Stress urinary incontinence (SUI) is a form of involuntary leakage from the urethral orifice synchronous with effort or physical exertion, or on sneezing or coughing (1). Among men, SUI is mainly caused by radical prostatectomy for prostate cancer. Artificial Urinary Sphincter (AUS) is a treatment option for moderate to severe male SUI. The aim of this study was  to determine firstly the way patients are counselled about  AUS and secondly explore the patient experiences and expectations of perioperative counselling in order to improve care for this patient group in our academic teaching hospital.

A qualitative study using semi-structured, individual in-depth interviews amongst nine patients with AUS was conducted between July and August 2023. A topic list was used during the interviews. Topics related to patients’ perceptions concerning, symptoms, expectations, treatment and outcome. The audio recordings of the interviews were transcribed verbatim. The data analysis was conducted using inductive coding in three stages, searching for themes and subthemes relevant to answering the research question.

Qualitative analysis yielded several themes important in perioperative care for patients treated with AUS for SUI. The themes were: choice for AUS, empathy, expectation management and experienced follow up care.
Patients felt heard in their request for help and had confidence in their practitioners. The initiation of  AUS as an option for SUI was done by a referring urologist or the initiative came from the patient himself, based on peer experiences. 
The information about AUS, given by a urologist and the nurse practitioner was experienced as clear, but too technical and lack of empathy. When opted for AUS, most patients needed a patient story from a fellow sufferer who received an AUS already to gain a better idea of the follow-up process and life with AUS. 
Patients expected less incontinence after AUS and would therefore be able to participate in physical and social activities again. This expectation is fulfilled postoperatively for the majority of patients. There was no expectation of achieving complete continence after AUS. Clear explanation of the expected outcome measures prior to surgery by the practitioners was the most important reason for this outcome. 
The diagnosis of prostate cancer followed by a radical prostatectomy can result in incontinence and impotence as side effects and has a great impact on daily bases. The impact of these side effects on quality of life became mostly apparent after surgery with AUS. It’s a stepwise process regarding acceptation and adapting to these side effects. Appropriate follow up care on residual incontinence and impotence after treatment with AUS was missed.

Patients’ expectations preoperatively corresponded sufficiently to reality postoperatively. This could be explained because patients had high treatment benefit with AUS and therefore experienced a more positive result. Also the clear explanation of the expected outcome measures prior to surgery by practitioners is an explanation for this result. 
Nearly 80% of the patients after AUS remain dry or experience major improvement on SUI (2). However patients still experience minor incontinence which may also have psychosocial consequences. This does not take into account the changed sexuality and self-image. This could apply to a much larger proportion of surgical patients, including those who are dry. 
The psychosocial impact of urinary incontinence was also an important item in this study. This  emphasizes that it is important to pay attention to these items in medical and nursing follow-up care Practitioners under-report items as incontinence or erectile dysfunction (3). This could indicate that practitioners may also insufficiently respond to the remaining need for help after AUS or that patients find it difficult to discuss this explicitly in the consultation room. The attention and discussion of the life challenges after AUS that are currently missed by the patients in this study fits within the core tasks of a nurse practitioner or specialist but should not necessarily take place in a clinical setting.

In addition to the technical explanation, men who undergo surgery with AUS also need contact with peers about living with AUS. The expected discrepancy that was assumed between the patient's expectations preoperatively and the postoperative outcomes regarding incontinence has not been found. This study shows that patients do not expect to be 100% dry after surgery with AUS. The current perioperative counselling is adequate, but patients need more empathy from practitioners and contact with peers. Better attention should be paid to the psychosocial impact and consequences of incontinence due to prostate cancer after men had AUS.

1.	D’Ancona CD, Haylen BT, Oelke M, Herschorn S, Abranches-Monteiro L, Arnold EP, Goldman HB, Hamid R, Homma Y, Marcelissen T, Rademakers K, Schizas A, Singla A, Soto I, Tse V, de Wachter S. (2019) An international continence society (ICS) Report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol Urodyn. DOI: 10.1002/nau.23897
2.	van der Aa, F., Drake, M. J., Kasyan, G. R., Petrolekas, A., & Cornu, J.-N. (2013). The artificial urinary sphincter after a quarter of a century: A critical systematic review of its use in male non-neurogenic incontinence. European Urology, 63(4), 681–689. https://doi.org/10.1016/j.eururo.2012.11.034
3.	Tillier, C.N., Boekhout, A.H., Veerman, H., Wollersheim, B.M., Groen, P., van der Poel, H.G., van de Poll-Franse, L.V. (2023) Patient-reported outcome measures compared to clinician reported outcomes regarding incontinence and erectile dysfunction in localized prostate carcinoma after robot assisted radical prostatectomy: Impact on management. Urology Oncology. Sep 8. https://doi: 10.1016/j.urolonc.2023.08.001