Post-prostatectomy incontinence: Etiology, evaluation, and management

Guiding Clinical Decision Making for Surgical Incontinence Treatment After Prostatectomy: A Review of the Literature

PURPOSE OF REVIEW

Stress urinary incontinence after prostatectomy is a common and debilitating side effect. Immediate post-prostatectomy management emphasizes pelvic floor muscle exercises. Per American Urologic Association guidelines, if incontinence persists for more than 12 months postoperatively, surgical interventions are the mainstay of treatment. Treatment decisions depend on a multitude of factors. The goal of this paper is to review recent literature updates regarding the diagnosis of male SUI to better guide surgical treatment decision-making.

RECENT FINDINGS

Patient history is a critical component in guiding surgical decision making with severity and bother being primary factors driving treatment decisions. Recent studies indicate that a history of pelvic radiation continues to impact the overall duration and complication rate associated with artificial urinary sphincters (AUS). Cystoscopy should be done on every patient preparing to undergo surgical SUI treatment. Urodynamics and standing cough stress tests are additional diagnostic testing options; these tests may augment the diagnosis of SUI and better delineate which patients may benefit from a male sling versus AUS. Treatment of SUI after prostatectomy can improve health-related quality of life. A patient history focused on severity and degree of bother in addition to the use of ancillary office testing can help guide surgical treatment decisions to optimize patient continence goals.

Men's satisfaction with female/unisex and male incontinence pads: a comparative clinical audit

BACKGROUND

Urinary incontinence is a common and impactful condition. Despite the availability of incontinence pads specifically designed for the male form, many men use pads designed to fit the female anatomy.

AIM

This clinical audit-based study compares female/unisex and male incontinence pads in male community patients with urinary incontinence.

METHOD

A survey was used to collect Likert-scale data on overall satisfaction and satisfaction with specific aspects of female/unisex and male incontinence pads, as well as with their health and wellbeing and situation and attitudes before and after intervention. Qualitative data were collected on positive features of, reasons for dissatisfaction with and suggested changes to each pad.

RESULTS

Among 18 participants, and in all but one domain, satisfaction scores were higher for male pads overall, with the greatest increases in score (1-5) for physical coverage of genital area (1.5), ability to hold urine without leaks (1.4) and level of comfort when wet (1.3). Using a male pad had a positive impact on participants' sense of health and wellbeing. Positive qualitative feedback focused on comfort, ease of use and reliability, as well as the anatomical fit of the male pad.

CONCLUSIONS

Sex-specific fit is an important factor in the acceptability of an incontinence pad for men with urinary incontinence. Wearing pads specifically designed for the male anatomy provides men with a greater sense of comfort and confidence.

Men's satisfaction with female/unisex and male incontinence pads: a comparative clinical audit

BACKGROUND

Urinary incontinence is a common and impactful condition. Despite the availability of incontinence pads specifically designed for the male form, many men use pads designed to fit the female anatomy.

AIM

This clinical audit-based study compares female/unisex and male incontinence pads in male community patients with urinary incontinence.

METHOD

A survey was used to collect Likert-scale data on overall satisfaction and satisfaction with specific aspects of female/unisex and male incontinence pads, as well as with their health and wellbeing and situation and attitudes before and after intervention. Qualitative data were collected on positive features of, reasons for dissatisfaction with and suggested changes to each pad.

RESULTS

Among 18 participants, and in all but one domain, satisfaction scores were higher for male pads overall, with the greatest increases in score (1-5) for physical coverage of genital area (1.5), ability to hold urine without leaks (1.4) and level of comfort when wet (1.3). Using a male pad had a positive impact on participants' sense of health and wellbeing. Positive qualitative feedback focused on comfort, ease of use and reliability, as well as the anatomical fit of the male pad.

CONCLUSIONS

Sex-specific fit is an important factor in the acceptability of an incontinence pad for men with urinary incontinence. Wearing pads specifically designed for the male anatomy provides men with a greater sense of comfort and confidence.

