To assess the incidence of re-intervention following AUS implantation for severe SUI post-radical prostatectomy. 
To identify risk factors associated with AUS-related re-interventions, including patient demographics and medical history. 
To evaluate the long-term efficacy of AUS implantation in achieving social continence.

The medical records from every patient who underwent AUS implantation between 2014 and 2023 were analyzed. Descriptive statistics were conducted on key variables, encompassing age at the time of surgery, primary comorbidities, habits, body mass index, incontinence grade before the procedure, as well as the subsequent follow-up spanning a maximum of 60-month period. Complication, revision and explantation rates were evaluated. Inferential statistics were employed with the dataset to achieve the study objectives, using SPSS - version 29.0.

During the mentioned span, 48 patients were included in the study, accounting 85 surgeries between AUS implantation, revision, substitution and explantation. In total, 62 AUS were implanted.
Radical prostatectomy accounted for the majority of SUI etiology (open surgery n=38; laparoscopic n=5; robotic n=3; transurethral resection (TURP) n=2). 
In terms of efficacy, after 93,5% (n=58) AUS implantation, social continence was achieved at least in the first 6 months. However, in 4 patients, this outcome was not achieved due to postoperative complications, namely, hematoma (n=3) and AUS early mechanical malfunction (n=1).
Of the total implanted AUS, 50% (n=31) sphincter required reoperation - 32,3% (n=20)  explantation and 17,7% (n=11) revision. Re-intervention causes were due to infection (14/62), erosion (14/62) and AUS malfunction (11/62). For the AUS implanted between 2014 and 2018, 1-year, 3-year and 5-year revision-free percentage were 88,6%, 71,4% and 68,6%, respectively. The average AUS lifetime was 68 months.
Re-intervention was statistically more frequent in patients with diabetes, obesity and peripheral arterial disease (p-value <0,001), while dyslipidemia and hypertension had no influence. Older patients (>70) have significantly more re-intervention rates than younger patients (<60) (ANOVA and Post-Hoc studies,  p-value = 0,034). Interestingly, we found significantly higher re-intervention rates for patients with previous urethral surgery, such as, previous urethrotomy, half of which re-interventions were due to urethral erosion. Nonetheless, there was no significant difference for patients with pelvic radiotherapy history. (p-value =0,18) Regarding etiology, re-intervention was more frequent in patients with a history of open radical prostatectomy, when compared with less invasive prostate surgeries (laparoscopic or robotic prostatectomy and TURP), although the difference was not statistically significant. (p-value =0,06) The second-time and third-time AUS implantation statistically increased the rate of re-intervention (62.5%), while the average lifetimes of AUS placed for the second and third times were 48.1 months and 23 months, respectively.

The findings of this study provide insight on the intricate landscape of AUS implantation and its outcomes.The noteworthy effectiveness of AUS in controlling SUI rivals with the high re-intervention rates, especially for AUS revision and explantation - highlighting the difficulties and complexity of long-term care associated with AUS. This is also demonstrated in various literature articles.
The average lifetime of the AUS was comparable to that reported in other studies, such as Montague et al. as well as the 5-year revision rates. However, our re-intervention rates were close to the maximum reported rates - that are commonly placed between 25-30%. Various explanations for this finding include differences in patient populations, variations in surgical techniques (perineal versus penoscrotal approach) or differences in follow-up protocols. Additionally, variations in surgical volume or experience among surgeons could also contribute to differences in outcomes. Further research is needed to explore these potential factors and elucidate their impact on re-intervention rates in AUS implantation.
On the other hand, Niranjan et al. also showed poorer outcomes for patients with diabetes and demonstrated no discernible increase in complication rates and revision surgery in previous irradiated patients. These findings are similar to ours.
In contrast, Ganesh et al. showed similar results for naïve versus second-time implanted AUS, while our study revealed higher re-intervention rates in second and third-time implanted AUS. 
Since multiple interventions increase the risk of complications in any surgery, our findings are plausible. Further research in this field should also be conducted to validate and expand upon our observations.

Half of the implanted AUS required re-intervention, indicating a notably high rate.
Older patients and cardiovascular risk factors (such as diabetes, obesity and peripheral artery disease) increase the risk for AUS related re-intervention. Previous urethral surgery and multiple AUS implantations are also significant risk factors. We found no difference regarding pelvic radiotherapy history. 
However, 93.5% achieve desirable social continence, reaffirming AUS implantation as the 'gold standard' for moderate-to-severe SUI management. 
More studies are needed to refine AUS implantation criteria and reduce re-intervention rates.

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Sathianathen, N.J., McGuigan, S.M. and Moon, D.A. (2014), AUS outcomes in irradiated vs non-irradiated patients. BJU Int, 113: 636-641. https://doi.org/10.1111/bju.12518
Raj, G. V., Peterson, A. C., Toh, K. L., & Webster, G. D. (2005). Outcomes following revisions and secondary implantation of the artificial urinary sphincter. The Journal of urology, 173(4), 1242–1245. https://doi.org/10.1097/01.ju.0000152315.91444.d0