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Surgery Insight: surgical management of postprostatectomy incontinence—the artificial urinary sphincter and male sling

Nature Clinical Practice Urology volume 4, pages 615–624 (2007)Cite this article

Abstract

Stress urinary incontinence in men is usually a result of intrinsic sphincter deficiency following prostate cancer surgery. Active conservative management with fluid restriction, medication management and pelvic floor exercises is indicated for the first 12 months. If bothersome incontinence persists, urodynamic evaluation is indicated in order to assess detrusor storage function, contractility and sphincteric integrity. Standard surgical options include urethral bulking agents, artificial urinary sphincter (AUS) and male sling. Periurethral injection of bulking agents is satisfactory in only a minority of patients, leaving AUS and male sling as the most common surgical treatments. In patients with severe urinary incontinence, AUS seems to have a higher rate of success than the male sling. Furthermore, AUS is indicated in men with detrusor hypocontractility as adequate detrusor contractility is needed to overcome the fixed resistance of the sling. In patients with milder levels of stress incontinence, the two techniques have approximately equal efficacy in the short-to-intermediate term. While current reports of the male sling are generally limited to 1–4 years' follow-up, the infection, erosion, and revision rate for the male sling seem somewhat lower than that for the AUS in appropriately chosen patients.

Key Points

  • In patients with severe urinary incontinence and total urinary incontinence caused by profound intrinsic sphincteric insufficiency, circumferential compression of the artificial urinary sphincter provides the most efficacious treatment

  • For patients with enough residual intrinsic sphincteric function to allow urinary storage and mild to moderate stress incontinence during strenuous activity, the artificial urinary sphincter and male sling seem to have equal efficacy in the short-term; long-term data is lacking for the male sling

  • The male sling allows spontaneous voiding without the need for device manipulation (in patients with adequate detrusor contractility), whereas the artificial urinary sphincter must be cycled for normal micturition

  • In the short-term, the complication rate (infection and erosion) and revision rate for the male sling is lower than that for the artificial urinary sphincter; however, long-term data is lacking for the male sling

  • While the design for the AUS has remained essentially unchanged since the late 1980s, the male sling is an evolving technique, with design changes guided by the goal of minimal invasiveness

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Figure 1: Six bone anchors with Number 1 polypropylene sutures are placed into either descending ramus.

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  1. CV Comiter is an Associate Professor of Urology at Stanford University, Stanford, CA, USA.,

    Craig V Comiter

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Correspondence to Craig V Comiter.

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CV Comiter has performed cadaveric studies on the male sling which were financed by Caldera Medical.

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Comiter, C. Surgery Insight: surgical management of postprostatectomy incontinence—the artificial urinary sphincter and male sling. Nat Rev Urol 4, 615–624 (2007). https://doi.org/10.1038/ncpuro0935

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