Quadrifecta outcomes and their predictors following robotic radical prostatectomy: a study of newly established robotic center in India

Active surveillance (AS), radical prostatectomy (RP), and radical radiotherapy (RT) are the three options for localized prostate cancer. Only a few studies have been conducted in developing countries or in centers in their initial learning curve that predict the outcomes of RARP. Therefore, this study aimed to present data from a novice center; how we started and progressed, and to compare our results with the rest of the world. This is a retrospective analysis to study the outcomes following robot-assisted radical prostatectomy and to identify the predictors of quadrifecta outcomes, i.e., the patients who were continent, did not have complications, were biochemical recurrence free with at least 1 year of follow-up and had negative surgical margins. In our data, we excluded the erectile function as one of the parameters as the majority of our patients were not sexually active or did not want to discuss this parameter. Seventy-two patients were included in this study, and 50 (69.4%) of these achieved the quadrifecta outcomes. Of all the factors, studied, seven factors were statistically significantly different between Group I (quadrifecta achieved) and Group II (quadrifecta not achieved), namely, BMI, co-morbidities like CAD, COPD, ASA grade, pre-op D'Amico risk stratification groups, clinical staging, positive lymph-node status, and hospital stay. With this study, we reported outcomes of RARP in a newly established robotic center and the results were fairly comparable with the well-developed center in India and abroad, emphasizing the short learning curve, and so, the requirement of establishing more robotic surgery centers in developing as well as developed countries.

The added value of devices to pelvic floor muscle training in radical post-prostatectomy stress urinary incontinence: A systematic review with metanalysis

PURPOSE

To investigate the role of pelvic floor devices (e.g., biofeedback, electrical stimulation, magnetic stimulation, or their combination) as adjunctive treatments in pelvic floor muscle training (PFMT) in stress urinary incontinence (SUI) after radical prostatectomy.

MATERIALS AND METHODS

A systematic review with meta-analysis. We searched for randomised controlled trials (RCTs) and prospective non-randomised studies investigating the effectiveness of pelvic floor devices as an adjunctive treatment for SUI symptoms assessed with weight pad-test or standardised questionnaires. To assess the risk of bias (RoB) and overall certainty of evidence, the RoB 2.0 or the ROBINS-I, and the GRADE approach were used.

RESULTS

Eleven RCTs met our eligibility criteria. One was at a 'low' RoB, one had 'some concerns', while nine were at a 'high' RoB. Two meta-analyses were conducted to analyse the pooled results of six RCTs included. Specifically, two RCTs reported at week 4 with a 1h pad test a mean difference of 0.64 (95% CI = [-13.09, 14.36]), and four RCTs reported at week 12 with a 24h pad test a mean difference of -47.75 (95% CI = [-104.18, 8.69]). The heterogeneity was high in both analyses (I2 = 80.0%; I2 = 80.6%). The overall level of certainty was very low.

CONCLUSIONS

In line with our results, we cannot conclude whether pelvic floor devices add any value as adjunctive treatment in the management of SUI after radical prostatectomy. Future studies require more comprehensive and standardised approaches to understand whether these devices are effective.

Does Medicaid cover artificial urinary sphincter and male urethral sling surgery?-a state-by-state analysis

Background

Information regarding the Medicaid coverage of artificial urinary sphincter (AUS) and male suburethral slings (MS) placement in the United States (US) is not readily available. In this manuscript, we seek to elucidate the state-by-state Medicaid coverage of these two procedures in the US.

Methods

State Medicaid websites were utilized to access publicly available physician fee schedules for the calendar year 2020. Fee schedules were searched for current procedural terminology (CPT) codes. CPT codes representing insertion of tandem cuff, insertion of AUS, removal of AUS, removal and replacement AUS, sling operation for correction of male stress urinary incontinence (SUI), and removal or revision of sling for male SUI were utilized. Data were recorded by the procedure for each device, including the coverage status and physician fees.

