Adjustable suburethral sling (male remeex system) in the treatment of male stress urinary incontinence: a multicentric European study

Mitigating infections in implantable urological continence devices: risks, challenges, solutions, and future innovations. A comprehensive literature review

PURPOSE OF REVIEW

Stress urinary incontinence is a growing issue in ageing men, often following treatment for prostate cancer or bladder outflow obstruction. While implantable urological devices offer relief, infections are a significant concern. These infections can lead to device removal, negating the benefits and impacting patient outcomes. This review explores the risks and factors contributing to these infections and existing strategies to minimize them. These strategies encompass a multifaceted approach that considers patient-specific issues, environmental issues, device design and surgical techniques. However, despite these interventions, there is still a pressing need for further advancements in device infection prevention.

RECENT FINDINGS

Faster diagnostics, such as Raman spectroscopy, could enable early detection of infections. Additionally, biocompatible adjuncts like ultrasound-responsive microbubbles hold promise for enhanced drug delivery and biofilm disruption, particularly important as antibiotic resistance rises worldwide.

SUMMARY

By combining advancements in diagnostics, device design, and patient-specific surgical techniques, we can create a future where implantable urological devices offer men a significant improvement in quality of life with minimal infection risk.

Surgical management of post prostatectomy incontinence

Post prostatectomy incontinence (PPI) is a well-recognized and bothersome complication following radical prostatectomy. Conservative measures such as pelvic floor physical therapy, biofeedback, and medication are first line management of PPI. When first line therapies fail, patients are offered a variety of surgical procedures based on the degree of incontinence, prior radiation therapy, and comorbidities. Among the various surgical options, placement of an artificial urinary sphincter (AUS) is the gold standard for PPI. However, AUS placement has a high rate of re-operation and requires good manual dexterity. In cases of mild-moderate incontinence, especially in patients without prior radiation therapy, male slings and proACT are a less invasive option. Bulking therapy, although highly successful for female stress urinary incontinence (SUI), is not currently advised in the treatment of male SUI. Regardless of surgical approach used to treat PPI, providers should counsel patients regarding risks of re-operation and have an open an honest discussion regarding the degree of continence that can be restored following each procedure.

A modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for male stress urinary incontinence: a pilot study

OBJECTIVES

The aim of this study was to demonstrate the feasibility of a modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for the treatment of male urinary incontinence and to preliminarily evaluate the short-term clinical efficacy of this technique.

PATIENTS AND METHODS

The clinical data of patients treated with the modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique using a Pelvimesh pelvic floor repair patch as a sling were collected. The primary evaluation criteria were surgery-related indicators and daily urinal pad usage before and after treatment, and the secondary evaluation criteria were the corresponding incontinence scores and the results of surgery-related questionnaires.

RESULTS

After 1-12 months of follow-up, seven patients were clinically cured. Follow-up 1 month after surgery showed that one patient (14.3%) used one pad daily, and six patients (85.7%) did not need pads. The incontinence quality of life questionnaire (I-QOL) scores at 3 days and 1 month postoperatively were 89.4 ± 2.5 and 88.1 ± 6.7, respectively, which were significantly higher than the preoperative scores (31.5 ± 18.9) (P < 0.05). The scores of the International Continence Control Association Incontinence Questionnaire Short Form (ICI-Q-SF) at 3 days and 1 month postoperatively were 3.2 ± 0.9 and 4.2 ± 1.7, respectively, which were significantly lower than the preoperative scores of 19.4 ± 5.0 (P < 0.05). In addition, the results of the surgery-related questionnaires were positive. No serious complications occurred in any of the patients.

CONCLUSION

The modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for the treatment of male urinary incontinence patients is safe, effective, minimally invasive, and has few complications. However, further validation in large sample, randomized, comparative, and longer-term follow-up studies is still needed.

Urethral Slings for Irradiated Patients With Male Stress Urinary Incontinence: A Meta-analysis

OBJECTIVE

To systematically compare success, cure and complication rates of urethral sling surgeries in stress urinary incontinence patients with and without a history of pelvic radiotherapy (RT).

MATERIALS AND METHODS

We searched PUBMED, EMBASE, and Web of Science to identify relevant articles. The primary outcomes were the success and cure rates. The secondary outcomes included the rates of infection, urethral erosion, total complications, explantation, and satisfaction. Outcomes were analyzed using a random-effects model to calculate the unadjusted odds ratio (OR) in patients with a history of RT compared with those without prior RT.

RESULTS

On pooled analysis, we found significantly lower odds of success (OR 0.68; 95% confidence interval [CI] 0.53-0.87, P < .001) and cure (OR 0.67; 95% CI 0.55-0.82, P < .001) in radiated patients than in nonirradiated patients. Subgroup analysis by type of sling showed significantly lower odds of success in Advance subgroup (OR 0.66; 95% CI 0.45-0.95, P < .001) and significantly lower odds of cure in Advance (OR 0.59; 95% CI 0.36-0.95, P < .001) and Atoms subgroups (OR 0.70; 95% CI 0.54-0.93, P < .001). We also found significantly greater odds of sling explantation (OR 2.93; 95% CI 1.62-5.29, P < .001) and infection (OR 3.06, 95% CI 1.03-9.07, P < .001) in radiated patients than in nonradiated patients.

CONCLUSION

Patients with a history of pelvic RT have lower odds of success and cure and higher odds of infection and sling explantation than those without a history of pelvic RT.

Management of Urinary Incontinence Following Radical Prostatectomy: Challenges and Solutions

Urinary incontinence is a common and debilitating problem in patients undergoing radical prostatectomy. Current methods developed to treat urinary incontinence include conservative treatments, such as lifestyle education, pelvic muscle floor training, pharmacotherapy, and surgical treatments, such as bulking agents use, artificial urinary sphincter implants, retrourethral transobturator slings, and adjustable male sling system. Pelvic floor muscle exercise is the most common management to improve the strength of striated muscles of the pelvic floor to try to recover the sphincter weakness. Antimuscarinic drugs, phosphodiesterase inhibitors, duloxetine, and a-adrenergic drugs have been proposed as medical treatments for urinary incontinence after radical prostatectomy. Development of new surgical techniques, new surgical tools and materials, such as male slings, has provided an improvement of outcomes after UI surgery. Such improvement is still ongoing, and the uptake of new devices might lead to even better outcomes after UI surgery.

