Stress urinary incontinence (SUI) is a common complication of prostate surgery with significant psychosocial and financial implications. Artificial urinary sphincter (AUS) has been the gold standard treatment for post-prostatectomy SUI since its introduction in the 1970s with excellent continence outcomes and high patient satisfaction. Implantation of AUS has been traditionally performed with an overnight hospital stay in most healthcare systems. As it is a relatively short operation in experienced hands without significant physiological disturbance, it is not unreasonable to be offered in a day-case setting with appropriate safety net in place.  To the best of our knowledge, there is very limited evidence available in the literature to support this practice. 

The aim of this prospective, comparative pilot study is to assess the feasibility, safety, and clinical outcomes of the AUS procedure in a day case setting against a similar cohort of patients having AUS implantation following the current standard of care with an overnight stay.

We conducted this prospective, comparative, non-randomised pilot study within a tertiary referral functional and reconstructive urology unit. We recruited patients who had been listed for AUS insertion for post prostatectomy stress urinary incontinence and were operated over an 18-month period. 

We included patients of any age who had transurethral, open retropubic, laparoscopic or robotic radical prostatectomy for benign prostatic obstruction (BPO) or prostate cancer complicated by stress urinary incontinence. We included patients with previous radiotherapy or stable metastatic disease on androgen deprivation therapy. We excluded patients who had previous major urethral surgery (urethroplasty), urological reconstruction or stress incontinence not related to prostate surgery. We also excluded redo AUS cases following infection/ erosion and patients who were deemed high risk for day-case surgery from the anaesthetic perspective. 

All patients who met the inclusion criteria were offered day case surgery. The patients who declined day case surgery or could not have day case surgery for logistical reasons had the standard of care treatment with overnight stay and formed the control group for the study.

The primary outcome of the study was the proportion of successful same day-discharges for the day case operations. We also reported complications for the two groups within the first 30 days and 1 year post surgery. Continence was assessed based on self-reported use of pads (per day) before the procedure and at 1 year post surgery. Finally, baseline demographic, clinical and urodynamics data were recorded and analysed for the two groups of patients.

Twenty-five patients were included in the study. Twelve patients consented for a day case procedure and 13 patients preferred to stay overnight and follow the standard of care pathway. Mean age of the participants was 69.5 years (range 58-79). Twenty-one patients (84%) had a primary AUS, whereas 4 patients (16%) had a redo procedure.  Sixteen patients (64%) had a history of robotic prostatectomy, 2 patients (8%) had previous laparoscopic prostatectomy and 2 patients (8%) had previous open prostatectomy. Four patients (16%) had SUI following transurethral prostate surgery for BPO. 

There were no statistically significant differences between the day case and overnight stay groups in the baseline demographic characteristics (age and BMI), clinical characteristics (ASA, previous urological surgeries, and history of radiotherapy) and urodynamic parameters. The only parameter that was significantly different between the two groups of patients was the duration of incontinence before the AUS implantation, which was significantly higher in the overnight stay group (median 36 vs 66 months, p=0.02). 

Eight of the 12 patients (66.7%) on the day-case group were successfully discharged on the same day. The reasons for the failed discharges included postoperative symptomatic bradycardia (n=1), slow recovery from the anaesthetic (n=1), initially high post void residuals which resolved without intervention (n=1) and decision to keep urethral catheter for 48 h due to suspected superficial urethral injury (n=1). 

At the end of the study, all patients in the day case group and all but one patient in the overnight stay group were continent or socially continent (0-1 pads/ 24h). Postoperative reduction in the number of pads (median -4 vs -3 pads, p=0.62) was not significantly different between the two groups of patients at the end of the study. Two patients in the day-case group experienced a Clavien-Dindo > 2 complication within 1 year post surgery but none required explantation of AUS. One patient in overnight stay group had his AUS explanted 6 months post surgery for infection/ erosion.

This prospective comparative pilot study demonstrated that the AUS procedure is feasible and safe for selected patients in an outpatient setting. The failed discharges in the day-case group of patients were mostly related with medical issues or delayed recovery from the anaesthetic. None of these patients needed intervention to resolve a procedure- related complication or to be readmitted in the hospital within 30 days of the procedure.  In addition, the midterm continence outcomes, and overall complications by the end of the study were comparable in the two groups and in keeping with the known outcomes of this procedure published in the literature.

Implantation of AUS is feasible and safe in selected patients with comparable continence outcomes and complication rates to those with standard overnight stays.