Results

Of the 50 US states analyzed, 49 publish publicly accessible physician fee schedules. All 49 of these states reported coverage for removal with and without revision of the AUS, and 48 states reported coverage for insertion of an AUS, and insertion of a tandem cuff. The median reimbursement for each AUS related procedure was $624.00 ($181.84-$10,960.90) for tandem cuff, $665.54 ($199.89-$11,949.86) for AUS insertion, $528.03 ($146.90-$1,893.12) for AUS removal, and $630.29 ($208.55-$11,586.74) for AUS revision. All 49 states reported coverage for placement of MS, and 48 states reported coverage for removal or revision of MS. The median reimbursement was $652.57 ($198.00-$5,237.35) for MS placement and $554.47 ($104.27-$2,288.93) for MS revision.

Conclusions

AUS and MS procedures in the Medicaid population are covered by nearly all states. Therefore, surgical treatment of SUI may be offered to Medicaid patients in most states without reimbursement concerns.

Urinary incontinence and use of incontinence surgery after radical prostatectomy: a national study using patient-reported outcomes

OBJECTIVES

To investigate whether patient-reported urinary incontinence and bother scores after radical prostatectomy result in subsequent intervention with incontinence surgery.

METHODS

Men diagnosed with prostate cancer in the English National Health Service between April 2014 and January 2016 were identified. Administrative data were used to identify men who had undergone a radical prostatectomy and those who subsequently underwent a urinary incontinence procedure. The National Prostate Cancer Audit database was used to identify men who had also completed a post-treatment survey. These surveys included the Expanded Prostate Cancer Composite Index (EPIC-26). The frequency of subsequent incontinence procedures, within 6 months of the survey, was explored according to EPIC-26 urinary incontinence scores. The relationship between "good" (≥75) or "bad" (≤25) EPIC-26 urinary incontinence scores and perceptions of urinary bother was also explored (responses ranging from 'no problem' to 'big problem' with respect to their urinary function).

RESULTS

We identified 11,290 men who had undergone a radical prostatectomy. The 3-year cumulative incidence of incontinence surgery was 2.5%. After exclusions, we identified 5,165 men who had also completed a post-treatment survey after a median time of 19 months (response rate 74%). 481 men (9.3%) reported a "bad" urinary incontinence score and 207 men (4.0%) also reported that they had a big problem with their urinary function. 47 men went on to have incontinence surgery within 6 months of survey completion (0.9%), of whom 93.6% had a "bad" urinary incontinence score. Of the 71 men with the worst urinary incontinence score (zero), only 11 men (15.5%) subsequently had incontinence surgery.

CONCLUSION

In England, there is a significant number of men living with severe, bothersome urinary incontinence following radical prostatectomy, and an unmet clinical need for incontinence surgery. The systematic collection of patient-reported outcomes could be used to identify men who may benefit from incontinence surgery.

Tissue Engineering and Its Potential to Reduce Prostate Cancer Treatment Sequelae-Narrative Review

Tissue engineering offers the possibility to overcome limitations of current management for postprostatectomy incontinence and ED. Developed in recent years biotechnological feasibility of mesenchymal stem cell isolation, in vitro cultivation and implantation became the basis for new cell-based therapies oriented to induce regeneration of adult tissue. The perspective to offer patients suffering from post-prostatectomy incontinence or erectile dysfunction minimal invasive one-time procedure utilizing autologous stem cell transplantation is desired management.

To sling or not to sling? Impact of intraoperative sling procedures during radical prostatectomy on postoperative continence outcomes: A systematic review and meta‐analysis

Purpose

This systematic review and meta‐analysis investigates the efficacy of intraoperative sling procedures in reducing postprostatectomy urinary incontinence compared to having no slings.

Methods

A comprehensive search of PubMed, Medline, Embase, and the Cochrane library from inception to November 2020 was performed. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized studies and Newcastle‐Ottawa Scale for nonrandomized studies. The GRADE approach was used for critical appraisal of evidences and meta‐analyses were conducted using random‐effects models.

