Intraoperative or secondary transurethral perforation of the urethra has been considered an indication to abandon implantation or remove the cuff respectably. Additionally transurethral endoscopic procedures are challenging in patients with artificial urinary sphincter regarding the high risk for urethral lesions. 
As a referral center for male sphincter surgery, we are confronted with many complex cases. We present a concept to rescue artificial sphincter (AUS) surgery in cases of urethral injuries.

The procedure was performed in seven cases of sterile urethral injuries. We reported the data of two cases of intraoperative perforation at initial implantation, three iatrogenic transurethral lesions and two necessities of transurethral passage of a fragile urethra in an emergency case. 
In all cases the artificial urinary sphincter cuff was placed or left in place respectively around the urethra despite there was a urethral injury. However, the cuff was loosely left open without close contact to the urethra with the loop around the connecting tube without closing it in order to preserve the fragile area and avoid any compression. After 6 – 8 weeks in a second minimal invasive surgery the loop was closed secondarily without further challenging preparation.

The urethral lesions occurred at rigid transurethral manipulation in three and at primary implantation in two cases of complex fragile urethra with multiple prior surgeries. The cuffs used were 3,5 (n=1), 4 (n=3), 4,5 cm(n=2) and 5cm (n=1). In 3of 7 cases the cuff was placed transcorporally at a different place away from the lesion. In all cuff closing surgeries cautery was used to identify and prepare the cuff. Closure was technically not challenging and there were no further intraoperative complications. Activation of AUS was performed after 5-6 weeks. After a mean FU of 29 months no erosions or strictures were reported, and no dysfunction of the AUS was observed.

Despite the small cohort the results are promising and demonstrate an alternative approach for complex cases. Keeping in mind that preparation of the urethra in patient with a history of previous incontinence surgeries can sometimes be challenging, leaving the cuff in situ in open and loss manner can be a solution in case of steril urethral erosion or when transurethral passage of a fragile urethra is required in patients with artificial urinary sphincter.

In select cases and under sterile circumstances urethral injuries can be managed without 
interruption of sphincter placement or explantation of the cuff. This appears worth presenting as particularly in complex cases the preparation of such urethras may be even more challenging in the re-do situation.

Continence 7S1 (2023) 100980
DOI: 10.1016/j.cont.2023.100980