Contemporary male slings for stress urinary incontinence: advances in device technology and refinements in surgical techniques

Synthetic male sling (MS) is considered an effective surgical treatment to restore male stress urinary incontinence. The modern MS can be categorised into adjustable or non-adjustable types, while the surgical techniques can be divided into retropubic or transobturator approaches. This narrative review paper evaluates the contemporary MS devices in the current commercial market regarding clinical outcomes and refinements in surgical techniques. Scientific advances in device design and technology, coupled with further surgical refinements will enhance the clinical outcomes and improve the safety profile of MS surgery. The newer generation of modern MS not only provides direct compression of the bulbar urethra but also allows for proximal urethral relocation by realigning the mobile sphincter complex to provide further urethral sphincter complex coaptation. Strict patient selection, use of MS with proven clinical records, adherence to safe surgical principles and judicious postoperative care are critical to ensure a high continence rate, good patient satisfaction and low postoperative complications.

Efficacy and Complications of the Re-Adjustable Male Sling System for Stress Urinary Incontinence after Radical Prostatectomy

The aim of this study was to investigate the outcomes of re-adjustable male slings in pa-tients with postoperative stress urinary incontinence (SUI) following radical prostatectomy (RP). We retrospectively analyzed 18 patients with SUI following RP for prostate cancer, who were treated with re-adjustable male slings from January 2016 to December 2021. The clinical outcomes were evaluated based on daily pad usage and urodynamic studies, both preoperatively and post-operatively. The degree of SUI was categorized as either mild, moderate, or severe. Success was defined as no more pad use or significantly decreased pad use. Complications were classified ac-cording to the Clavien-Dindo system. The mean age of patients was 70.4 ± 5.9 years, and 61.1% of cases were diagnosed as locally advanced prostate cancer. Mild, moderate, and severe SUI were reported as 33.3%, 50.0%, and 16.7%, respectively. The average daily pad use after RP was 3.3 pads and there was a significant reduction in the number of daily pads used after the re-adjustable male sling procedure (3.3 vs. 1.3; p = 0.002). Overall, the operation was considered successful in 11 pa-tients (61.1%), 1 case showed improvement (5.6%), and it was considered unsuccessful in 6 patients (33.3%). Impressively, in the severe incontinence subgroup (three patients), one (33.3%) had im-provement and one (33.3%) had success. Transient perineal discomfort after the operation was the most common complaint. However, two patients had severe complications with bowel injury during sling implantation (Clavien-Dindo grade III). The re-adjustable male sling system was an efficient surgical treatment option for post-RP SUI, even in a locally advanced disease dominant population. One should pay attention to the complication of bowel perforation during surgery.

[Treatment of female recurrent or not stress urinary incontinence with intrinsic sphincter deficiency: Sub-urethral retropubic adjustable sling (Remeex)]

INTRODUCTION

Recommendations for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincteric deficiency (ISD) or recurrent, are complex. They accept the use of sub-urethral slings (BSU), if unsuccessful the artificial urinary sphincter. The objective was to report the results in terms of continence and morbidity of the Remeex® Adjustable BSU in the treatment of SUI by ISD recurrent or non-recurrent.

METHOD

Monocentric retrospective study of 70 patients with a mean age of 67.7 years (±12) operated of Remeex sling, between 2015 and 2019, was conducted. Preoperative and postoperative characteristics were analyzed from medical records. Two groups were analyzed: Group A (n=28) with no history of incontinence surgery and Group B (n=42) with history (recurrent). Patients who were totally continent (0 protection) and those who were socially continent (1 safety protection) were considered successful.

RESULT

Postoperative success rate was similar between groups B (90 %) and A (92%) with respectively: 64% versus 71% of totally continent patients, 26% versus 21% wearing safety protection. The postoperative complications were mainly Clavien II (28%) such as urinary tract infections (6%), transient urinary retention (3%) and de novo bladder overactivity (20%) with no significant statistical difference between the groups. Six patients were reoperated (Clavien III): BSU detension (1%), vaginal exposure (4%) (including one total material removal for infection), varitensor explantation (1%) or scar disunion (1%).

CONCLUSION

The Remeex® BSUA seems to lead to satisfactory perioperative results in patients with SUI with ISD recurrent or non-recurrent.

Narrative review of male urethral sling for post-prostatectomy stress incontinence: sling type, patient selection, and clinical applications

Male stress urinary incontinence (SUI) following prostate treatment is a devastating complaint for many patients. While the artificial urinary sphincter is the gold standard treatment for male SUI, the urethral sling is also popular due to ease of placement, lack of mechanical complexity, and absence of manual dexterity requirement. A literature review was performed of male urethral sling articles spanning the last zz20 years using the PubMed search engine. Clinical practice guidelines were also reviewed for comparison. Four categories of male urethral sling were evaluated: the transobturator AdVance and AdVance XP, the bone-anchored InVance, the quadratic Virtue, and the adjustable sling series. Well selected patients with mild to moderate urinary incontinence and no prior history of radiation experienced the highest success rates at long-term follow up. Patients with post-prostatectomy climacturia also reported improvement in leakage after sling. Concurrent penile prosthesis and sling techniques were reviewed, with favorable short-term outcomes demonstrated. Male urethral sling is a user-friendly surgical procedure with durable long-term outcomes in carefully selected men with mild stress urinary incontinence. Multiple sling types are available with varying degrees of efficacy and complication rates. Longer follow-up and larger cohort sizes are needed for treatment of newer indications such as climacturia as well as techniques involving dual placement of sling and penile prosthesis.