Results

Ten studies were included (n = 1,447). Quality of evidence ranged from moderate to very low. Sling procedure was generally favorable for short‐term continence outcomes, although discrepancies exist due to variability in continence definition. Sling procedure resulted in reduced urinary pad weight at 1 month postoperatively (MD: 21.55; 95%CI: 12.58 to 30.52). Patient‐reported questionnaires were also favorable for the sling group for up to 3 months (IPSS; (MD: 1.44; 95%CI: 0.14 to 2.74), ICIQ‐SF; (MD: 2.25; 95%CI: 1.26 to 3.24), EPIC‐U; (MD: 5.30; 95%CI: 1.12 to 9.39)) postoperatively. Sling procedure improved the number of continent patients at 1 month with continence definition of zero pad use/day (RR:1.41; 95%CI: 1.10 to 1.83) but not with the definition of ≤ 1pad/day. Similarly, it reduced the time to continence with the ≤ 1 pad/day definition (MD: 0.5; 95%CI: 0.1 to 0.9) but not with the zero pad/day definition.

Conclusion

The current literature suggests that intraoperative sling procedures during radical prostatectomy may promote early return of continence compared to having no sling, however, there are no long‐term differences.

Imaging and Treatment of Complications of Abdominal and Pelvic Mesh Repair

Surgical mesh is used most frequently for tension-free repair of abdominal wall hernias in adults, because the rate of hernia recurrence is lower with mesh than with primary soft-tissue repair. Since the introduction of polypropylene mesh in the middle of the 20th century, many mesh materials and configurations for specific surgical procedures have been developed. In addition to abdominal wall hernia repair, mesh may be used for repair of diaphragmatic hernias, urinary incontinence in women (female slings), genitourinary prolapse (vaginal mesh and sacrocolpopexy), rectal prolapse (rectopexy), and postprostatectomy male urinary incontinence (male slings). General mesh repair complications include chronic pain; fluid collections such as seromas, hematomas, and abscesses; adhesions that may lead to intestinal blockage; erosion into solid or hollow viscera including enterocutaneous fistulizing disease; and mesh failure characterized by mesh shrinkage, detachment, and migration with repair malfunction. Several mesh complications are often diagnosed with imaging, primarily with CT and less frequently with MRI and US, despite variable mesh visibility at imaging. This article reviews the common surgical mesh applications in the abdomen and pelvis, discusses imaging of mesh repair complications, and provides complication treatment highlights.^©RSNA, 2020.

Safety and efficacy of male urethral slings for management of persistent stress urinary incontinence after holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate gland (HoLEP) is an alternative to the traditional transurethral resection of the prostate, especially for large-volume prostates. One complication is urinary incontinence, which is usually stress urinary incontinence (SUI). Little data exist on surgical interventions for SUI after HoLEP. This retrospective case series examined the safety and possible efficacy of a midurethral sling (MUS) following HoLEP. Between January 2016 and February 2019, 610 HoLEPs were performed at our institution. Three (0.5%) had persistent, overly bothersome symptoms of SUI. All three underwent MUS placement with a transobturator AdVance^® male sling after failed pelvic floor rehabilitation. The degree of SUI was evaluated by pad use pre-HoLEP, post-HoLEP, and post-MUS placement. Surgical times for HoLEP and MUS were evaluated. No patients were using pads for incontinence before HoLEP. The average pad use was 7 post-HoLEP and 0.3 post-MUS. The average morcellated prostate was 48 g, and surgical time was 68 min (52 for enucleation and 15 for morcellation). No complications were reported with MUS placement intraoperatively or postoperatively. MUS for persistent and bothersome SUI after HoLEP shows promise as a safe and effective surgical option.

Is pre-operative urodynamic bladder function the true predictor of outcome of male sling for post prostatectomy incontinence?

PURPOSE

To investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection.

METHODS

We performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre.

RESULTS

Successful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1-6.5) for success vs 3.6 (range 1-10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25).

CONCLUSION

Urodynamic parameters related to bladder function-detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.

Improving early urinary continence recovery after radical prostatectomy by applying a sutureless technique for maximal preservation of the intrapelvic urethra: A 17-year single-surgeon experience

BACKGROUND

There is a growing concern about postsurgical outcomes of radical prostatectomy, especially in the younger population and patients with earlier tumor stages. Here, we present our 17 years' experience of sutureless vesico-urethral alignment after radical prostatectomy with a focus on postoperative functional urinary outcomes.

