Disparities in Access to Severe Incontinence Surgical Treatment with Artificial Urinary Sphincter after Radical Prostatectomy in France: A Nationwide Nested Case-control Study

Background: Socioeconomic and geographic disparities in surgical treatment utilization may persist even within universal healthcare systems. Objective: To determine whether socioeconomic and geographic disparities exist in artificial urinary sphincter (AUS) utilization among men with post-prostatectomy incontinence in a universal healthcare setting. Design setting and participants: This nationwide, population-based, nested case-control study used French administrative health data from 2006 to 2018. Among 718,360 men diagnosed with prostate cancer, 266,927 underwent radical prostatectomy. Of these, 5,064 received AUS for post-prostatectomy incontinence (cases). A comparator group of 3,022 men with documented persistent incontinence but no AUS was identified using repeated penile sheath prescriptions more than one year after surgery. Outcome measurements and statistical analysis: Associations between AUS implantation and demographic, clinical, socioeconomic, and geographic factors were assessed using multivariable conditional logistic regression accounting for follow-up time and center-level clustering. Results and limitations: AUS implantation occurred in 1.9% of post-prostatectomy patients. Higher odds of implantation were observed across socioeconomic deprivation categories, with the strongest association in the most socially deprived group (FDEP Q5: OR 1.64, 95% CI 1.32-2.02). Factors linked to lower odds of AUS implantation included older age (70-80 years: OR 0.44, 95% CI 0.36-0.54; >80 years: OR 0.24, 95% CI 0.08-0.78), prior TURP (OR 0.17, 95% CI 0.13-0.22), and radiotherapy (OR 0.73, 95% CI 0.60-0.89). Urban residence was associated with slightly lower odds of AUS implantation compared with rural residence (OR 0.84, 95% CI 0.72-0.99), whereas distance to a high-volume center was not significantly associated. Conclusions: In France's universal healthcare system, socioeconomic and geographic factors were not associated with lower odds of receiving AUS among more deprived or rural groups, indicating no evidence of disadvantage for these populations. However, the low overall use of AUS highlights potential non-structural barriers such as limited referral, clinical awareness, or patient engagement that may affect treatment uptake.