Remeex® System Effectiveness in Male Patients with Stress Urinary Incontinence

Background: When conservative management fails, patients with stress urinary incontinence (SUI) are considered for surgical treatment. Simpler, more economical and less invasive surgical techniques, such as the Remeex^® system, have been developed. Objectives: To analyze the objective effectiveness of the Remeex^® system in the treatment of male stress urinary incontinence. To study survival and complication rates of the Remeex^® system in male SUI patients. Materials and methods: Prospective observational study between July 2015 and May 2020. Group A (n = 7; GA) patients with mild SUI. Group B (n = 22; GB) patients with moderate SUI. Group C (n = 18; GC) patients with severe SUI. Effectiveness was assessed by the number of patients achieving complete and partial dryness. Complete dryness was defined as patients using 0–1 safety pads per day; partial dryness as a >50% reduction in the number of pads used. Results were analyzed using descriptive statistics, Student’s t-test. Chi2, Fisher’s exact test, ANOVA, and multivariate analysis. Significance was set at p < 0.05. Results: Mean age 69.76 years, mean follow-up 33.52 months. Objective effectiveness was observed in 89.36% of patients with incontinence. The effectiveness was 85.71% in GA, 90.91% in GB and 88.89% in GC. There were no significant differences among groups (p = 1.0000). 34.04% of patients with an implant required at least one readjustment, while 66.00% did not require any. There were no significant differences among groups (p = 0.113) Chi2 = 4.352. 95.74% of implants remained in place by the end of follow-up. We observed complications in 17.02% of patients. Conclusions: Remeex^® system is an effective and safe method for male stress urinary incontinence treatment, regardless of the severity of the incontinence, with high survival and low complication and removal rates. System readjustments are required in one-third of the cases.

Patients' quality of life after implantation of ZSI 375 artificial urinary sphincter due to stress urinary incontinence

Introduction

The study aimed to evaluate the outcomes of artificial urinary sphincter ZSI 375 implantation for stress urinary incontinence, focusing on quality of life assessment (QoL).

Material and methods

The study had a prospective and non-randomized design. It was conducted in two urological centres in Poland. Between July 2013 and June 2019, artificial urinary sphincter ZSI 375 was implanted in 86 consecutive men with stress urinary incontinence. The follow up was completed in December 2019. The assessment of functional results was based on number of pads used and declared to have been used by patients. The quality of life was assessed on the basis of the ICIQ-SF questionnaire (International Consultation on Incontinence Questionnaire-Short Form), SF-36 questionnaire (Short Form 36 Health Survey Questionnaire) and the severity of pain by means of the NRS (numerical rating scale of pain intensity).

Results

The operations were performed in 86 patients aged 28 to 80 (median 69). With the median (SD; range) follow-up of 21 (20.2; 1–68) months, daily pad usage decreased significantly from ≥4 to 1.1 (±0.97 pads) per day. Seven (8.1%) patients achieved total continence, 60 (69.8%) social continence, 14 (16.3%) improvement and 5 (5.8%) failures (≥4 pads per day). 15 patients (17.5%) experienced complications after surgery. The study showed a significant improvement of QoL evaluated by ICIQ-UI SF and SF-36.

Conclusions

Therapy with the use of ZSI 375 device is successfully applied in surgical management of moderate to severe male stress urinary incontinence. The life quality of patients assessed using questionnaires is at a high level.

Treatment of Urinary Incontinence in Patients With Erectile Dysfunction

INTRODUCTION

Concurrent urinary incontinence (UI) and erectile dysfunction (ED) can greatly damage a patient's quality of life. Owing to the intertwined anatomy, treatment options for one most certainly have implications on the other.

OBJECTIVE

The aim of this review is to characterize and elucidate the treatment patients with postprostatectomy UI undergoing concurrent or subsequent treatment of ED. These principles can be extrapolated to all patients with UI and ED.

METHODS

The literature on postprostatectomy UI treatment in the context of concurrent ED was reviewed through a Medline search. Original research using quantitative and qualitative methodologies was considered.

RESULTS

The epidemiology, workup, and management of postprostatectomy UI being mindful of ongoing or future ED treatments are the main outcome measures. Owing to the intertwined anatomy, treatment options for UI and ED have implications on the other. It is essential for the surgeon to obtain an understanding of the patient's degree of bother for each process, personal preference on treatment options, and management of expectations. Surgical treatment options include a combination of the artificial urinary sphincter, sling, inflatable penile prosthesis, semi-rigid penile prosthesis, and new techniques such as the Mini-Jupette. The appropriate combinations will be determined by patient factors of dexterity, preference, degree of leakage, history of radiation, and so on. The decision of staged vs dual implant will be largely driven by the surgeons' preference, payor limitations, and comfort level. This issue is particularly challenging in redo cases where we advocate for cuff downsizing or tandem cuff before the transcorporal approach is used with the goal of preserving sexual function.

CONCLUSION

The concurrent treatment of ED and UI requires thoughtful workup, meticulous attention to detail, and an armamentarium of surgical skills. It is crucial for the surgeon to understand and manage patient expectations in treating these delicate and difficult pathologies. Ajay D, Mendez MH, Wang R, et al. Treatment of Urinary Incontinence in Patients With Erectile Dysfunction. J Sex Med 2020;XX:XXX-XXX.

Systematic review and meta-analysis comparing Adjustable Transobturator Male System (ATOMS) and male Readjustment Mechanical External (REMEEX) system for post-prostatectomy incontinence

OBJECTIVE

To assess the efficacy and safety of Adjustable Transobturator Male System (ATOMS) compared to male Readjustment Mechanical External (REMEEX) system for post-prostatectomy incontinence (PPI).

MATERIAL AND METHODS

A systematic review and meta-analysis on adjustable device ATOMS compared to male REMEEX is presented. Studies on female or neurogenic incontinence were excluded. Primary objectives were evaluation of dryness (the proportion of patients with no-pad or one safety pad/day after device adjustment) and improvement between devices. Secondary objectives were complications and explant rate. They were estimated using a random-effect model. Statistical heterogeneity among studies was assessed using Cochran's Q test, Higgins's I² statistics and tau2.

RESULTS

Combined data of 29 observational studies with 1919 patients showed an equivalent proportion of patients treated with radical prostatectomy (p = .125) and previous radiation (p = .126). Dryness rate was 69.3% for ATOMS and 53.4% for male REEMEX (p = .008). Improvement rate was 90.8% for ATOMS and 80.2% for REMEEX (p = .007). Complication rate was 18.9% for ATOMS and 35.8% for REMEEX (p = .096) and explant rate was 5.5% for ATOMS and 13.9% for REMEEX (p = .027). Significant heterogeneity was evidenced, due to absence of randomized studies, variable incontinence severity baseline, difficulties for a common reporting of complications and difference in the follow-up. Differences observed between devices remained statistically significant when only studies with silicone-covered scrotal port (SSP) ATOMS and male REMEEX system II were considered.