METHODS

Data of 784 patients who underwent radical prostatectomy during 2001-2017 were evaluated retrospectively. Before surgery, patients' demographic information, pathologic stage, margin of surgery, prostate-specific antigen, and Gleason score were obtained. Then, serum prostate-specific antigen level, urinary continence, potency, and other functional outcomes of surgery were recorded after each postoperative visit.

RESULTS

The mean age (±standard deviation) of patients was 61.3 (±6.30) years. The median (IQ_25-75) duration of follow-up was 30 (12-72) months. Full continence was achieved in 90% and 95.9% of patients at 3 and 6 months post surgery and 96.4% of the patients were continent at the last follow-up visit. Bladder neck stricture occurred in 167 patients (21.3%). During the follow-up period, none of the patients complained of total incontinence and at the last visit, 36.6% of patients reported potency. The frequency of grade 2 continence was significantly higher in patients with high-stage tumors (T3/T4), high Gleason score (⩾8), high preoperative serum prostate-specific antigen (>20 ng/dL), and positive margin of surgery. Potency had a significant relationship with age, stage of the disease, and preoperative prostate-specific antigen.

CONCLUSION

Maximal sparing of intrapelvic urethral length through sutureless vesico-urethral alignment technique results in excellent early urinary continence recovery after radical prostatectomy. A more advanced tumor stage (T1/T2), a higher Gleason score, high preoperative prostate-specific antigen, as well as positive surgical margin are risk factors of postoperative incontinence in patients who undergo radical prostatectomy.

Effect of diaphragm and abdominal muscle training on pelvic floor strength and endurance: results of a prospective randomized trial

Pelvic floor muscles (PFMs) play a crucial role in urinary continence. Therefore, training the PFMs remains the most popular conservative treatment for urinary incontinence (UI). The effect of training other body muscles on the PFMs is unclear and mostly hypothetical. The objective of our study was to evaluate the effectiveness of postoperative diaphragm muscle, abdominal muscle and PFM training on PFM strength (PFMS) and endurance (PFME) as well as on UI in men after radical prostatectomy (RP). Per-protocol PFMS, PFME and urine loss measurements were performed at 1, 3, and 6 months postoperatively. The primary endpoints were PFMS and PFME differences among the study groups. The secondary endpoint was the correlation between UI and PFMS and PFME. In total, 148 men were randomized to the treatment groups. An increase in PFMS and PFME was observed in all groups compared to baseline (p < 0.001). The greatest difference in PFMS was in the PFM training group, but diaphragm training had the best effect on PFME. The highest (from moderate to strong) correlation between UI and PFME and PFMS (r = −0.61 and r = −0.89, respectively) was observed in the diaphragm training group. Despite different but significant effects on PFMS and PFME, all rehabilitation-training programmes decreased UI in men after RP.

Psychological nursing approach on anxiety and depression of patients with severe urinary incontinence after radical prostatectomy - a pilot study

Objective

To implement a psychological intervention programme and explore its effects on anxiety and depression in patients with severe urinary incontinence following radical prostatectomy.

Methods

This pilot randomized controlled trial recruited patients that underwent laparoscopic radical prostatectomy. Patients were randomized to conventional nursing and psychoeducation groups. The primary outcome was the levels of anxiety and depression evaluated by the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) at 3 months after urinary catheter removal. The quality of life (secondary outcome) was evaluated using the incontinence-specific quality of life scale (I-QOL).

Results

The study analysed 35 patients: 16 received conventional nursing and 19 received a psychoeducational intervention. There were no significant differences in the sociodemographic data and SAS, SDS and I-QOL scores between the two groups at baseline. At 3 months after catheter removal, the SAS and SDS scores in the psychoeducation group were significantly lower compared with the conventional nursing group; and the I-QOL score in the psychoeducation group was significantly higher compared with the conventional nursing group.

Conclusion

This pilot study suggests that the psychological nursing intervention improved the symptoms of anxiety and depression, and improved quality of life, in patients with severe urinary incontinence following radical prostatectomy.

Is the adjustable transobturator system ATOMS® useful for the treatment of male urinary incontinence in low to medium volume urological centers?

INTRODUCTION

Urinary incontinence (UI) is a complication of radical prostatectomy (RP) and transurethral resection of the prostate (TURP). The gold-standard treatment is the artificial urinary sphincter, however, new treatments have been investigated.

