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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.

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Purpose: Patients with post prostatectomy incontinence (PPI) seem to have different needs. Therefore, device post-operative readjustability may be a beneficial feature in PPI management, even though it lacks study support. The purpose of this study is to describe our surgical technique for male sling (MS) implantation, assess outcomes, and the impact of readjustability. Methods: We performed a retrospective analysis of 89 consecutive patients who underwent PPI correction with MS Argus-T™ (Promedon, Córdoba, Argentina) from 2009 to 2021. The median follow-up was 48 months (12–120). Data were collected in a dedicated database. Perioperative variables were assessed. A descriptive statistical analysis was performed. Clinical and urodynamic variables were correlated with the need for readjustments and success. Results: In this cohort, objective success was achieved in 80.5% of the patients (65.9% cured and 14.6% improved). A total of 85.4% of the patients met the criteria for subjective success (74.4% cured and 11% improved). For the subgroup of patients who received previous treatment for urethral stricture (US), 79% achieved objective success (63.2% cured, 15.8% improved), and 84.2% achieved subjective success (78.9% cured, 5.3% improved). For the subgroup of patients who received previous radiotherapy (RT) before sling surgery, 68.7% achieved objective success (37.5% cured, 31.2% improved), and 75% achieved subjective success (37.5% cured, 37.5% improved). Procedures for device readjustment were necessary for 27.7% of patients in the total study population. RT and previous US treatment were predictive factors for the need of readjustment, with rates of 66.7% and 61.1% (OR: 8.46; CI: 2.46–29.00; p = 0.001/OR: 6.41; CI: 2.05–20.03; p = 0.001, respectively). Conclusions: MS adjustability improved success rates, especially among irradiated patients and those with previous US. RT was an adverse predictor of total continence status even after readjustments. [ABSTRACT FROM AUTHOR]

Objective: To investigate the outcomes of artificial urinary sphincter (AUS) placement in patients with post‐prostatectomy urinary incontinence (PPUI) with or without a prior male sling. Patients and Methods: We performed a retrospective chart review of patients who underwent AUS for PPUI from 2007 to 2022. The primary endpoint was to determine the proportion of patients who achieved social continence, defined as self‐reported use of 0–1 pad/day. The secondary endpoints were device failure rates and device failure‐free survival. Results: The analysis included 210 patients, with 30 (14.3%) having had prior slings and 180 (85.7%) without prior slings. After AUS insertion, 80.0% of patients with prior slings and 76.7% of those without prior slings achieved continence (0–1 pad/day). There were six (20.0%) and 53 (29.4%) device failures in patients with and without prior slings, respectively. The median device failure‐free survival was not reached in patients with prior slings and was 8.9 years in patients without prior slings (P = 0.048). Limitations include retrospective nature and small sample size. Conclusions: The efficacy and safety of AUS in patients with prior slings are similar to those without. Prior sling is associated with a longer device failure‐free survival. AUS remains a viable option in patients who have persistent PPI after prior slings. [ABSTRACT FROM AUTHOR]

Objective:: To present the recommendations for post-prostatectomy urinary incontinence from the 7th International Consultation on Incontinence (ICI). Methods:: This review was based on hand- and electronically-searched literature, abstracts from scientific meetings, and articles from peer-reviewed publications. Results:: Bladder diary and pad tests are useful in determining the amount of leaking. Treatment planning may benefit from cystoscopy and/or urodynamics, depending on underlying comorbidities and subtype of LUTS. Men with SUI have a low success rate with injectable bulking agents. The artificial sphincter is the preferred treatment for properly selected men who have moderate to severe stress incontinence after radical prostatectomy as the AUS has the longest record of safety and efficacy. This recommendation relates exclusively to the AMS 800 as newer devices do not have a similar evidence base or experience. Male slings are an acceptable surgical approach with several-year follow-up data supporting their safety and efficacy in men with mild to moderate degrees of PPI, particularly if there is no prior history of radiation. Conclusions:: Prospective randomized clinical trials are still needed, even though there are a number of series detailing the results of various surgical procedures for PPUI. Standardized workup and outcome metrics, as well as comprehensive long-term reporting of adverse events, are among the recommendations for future research.

Abstract Objectives To evaluate long‐term effects, complications and satisfaction among patients treated with AdVance™ and AdVance™ XP slings (AS) at a Norwegian specialist care hospital. Materials and Methods Patients who had an AS implanted due to stress urinary incontinence (SUI) 2009–2016 were identified retrospectively. Demographic and perioperative data were extracted from electronic patient files. We did a patient‐reported outcome measure (PROM) survey with the Expanded Prostate Cancer Index Composite (EPIC‐26) urinary domain and a Satisfaction Questionnaire (SQ) 2018–2020. Cure was defined as use of ≤1 pad/day. Results The AS was implanted in 165 patients, mainly due to mild to moderate SUI (median leakage 112 g, range 13–589 g/24 h). Preoperative urodynamics showed mild detrusor overactivity (DO) in 11 patients. At 6‐week follow‐up, 148 patients (90%) were cured. The most common complication was urinary retention (N = 38), transient in 32 patients (range 1–42 days). Two patients were later operated with division of the sling due to persistent retention. During clinical follow‐up of up to 12 years, 27 patients were reoperated due to persistent/recurrent incontinence. The PROM survey was sent to 125 patients and 115 (92%) replied at median 73 (20–134) months postoperatively. Ninety‐one (79%) used ≤1 pads/day, 97 (85%) were satisfied, one patient‐reported pain. Regression analyses showed that failure (>1 pad/day) was significantly associated with a higher amount of leakage preoperatively and at the 6‐week follow‐up. Total cure rate in the complete cohort was 64% at median 73 (20–134) months follow‐up. Conclusions The AS shows good and persistent long‐term results in patients with mild to moderate SUI. The only identified risk factor for long‐term failure was higher amount of leakage preoperatively. The incidence of high body mass index (BMI), DO and previous radiotherapy was low and not significantly associated with failure but is still considered risk factors.