CONCLUSIONS

Despite the absence of direct comparison and the limitations observed ATOMS appears more effective than male REMEEX to treat PPI, and with less explant rate as reported in the literature.

Salvage perineal-retropubic AUS cuff in paraplegic patient with exstrophy-epispadias complex after previous cuff erosion at bladder neck

Cuff erosion at the bladder neck of an implanted artificial urinary sphincter (AUS) needs complete explantation of the device. The subsequent scar tissues predispose to repeated cuff erosion, when another AUS is implanted with the cuff at a similar location. We describe a paraplegic patient with exstrophy-epispadias complex that suffered from an AUS cuff erosion at the bladder neck. We use a novel perineal-retropubic route for cuff placement, with preparation similar to a retropubic male sling. At 12 years follow-up the AUS is still functional and the patient continent.

Retropubic vs transobturator Argus adjustable male sling: Results from a multicenter study

AIMS

To comparatively analyse outcomes after ARGUS classic and ArgusT adjustable male sling implantation in a real-world setting.

METHODS

Inclusion criteria encompassed: non-neurogenic, moderate-to-severe stress urinary incontinence (≥2 pads), implantation of an ARGUS classic or ArgusT male sling between 2010 and 2012 in a high-volume center (>150 previous implantations). Functional outcomes were assessed using daily pad usage, 24-hour pad testing, and International Consultation on Incontinence (ICIQ-SF) questionnaires. Continence was defined as zero pads per 24 hours. Complications were graded using Clavien-Dindo scale. For multivariate analysis, binary logistic regression models were used (P < .05).

RESULTS

A total of 106 patients (n = 74 [ARGUS classic], n = 32 [ArgusT]) from four centers were eligible. Median follow-up was 44.0 months (24-64). Patient cohorts were well-balanced. We observed a statistical trend in favor of ARGUS classic regarding postoperative urine loss based on standardized 24-hour pad test (71 ± 162 g [ARGUS classic] vs 160 ± 180 g [ArgusT]); P = .066]. Dry rates were 33.3% (ARGUS classic) and 11.8% (ArgusT, P = .114). In multivariable analysis, ArgusT male sling could not be confirmed as an independent predictor of decreased success (OR, 0.587; 95% CI; 0.166-2.076, P = .408). There were no Clavien IV and V complications. Inguinal pain was significantly higher after ArgusT implantation (P = .033). Explantation rates were higher for ArgusT compared to ARGUS classic (14.0 vs 23.3%; P = .371). Longer device survival for the ARGUS classic male sling was observed in Kaplan-Meier analysis (P = .198).

CONCLUSIONS

In the largest comparative analysis of ARGUS classic and ArgusT male sling with the longest follow-up to date, we observed low continence rates with superior functional outcomes and decreased explantation rates after ARGUS classic implantation.

Artificial Urinary Sphincter for Postradical Prostatectomy Urinary Incontinence - Is It the Best Option?

Male stress urinary incontinence (SUI) can undoubtedly reduce quality of life and promote personal distress and psychosocial alienation. The frequency of postprostatectomy urinary incontinence (PPI) counts on the characterization of urinary incontinence and the periods of patient follow-up. Operational therapeutics, for instance, urethral male slings and artificial urinary sphincters, are well-chosen as adequate and secure surgeries for male SUI in men with continual PPI when conservative treatment is ineffective. Over the former 2 decades, surgery has progressed regarding both operative approach and sling architecture. However, there are no guidelines about when surgery should be carried out and which is the most appropriate surgical option. In this review, we summarize recent advances in implantable devices for PPI and also discuss traditional surgical care. When we are planning the male PPI surgery, careful preoperative work-up should be performed and surgical method should be chosen according to the severity of the disease. Male sling is preferred in mild and moderate symptomatic patients with normal detrusor pressure and it is recommended to select traditional artificial urinary sphincter device in those with severe symptoms. It is expected that effective devices without adverse events will be developed with technical advances in near future.

Preliminary outcomes of the European multicentre experience with the ZSI 375 artificial urinary sphincter for treatment of stress urinary incontinence in men

Introduction

The ZSI 375 is a new artificial urinary sphincter utilised in men suffering from stress urinary incontinence (SUI). We present the first European multicentre study on the effectiveness of ZSI 375.

Material and methods

This study was conducted in a retrospective, non-randomized format in centres across Europe. Between May 2009 and December 2014, ZSI 375 was fitted in 109 SUI patients following radical prostatectomy, transurethral resection of prostate (TURP), rectal surgery and high intensity focused ultrasound (HIFU). Patients with history of pelvic radiotherapy or previous surgical treatment for incontinence or stricture were excluded from the series. Follow-up was completed by December 2016. The key outcome measures included overall improvement and complication rates.

Results

A total of 109 patients in 10 European centres were recruited and had the ZSI 375 device implanted. The average patient age was 72 years old. The indication for the majority of patients was incontinence following radical prostatectomy (100/109 patients, 91.74%). On average, patients were incontinent for 48.6 months prior to treatment. All patients used ≥4 pads daily at baseline and thus were classified as suffering from ‘severe incontinence’. The average follow-up until the final visit was 43 months. The pad usage decreased to 0.84 on average by the last visit. There were no reported cases of device infection. A total of 9 patients had urethral cuff erosion (8.25%),which was the most common complication in this series. A further 3 men (2.75%) experienced mechanical failure requiring subsequent device reimplantation. The implantation of the ZSI 375 device was considered successful in 92.66% of patients.

Conclusions

The ZSI 375 is an effective surgical treatment option in men with severe stress urinary incontinence.

Effectiveness of surgical management with an adjustable sling versus an artificial urinary sphincter in patients with severe urinary postprostatectomy incontinence: a systematic review and network meta-analysis

Background:

The purpose of this study was to determine the effectiveness of an adjustable sling compared with an artificial urinary sphincter (AUS) in patients with severe urinary incontinence (SUI) postprostatectomy (PP).

Methods:

This review was carried out following the Cochrane Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. We searched Medline, Embase, LILACS, and CENTRAL databases. Studies with patients older than 18 years of age with SUI PP who underwent sling or AUS intervention and had been monitored for longer than 12 months were included.

