Delayed management of artificial urinary sphincter cuff erosion: a case series.

Background: The artificial urinary sphincter (AUS) has been used to treat post-prostatectomy incontinence in men for decades with excellent outcomes and low complication rates. A successful AUS placement can dramatically improve the quality of life in men with stress urinary incontinence. Consequently, complications in this population can be devastating for the patient. One of the most troublesome complications is cuff erosion, which necessitates explantation of the device and dooms a man to recurrent incontinence. While the device can be replaced, device replacements are fraught with high erosion rates. Furthermore, it is not uncommon for men undergoing AUS placement to have multiple medical comorbidities that make urgent surgery for explantation unideal. Nonetheless, men with cellulitis and significant symptoms must undergo removal of an eroded AUS. There is little to no literature published on the timing or need for device removal in the man who has an asymptomatic erosion. Case Description: We report a case series of five men undergoing delayed or no explantation of an asymptomatic cuff erosion. All five men were asymptomatic at the time of presentation and underwent a delayed explant or no explant. No man required urgent device explant while the erosion was present. Conclusions: Urgent device explantation may not be necessary in the asymptomatic AUS cuff erosion, and further study may be able to elucidate men who can avoid removal of cuff erosion when no symptoms are present.

Multi-institutional analysis of clinical and imaging risk factors for detecting clinically significant prostate cancer in men with PI-RADS 3 lesions.

BACKGROUND: Most Prostate Imaging-Reporting and Data System (PI-RADS) 3 lesions do not contain clinically significant prostate cancer (CSPCa; grade group ≥2). This study was aimed at identifying clinical and magnetic resonance imaging (MRI)-derived risk fac- tors that predict CSPCa in men with PI-RADS 3 lesions. METHODS: This study analyzed the detection of CSPCa in men who underwent MRI-targeted biopsy for PI-RADS 3 lesions. Multivariable logistic regression models with goodness-of-fit testing were used to identify variables associated with CSPCa. Receiver operating curves and decision curve analyses were used to estimate the clinical utility of a predictive model. RESULTS: Of the 1784 men reviewed, 1537 were included in the training cohort, and 247 were included in the validation cohort. The 309 men with CSPCa (17.3%) were older, had a higher prostate-specific antigen (PSA) density, and had a greater likelihood of an anteriorly located lesion than men without CSPCa (p < .01). Multivariable analysis revealed that PSA density (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.05-1.85; p < .01), age (OR, 1.05; 95% CI, 1.02-1.07; p < .01), and a biopsy-naive status (OR, 1.83; 95% CI, 1.38-2.44) were independently associated with CSPCa. A prior negative biopsy was negatively associated (OR, 0.35; 95% CI, 0.24-0.50; p < .01). The application of the model to the validation cohort resulted in an area under the curve of 0.78. A predicted risk threshold of 12% could have prevented 25% of biopsies while detecting almost 95% of CSPCas with a sensitivity of 94% and a specificity of 34%. CONCLUSIONS: For PI-RADS 3 lesions, an elevated PSA density, older age, and a biopsy-naive status were associated with CSPCa, whereas a prior negative biopsy was negatively associated. A predictive model could prevent PI-RADS 3 biopsies while missing few CSPCas. LAY SUMMARY: Among men with an equivocal lesion (Prostate Imaging-Reporting and Data System 3) on multiparametric magnetic resonance imaging (mpMRI), those who are older, those who have a higher prostate-specific antigen density, and those who have never had a biopsy before are at higher risk for having clinically significant prostate cancer (CSPCa) on subsequent biopsy. However, men with at least one negative biopsy have a lower risk of CSPCa. A new predictive model can greatly reduce the need to biopsy equivocal lesions noted on mpMRI while missing only a few cases of CSPCa.