term results are promising and the technique can provide an alternative approach in case of urethral erosion or other difficult conditions. However longer follow ups and bigger cohorts are needed to confirm this results.

Dealing with urethral complications after AUS implantation remains a challenging topic in reconstructive urology.  Using the tunica albuginea flap may provide a salvage procedure in complex cases after urethral cuff injuries. However long-term results must be awaited, and this technique should be reserved to expert centers.

Vasan R, Myrga J, Miller D, Patnaik S, Morrill C, Rusilko P. The Gullwing Technique: A Novel Method of Transcorporal Artificial Urinary Sphincter Placement for the Fragile Urethra. Urology. 2022 Nov;169:237-240. doi: 10.1016/j.urology.2022.06.032. Epub 2022 Jul 16. PMID: 35843352.