Results:

Seven studies were included, yielding a sample size of 420. Pads were reportedly dry or improved in 70% of the sling group compared with 74% in the AUS group. The Incontinence Impact Questionnaire, Short Form (IIQ-7) was the most frequently used scale and showed improvement, with a score of 82.8% in the AUS group compared with 86.1% in the sling group. When comparing interventions with nonintervention, relative risks (RRs) of 35.37 (95% confidence interval [CI]: 7.17–174.35) and 45.14 (95% CI: 11.09–183.70) were found for the adjustable sling and AUS, respectively, which were statistically significant. No significant differences were found when AUS versus adjustable sling were compared, with an RR of 0.78 (95% CI: 0.09–6.56). We found a low risk of bias in most studies.

Conclusions:

Both interventions can reduce incontinence and improve the quality of life of patients with SUI PP. The published literature is substantially limited as no randomized clinical trials are available, no consensus has been reached regarding the definition of severity of incontinence, and considerable heterogeneity exists across the outcome variables measured.

[Retrospective multicentric evaluation of the efficacy of four-arms and adjustable male slings in the management of mild and moderate urinary incontinence after radical prostatectomy]

INTRODUCTION

Objective of the study to carry out a retrospective multicentric evaluation of the efficacy of male slings in the management of mild and moderate urinary incontinence after radical prostatectomy.

METHOD

We performed a multi-center study that included all patients with mild to moderate urinary stress incontinence after radical prostatectomy with adjustable slings or four-arm slings. We collected the number of protections before the procedure and one year after the application of the male sling.

RESULTS

A 4 arms or adjustable sling was put to 65 men. The cure rate was 33.3% (n=5) for Remeex, 52% (n=13) for TOMS, and 46.7% (n=12) for Virtue (P=0.07). The failure rate was 26.7% (n=4) for Remeex, 24% (n=6) for TOMS, and 40% (n=10) for Virtue (P=0.18). The overall complication rate was 40% (n=6) for Remeex, 28% (n=7) for TOMS, and 16% (n=4) for Virtue (P=0.19).

CONCLUSION

This multicentric retrospective series confirms that male slings are a usefull therapy for patients with mild or moderate urinary incontinence.

LEVEL OF EVIDENCE

4.

Sling Surgery for Male Urinary Incontinence Including Post Prostatectomy Incontinence: A Challenge to the Urologist

The management of postprostatectomy urinary incontinence (PPI) is still challenging for urologists. In recent decades, various kinds of male sling system have been developed and introduced; however, they have not yet shown as good a result as that of artificial urinary sphincter (AUS). However, a male sling is still in an important position because patients have a high demand for sling implantation, and it can allow the avoidance of the use of mechanical devices like AUS. Recently, the male sling has been widely used in mild-to-moderate PPI patients; however, there are no studies that compare individual devices. Thus, it is hard to directly compare the success rate of operation, and it is impossible to judge which sling system is more excellent. It is expected that many sling options will be available in addition to AUS in the near future with the technological development of various male slings and the accumulation of long-term surgical outcomes. In that in patients with PPI, sling implantation is an option that must be explained rather than an option that need not be explained to them, this review would share the latest outcomes and complications.

Adjustable sling for the treatment of post-prostatectomy urinary incontinence: systematic review and meta-analysis

Urinary incontinence after prostatectomy has a significant negative impact on the quality of life of the patient. The surgical treatment includes several models of male slings, such as adjustable slings. The objective of this study was to evaluate the effectiveness and safety of adjustable sling in the treatment of post-prostatectomy urinary incontinence. This is a systematic review of literature. The following electronic databases were searched until January 2018: PubMed®, Embase, CENTRAL and LILACS. The keywords used in the search strategies were: "prostatectomy" [Mesh], "urinary incontinence" [Mesh] and "suburethral slings" [Mesh]. Randomized clinical trials and observational studies, with or without Control Group, and follow-up of more than 12 months were included. Only one randomized study with high risk of bias was included and it concluded the effectiveness equivalence between adjustable and non-adjustable slings. All other studies were cases series with patients of varying levels of incontinence intensity and history of pelvic radiation therapy and previous surgeries. The meta-analysis for 0 pad in 24 hours demonstrated an effectiveness of 53%. For the 0 to 1 pad test in 24 hours, the meta-analysis resulted in an effectiveness of 69%. Risk factors for surgery failure include prior radiation, severity of post-prostatectomy urinary incontinence, and previous surgeries. The meta-analysis of the extrusion rate was 9.8% and the most commonly reported adverse effects were pain and local infection. Evidence of low quality indicates that adjustable slings are effective for treating post-prostatectomy urinary incontinence, with frequency of adverse events similar to the surgical option considered gold standard (the artificial urinary sphincter implant).

Male Slings for Postprostatectomy Incontinence: A Systematic Review and Meta-analysis

CONTEXT

Male slings are recommended by the European Association of Urology guideline for the treatment of mild to moderate postprostatectomy incontinence. However, none of them has been proved to be superior to the others, and there are no defined guidelines to preference of a given sling model.

OBJECTIVE

To evaluate and compare the efficacy and safety of the different types of male slings in the treatment of postprostatectomy incontinence.

EVIDENCE ACQUISITION

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. A systematic literature search in the databases of PubMed, Embase, and Cochrane using the keywords "incontinence," "prostatectomy," and "male sling/system" was conducted in June 2018. Studies in English with at least 15 patients and a minimum follow-up of 12 mo were included. As the primary endpoint, we assessed the cure rate of the different sling types. As secondary endpoints, we assessed the improvement rate, subjective cure rate, overall complication rate, explantation rate, risk factors for failure, and effect on patients' quality of life.

EVIDENCE SYNTHESIS

The literature search identified 833 articles. A total of 64 studies with 72 patient cohorts were eligible for inclusion. Fixed slings were implanted in 55 (76.4%) of the patient cohorts. The objective cure rate varies between 8.3% and 87% (pooled estimate 0.50, 95% confidence interval [CI] 0.45-0.56, I²=82%). Subjective cure was achieved in 33-94.4%. Adjustable slings showed objective cure rates between 17% and 92% (pooled estimate 0.61, 95% CI 0.51-0.71, I²=88%). The subjective cure rate varies between 28% and 100%. In both types of slings, pain was the most common complication, but chronic painful conditions were really rare (1.3% in fixed slings and 1.5% in adjustable slings). The most common complication after pain was urinary retention in fixed slings, and infection and consequential explantation in adjustable slings.