OBJECTIVE

To examine the outcome of an adjustable transobturator male system (ATOMS^®) in men with UI after prostatic surgery in a low to medium volume continence center.

MATERIALS AND METHODS

Twenty-five men with UI were implanted with ATOMS^® system between 2012 and 2014. The most common indication was UI after RP (92%), followed by UI after TURP (8%). Eleven patients (44%) had received adjuvant external beam radiotherapy (RT). Patients were considered to be 'dry' if they stopped wearing pads or needed just one protective pad per day; and improved if the daily number of pads used decreased by at least half. The Incontinence Quality of Life questionnaire (ICIQ-SF) was used, adding a verbal question about the satisfaction of the patient considering the outcome.

RESULTS

After a mean follow-up of 21.56 months, 64% were dry and 8% revealed a significant improvement. The success of the procedure was negatively correlated with the severity of the previous UI and with previous treatment with RT. Concerning patients satisfaction, 84% of the patients would repeat the procedure.

CONCLUSION

ATOMS^® offers good rates of cure and improvement of UI after prostatic surgery with a reasonable rate of minor complications. The results of this study, performed in a low to medium volume continence center, are comparable to the results achieved in high volume continence centers.

Refined nomogram incorporating standing cough test improves prediction of male transobturator sling success

AIMS

To develop a decision aid in predicting sling success, incorporating the Male Stress Incontinence Grading Scale (MSIGS) into existing treatment algorithms.

METHODS

We reviewed men undergoing first-time transobturator sling for stress urinary incontinence (SUI) from 2007 to 2016 at our institution. Patient demographics, reported pads per day (PPD), and Standing Cough Test (SCT) results graded 0-4, according to MSIGS, were assessed. Treatment failure was defined as subsequent need for >1 PPD or further procedures. Parameters associated with failure were included in multivariable logistic models, compared by area under the receiver-operating characteristic curves. A nomogram was generated from the model with greatest AUC and internally validated.

RESULTS

Overall 203 men (median age 67 years, IQR 63-72) were evaluated with median follow-up of 45 months (IQR 11-75 months). A total of 185 men (91%) were status-post radical prostatectomy and 29 (14%) had pelvic radiation history. Median PPD and SCT grade were both two. Eighty men (39%) failed treatment (use of ≥1 PPD or subsequent anti-incontinence procedures) at a median of 9 months. History of radiation (P = 0.03), increasing MSIGS (P < 0.0001) and increasing preoperative PPD (P < 0.0001) were associated with failure on univariate analysis. In a multivariable model with AUC 0.81, MSIGS, and PPD remained associated (P = 0.002 and <0.0001 respectively, and radiation history P = 0.06), and was superior to models incorporating PPD and radiation alone (AUC 0.77, P = 0.02), PPD alone (AUC 0.76, P = 0.02), and a cutpoint of >2 PPD alone (AUC 0.71, P = 0.0001).

CONCLUSIONS

MSIGS adds prognostic value to PPD in assessing success of transobturator sling for treatment of SUI.

SURGICAL MANAGEMENT OF POST-PROSTATECTOMY INCONTINENCE

Post-prostatectomy incontinence (PPI) is a common and significant issue that can affect the quality of life in men who are undergoing treatment for prostate cancer. While some patients opt for conservative management of their incontinence, many elect to undergo surgical treatment as a result of the significant impact to quality of life. The most commonly employed surgical techniques to address PPI are placement of a male sling or artificial urinary sphincter (AUS). Currently, the AUS continues to serve as the gold standard for management, with robust data concerning longitudinal outcomes available. However, in recent years, the various methods to place the male sling have emerged as viable, less complex alternatives that avoid the need for pump manipulation. In the present review, we discuss these main surgical treatment modalities for PPI, and focus on the selection criteria that may influence appropriate operative stratification of PPI patients. Indeed, an individualised, comprehensive assessment of baseline urinary function, age, radiation, prior surgeries, functional status, and other comorbidities must be considered in the context of shared decision-making between the treatment provider and the patient in determining the optimal approach to managing PPI.