CONCLUSIONS

Both fixed and adjustable slings are beneficial for the treatment of postprostatectomy incontinence. Although adjustable slings might lead to higher objective cure rates, they might be associated with higher complication and explantation rates. However, at present, due to significant heterogeneity of the data, this cannot be said with certainty. More randomized controlled trials with long-term follow-up and the same definition for continence are needed.

PATIENT SUMMARY

Fixed and adjustable slings are effective treatment options in mild to moderate postprostatectomy incontinence.

Implantable Systems for Stress Urinary Incontinence

Stress urinary incontinence (SUI), the involuntary urine leakage due to failure of the urethral closure mechanism, is a global health challenge with substantial human suffering and socioeconomic costs. Approximately 167 million male and female patients are predicted to suffer from SUI in 2018, worldwide. A wide range of surgical interventions are available for the treatment of SUI. Severe cases, however, usually require the implantation of artificial urinary sphincter devices. This review comparatively presents and analyzes the working principles, as well as the challenges, associated with the current implantable SUI systems in clinical use. These include slings, urethral bulking agents, artificial urinary sphincters, and adjustable continence devices. It further reports on recent research progress and state-of-the-art in the field of SUI implants, including an original approach proposed by the authors with a pressure feedback sensory mechanism. The new emerging field of artificial muscle devices, including electroactive polymers, provides a promising innovative solution for replacing the weakened urethral sphincter in SUI patients.

Contemporary surgical devices for male stress urinary incontinence: a review of technological advances in current continence surgery

Male stress urinary incontinence (SUI) remains a debilitating condition that adversely impacts all domains of quality of life and is associated with significant social stigma and health economic burden. The incidence of post-prostatectomy urinary incontinence (PPI) depends on the definition of urinary incontinence and the length of patient follow up. In patients with persistent PPI following failure of conservative measures, surgical treatment is recommended although there is no published guideline on when surgery should be performed, and what the best surgical option is. Male slings (MS) can be divided into adjustable or non-adjustable types, and offers an attractive option for patients who wish to avoid mechanical handling during urinary voiding. Published intermediate data supports good safety and efficacy rate in men with mild to moderate degree of SUI. The AMS 800 artificial urinary sphincter (AUS) remains the standard of treatment for complete continence and has the longest efficacy and safety records. Other AUS-like devices are designed to address current AMS 800 limitations but themselves are fraught with their own issues.

The role of male slings in post prostatectomy incontinence: ICI-RS 2015

AIMS

Post prostatectomy stress urinary incontinence can significantly impact on quality of life and is bothersome for patients. The artificial urinary sphincter is still considered the gold standard surgical treatment. Male slings are an alternative surgical option and several designs are currently available. This review will focus on efficacy, adverse events, and mechanism of action of male slings. The context of this review was a proposal at the ICI-RS meeting 2015. Following synthesis of the evidence we address the question: does it matter how male slings work?

METHODS

The proposal lecture was reviewed and a comprehensive review of the literature undertaken utilising the PubMed database.

RESULTS

Male slings can be broadly divided into adjustable retropubic and suburethral transobturator slings. Male slings are efficacious and can improve quality of life. Adjustable retropubic slings appear to be compressive but studies suggest efficacy can be achieved without voiding dysfunction. Transobturator slings work by urethral compression and/or re-locating the urethral bulb. There is a recognized failure rate in all sling types and most studies suggest radiotherapy as a risk factor for failure. Adjustable slings have the ability to be altered to optimize continence or to prevent retention of urine. However, there appears to be a higher explantation rate in some of these systems.

CONCLUSIONS

It is important to understand how male slings work and by doing so we are more reliably able to choose the appropriate sling, predict outcomes, and as a result counsel patients. Suggestions for future research are proposed.

Multicentre Experience with ZSI 375 Artificial Urinary Sphincter for the Treatment of Stress Urinary Incontinence in Men

Objectives

The aim of this study was to evaluate the safety and efficacy of the artificial urinary sphincter ZSI 375 device in male patients with stress urinary incontinence (SUI) at 10 centres.

Methods

This was a retrospective, nonrandomised, multicentre study. From January 2012 to December 2014, and follow-up to February 2016, men with SUI were treated with the ZSI 375 device. The primary outcome was continence. The secondary outcome was complications rate.

Results

A total of 147 patients with moderate-to-severe stress incontinence and mean age of 70.67 (26-85) years underwent implantation of the ZSI 375 device at 10 centres. The most common indication for placement was incontinence after radical prostatectomy (121 patients: 82.31%). The ZSI 375 device was considered successful in 86.40% of cases after 12 months follow-up, 83.52% after 24 months follow-up and 78.26% after 36 months follow-up. The infection rate was 6.12%, urethral erosion was 12.92% and mechanical failure was limited to 3.40% leading to ZSI 375 improvement.

Conclusions

This study confirmed safety and efficacy of ZSI 375 device to treat moderate-to-severe SUI in men.

Urinary Artificial Sphincter ZSI 375 for Treatment of Stress Urinary Incontinence in Men: 5 and 7 Years Follow-Up Report

Study Design

This is a retrospective, non-randomised study.

Objectives

The aim of this study was to evaluate safety and efficacy of artificial urinary sphincter ZSI 375 inserted in male patients with stress urinary incontinence (SUI).

Methods

Between May 2009 and January 2017, 45 men with SUI underwent ZSI 375 device insertion. Operations were performed in two French centres by one surgeon. Complications and pad used to manage continence were recorded.

Results

From May 2009 to January 2012, 45 patients with a mean age of 70.42 years underwent placement of the ZSI 375 device in France. The most common cause for incontinence was radical prostatectomy (RP, 33/45 ­patients, 73.33%). The minimal period of incontinence was 6 months. Twenty-seven out of 45 patients (60.00%) had a severe incontinence (at least four pads per day), 13 patients (28.89%) had moderate incontinence (three pads per day) and five patients (11.11%) had two pads per day. With a long follow-up, the ZSI 375 device was considered to be successful in 73.33% patients after 5 years (60 months) and 72% of patients after 7 years (84 months). The infection rate was 2.2 % affecting one in 45 patients. Six out of 45 patients presented a urethral erosion (13.33%). Mechanical failure with a revision occurred in three patients (6.67%).

Conclusions

The ZSI 375 device is a safe and effective device to treat severe SUI in men.

Surgical treatment for urinary incontinence after prostatectomy: A meta-analysis and systematic review

Background

This meta-analysis was designed to assess the efficacy of the male sling and artificial urinary sphincter on treating post-prostatectomy incontinence by evaluating daily pad use, cure rate, frequency of improvement in incontinence, and quality of life.

Methods

Medline, Cochrane, Google Scholar, and ClinicalTrials.gov were searched (until March 31, 2014) for studies that investigated the effectiveness of artificial urinary sphincter or sling surgical treatments for prostate cancer. The primary outcome was daily pad use before and after surgery and secondary outcomes were quality of life before and after surgery, and frequency of cures (no need to use of a pad for at least 1 day) and improvements (decreased pad usage) in incontinence after surgery.

Results

We found that that both the sling and artificial urinary sphincter significantly decreased the number of pads used per day by about 3 (P-values <0.001) and increased the quality of life compared with before intervention (P-values < 0.001). In addition, the cure rate and was around 60%. Intervention resulted in improvement in incontinence by about 25% (P < 0.001).

Conclusion

Our findings indicate that both sling and artificial urinary sphincter interventions are effective in reducing incontinence and improving the patient’s quality of life.

Single-centre experience in using the adjustable transobturator male system in treatment of stress urinary incontinence in patients after radical prostatectomy

Context:

Urinary incontinence is the most threatening complication after radical prostatectomy. This disorder has an important impact on the quality of life of patients and its treatment is a challenge for urologists as well.

Objective:

The objective of this article is to report our experience with the adjustable transobturator male system (ATOMS, AMI, Austria) for the treatment of post-prostatectomy incontinence.

Material and methods:

A total of 35 men with post-prostatectomy incontinence were treated. Before and after device implantation, the number of pads used per day was counted, and a one-hour pad test, uroflowmetry and postmicturition residual volume were assessed. Prior to surgery, anastomosis stricture was either ruled out or treated. To evaluate the success rate, ‘cured’ was defined as no pad use or one safety pad, ‘improved’ was defined as one or two pads or reduction of pad usage by more than 50%, respectively. All data about efficacy and safety were collected from all 35 patients.

Results:

After a median (range) follow-up of 21.2 (3–63) months, the success rate was 32 out of 35 patients (91.5%) with 22 patients (62.9%) ‘cured’ and 10 patients (28.6%) ‘improved’. Recovery of continence was achieved in seven patients (20.0%). The remaining patients (80%) needed an adjustment. The mean (range) number of adjustments to reach desired results (continence, improvement or patient satisfaction) was 4.3 (1–15). The most common adverse event was transient perineal pain, which was reported in 14 (40%) patients and disappeared within two weeks. Temporary urine retention appeared in one patient (2.9%). There were three cases (8.6%) of wound infection at the site of a port leading to explantation of the port in two patients (5.7%) and the removal of the system in one patient (2.9%).

Conclusion:

Treatment of post-prostatectomy incontinence with the self-anchoring ATOMS is safe and effective.

[Not Available]

Zusammenfassung. Dieser Übersichtsartikel beleuchtet den aktuellen Kenntnisstand zur Ätiologie, Diagnostik und Therapie der Harninkontinenz des Mannes. In der Ätiologie der Harninkontinenz beim Mann spielt die radikale Prostatektomie eine herausragende Rolle, aber auch das benigne Prostatasyndrom, neurologische Erkrankungen oder metabolische Störungen können zu einer Harninkontinenz beim Mann führen. In der Diagnostik ist neben der Basisdiagnostik eine qualifizierte urodynamische Beurteilung unabdingbar, um die zugrunde liegenden pathophysiologischen Mechanismen aufzudecken und Chancen und Risiken der verfügbaren Therapie- bzw. Operationstechniken abschätzen zu können. Die Primärtherapie der Harninkontinenz beim Mann ist konservativ und schliesst eine qualifizierte Beckenboden- und Sphinktertherapie einschliesslich Biofeedback ein. Die Auswahl der operativen Techniken unterliegt dem Ausmass der Inkontinenz, den individuellen Gegebenheiten des Patienten, der Patientenpräferenz, der Expertise des Operateurs und einzelnen Kontraindikationen für bestimmte Verfahren. Auch ein längeres Intervall nach radikaler Prostatektomie oder ein Tumorprogress sind keine Ausschlusskriterien für eine operative Therapie. Der oft hohe Leidensdruck und das breite Spektrum von in geübten Händen wenig invasiven Operationstechniken rechtfertigen eine breite Indikationsstellung für eine prothetische Versorgung.

[Adjustable retropubic suburethral sling Remeex® in the treatment of male stress urinary incontinence: One-year results]

OBJECTIVE

To evaluate the efficacy and safety of the adjustable suburethral sling Remeex^® in the treatment of male stress urinary incontinence (SUI).

PATIENTS AND METHODS

Single-center prospective study of patients treated for SUI after radical prostatectomy or transurethral resection of prostate. The severity of incontinence was evaluated by the number of pads used per day. Success rate, complications and number of adjustments were studied.

RESULTS

From February 2011 to May 2015, Remeex^® was implanted in 25 patients. The average preoperative number of pads used per day was 3,8 (±1,8). Sling tension has been adjusted the day after surgery in all patients. Mean follow-up was 31 months (±15). During follow-up, 6 patients did not need any readjustment (24%) and 15 patients (60%) had to be readjusted. One Remeex system had to be completely removed because of a sub-occlusive syndrome. Three patients had early infection requiring partial system removal (Varitensor). At the end of follow-up, 9 patients were cured (36%), 9 patients (36%) were significantly improved and 7 patients (28%) were not improved. Five patients are waiting for a new readjustment.

CONCLUSION

In this short series of patients who had prostatic surgery, at mid-term follow-up, the placement of a BSUA-R was associated with an improvement or cure of urinary incontinence symptoms in two-thirds of cases.

LEVEL OF EVIDENCE

4.

Long-term follow-up for the treatment of male urinary incontinence with the Remeex system

OBJECTIVES

To relate our experience in treating postprostatectomy stress urinary incontinence (SUI) with the male Remeex system (MRS). We also list the elements that comprise this system, the implantation technique and its proper adjustment. Similarly, we attempt to determine whether the latest changes made to this device, which constitute the MRS-II, have resulted in fewer mesh readjustments.

MATERIAL AND METHOD

From March 2007 to March 2014, we operated on 24 men with postprostatectomy SUI between the ages of 55 and 78 years (mean, 67 years), through the placement of a Remeex suburethral tension-adjustable sling. All patients had severe urinary incontinence, with considerable impact on their quality of life.

RESULTS

All patients, except for 2 who required the removal of the system, remained continent. Nine of the patients (39%) occasionally required incontinence pads when performing intense physical exercise. The mean number of adjustments was 2.4 (range 0-6). The score on the Incontinence Impact Questionnaire (IIQ 7) performed before the surgery and 6 months after, went from 79±7 points to 11±3, with a very high degree of satisfaction.

CONCLUSIONS

The MRS is a valid therapeutic option for postprostatectomy incontinence and is a reproducible technique that is easy to perform, has a low rate of complications and provides excellent and lasting results. There is also a clear trend towards reducing number of adjustments with the new MRS-II.

Systematic review of surgical treatment of post radical prostatectomy stress urinary incontinence

Context Stress urinary incontinence (SUI) after radical prostatectomy (RP) continues to be a significant problem with several implications including patient quality of life and other critical postoperative outcomes. Objectives To report the results in terms of efficacy (pad count, 24 hr pad test, QOL questionnaires) and safety (complication rate and type of complications) of all surgical devices approved for the treatment of SUI after RP. Evidence Acquisition A systematic review was conducted in accordance with the PRISMA Statement. A literature search was carried out through the PubMed/Medline, SCOPUS, and Web of Science databases using the keywords "incontinence," "radical prostatectomy," and "'treatment". Inclusion criteria were: number of patients higher than 30, mean follow up longer than 12 months and definition of a successful outcome as the use of 0 to 1 safety pads a day. Evidence Synthesis 113 papers underwent primary review. 51 papers met the inclusion criteria with a total sample size of 4022 patients. Efficacy (0-1 safety pads) was on average 65.7% for AUS, 48.2% for Invance Sling, 48.8% for Advance Sling, 64.2% for ProACT. Twenty four hour pad test and QOL questionnaires were respectively available only in 4 and 18 studies. The overall complication rate was 19.43% for AUS, 7.4% for Invance Sling, 12.3% for Advance Sling, 12.3% for ProACT. Authors' Conclusions Due to the poor overall quality of available studies, it was impossible to identify or refute clinically important differences between the alternative surgical procedures. Although our data seems to suggest that AUS has the highest efficacy in the treatment of SUI following RP it is also associated with the highest complication rate, but this may be due to the longest follow up. Larger rigorous trials are needed in order to support this evidence. Neurourol. Urodynam. 35:875-881, 2016. © 2015 Wiley Periodicals, Inc.

[Functional results and treatment of functional dysfunctions after radical prostatectomy]

OBJECTIVE

To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer.

MATERIAL AND METHOD

Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta.

RESULTS

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9-16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach.

CONCLUSION

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.

[Urinary incontinence in men]

Stress urinary incontinence in men is predominantly iatrogenic whereby radical prostatectomy is the most common cause with persistent stress urinary incontinence rates varying between 10 % and 25 %. The first line therapy for postoperative male stress urinary incontinence is physiotherapy, especially pelvic floor muscle rehabilitation. If conservative treatment fails to show sufficient improvement, surgical therapy is recommended. Several treatment options are currently available for the surgical treatment of male stress urinary incontinence including artificial sphincters, adjustable and functional sling systems, bulking agents and implantable balloon systems.

Evaluation and Management of Postprostatectomy Incontinence: A Systematic Review of Current Literature

CONTEXT

Radical prostatectomy is the most common reason for male stress urinary incontinence. There is still uncertainty about its diagnostic and therapeutic management.

OBJECTIVE

To evaluate current evidence regarding the diagnosis and therapy of postprostatectomy incontinence (PPI).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in October 2015 using the Medline database.

EVIDENCE SYNTHESIS

Diagnosis and conservative treatment of PPI are currently mostly based on expert opinions. Pelvic floor muscle training is the noninvasive treatment of choice of PPI. For invasive management of moderate to severe PPI, the artificial urinary sphincter is still the treatment of choice, but an increasing number of adjustable and nonadjustable, noncompressive as well as compressive devices are used more frequently. However, no randomized controlled trial has yet investigated the outcome of one specific surgical treatment or compared the outcome of different surgical treatment options.

CONCLUSIONS

The level of evidence addressing the surgical management of PPI is still unsatisfactory. Further research is urgently needed.

PATIENT SUMMARY

Incontinence after the removal of the prostate (postprostatectomy incontinence) is the most common cause of male stress urinary incontinence. First-line therapy is physiotherapy and lifestyle changes. If no satisfactory improvement is obtained, various surgical treatment options are available. The most commonly used is the artificial urinary sphincter, but other treatment options like male slings are also available.

The artificial urinary sphincter and male sling for postprostatectomy incontinence: Which patient should get which procedure?

Surgery is the most efficacious treatment for postprostatectomy incontinence. The ideal surgical approach depends on a variety of patient factors including history of prior incontinence surgery or radiation treatment, bladder contractility, severity of leakage, and patient expectations. Most patients choose to avoid a mechanical device, opting for the male sling over the artificial urinary sphincter. The modern male sling has continued to evolve with respect to device design and surgical technique. Various types of slings address sphincteric incompetence via different mechanisms of action. The recommended surgery, however, must be individualized to the patient based on degree of incontinence, detrusor contractility, and urethral compliance. A thorough urodynamic evaluation is indicated for the majority of patients, and the recommendation for an artificial urinary sphincter, a transobturator sling, or a quadratic sling will depend on urodynamic findings and the patient's particular preference. As advancements in this field evolve, and our understanding of the pathophysiology of incontinence and mechanisms of various devices improves, we expect to see continued evolution in device design.