We aimed to determine the risk factors for postoperative overactive bladder (OAB) in patients treated with an adjustable trans-obturator male system (ATOMS) for stress incontinence after radical treatment of prostate cancer. A prospective study was performed on 56 patients implanted with an ATOMS for PPI. Clinical and urodynamic information was recorded before and after ATOMS implantation. We built a multivariate model to find out the clinical and urodynamic factors that independently influenced postoperative OAB and the prognostic factors that influenced the efficacy of medical treatment of OAB. We found that the clinical risk factors were the preoperative intensity of urinary incontinence (number of daily pads used and amount of urinary leakage), International Consultation on Incontinence Questionnaire (ICIQ) score, postoperative number of ATOMS adjustments, final cushion volume, and incontinence cure. The urodynamic data associated with OAB were cystometric bladder capacity, voided volume, volume at initial involuntary contraction (IC), maximum flow rate, bladder contractility index (BCI), and urethral resistance (URA). The prognostic factors for the efficacy of oral treatment of OAB were the volume at the first IC (direct relationship) and the maximum abdominal voiding pressure (inverse relationship). The multivariate model showed that the independent clinical risk factors were the daily pad count before the implantation and the ICIQ score at baseline and after treatment. The independent urodynamic data were the volume at the first IC (inverse relationship) and the URA value (direct relationship). Both predictive factors of treatment efficacy were found to be independent. Detrusor overactivity plays an important role in postoperative OAB, although other urodynamic and clinical factors such as the degree of urethral resistance and abdominal strength may influence this condition. [ABSTRACT FROM AUTHOR]

Simple Summary: Stress urinary incontinence is a common sequela in men after radical prostatectomy for the treatment of prostate cancer. Varying degrees of post-prostatectomy incontinence will present after surgery and surgical treatment may be recommended after one year. The severity of incontinence can range from less than 1 urinary pads per day (PPD) to more than 5 PPD. Treatments for mild incontinence include the male sling while more severe incontinence often requires an artificial urinary sphincter (AUS). Currently, patients with moderate incontinence are treated with either a sling or AUS with variable results. In this paper, we reviewed recent research to demonstrate that AUS should be considered first-line for moderate incontinence. While patients and physicians may be hesitant to proceed with an implantable device, patients achieved better continence rates and overall quality of life when they underwent AUS placement for moderate post-prostatectomy incontinence. Male urinary incontinence is a common complication after radical prostatectomy. The severity of incontinence can be assessed in various ways and helps determine the best surgical intervention to restore continence. While most patients with mild incontinence receive a sling and those with severe incontinence receive an artificial urinary sphincter (AUS), there are no clear guidelines on how to manage patients with moderate post-prostatectomy incontinence (PPI). Our discussion will focus on the current literature, which demonstrates that an AUS should be considered first-line in men with moderate PPI despite perceived concerns over complications and reintervention rates. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to compare the outcomes of the AUS and an adjustable male sling (ATOMSTM). Methods: It was a retrospective observational cohort study with two arms. Propensity score matching (PSM) was performed in order to limit selection bias and, consequently, a comparison between groups in terms of functional outcomes (24 h pad test and perception of improvement questionnaires), complications (overall complications, high-grade complications, reinterventions and explantations) and device survival was performed. Results: 49 patients in both arms were included. The baseline characteristics were similar between the groups. The mean follow up was 43 ± 35 months. Dryness was achieved in 22 patients (44.9%) in the AUS group and 11 (22.5%) in the sling group (p = 0.03). A total of 40 patients declared themselves well improved in the sling group (81%), while 35 (71%) declared the same in the AUS group (p = 0.78). The AUS was associated with more high-grade complications, reinterventions and explantations than the ATOMSTM. Survival at 60 months was 82 ± 9% in the sling group and 67 ± 7% in the AUS group (p = 0.03). Conclusions: While the AUS may be characterized by a higher dry rate, it has an increased risk of high-grade complications and reinterventions. It is proposed that the ATOMS prosthesis can be successfully used for patients who require a less invasive procedure that maintains good functional outcomes. [ABSTRACT FROM AUTHOR]

Stress urinary incontinence is still a frequent problem for women and men, which leads to pronounced impairment of the quality of life and withdrawal from the social environment. Modern diagnostics and therapy improved the situation for individuals affected. But there are still limits, including the correct diagnosis of incontinence and its pathophysiology, as well as the therapeutic algorithms. In most cases, patients are treated with a first-line regimen of drugs, possibly in combination with specific exercises and electrophysiological stimulation. When conservative options are exhausted, minimally invasive surgical therapies are indicated. However, standard surgeries, especially the application of implants, do not pursue any causal therapy. Non-absorbable meshes and ligaments have fallen into disrepute due to complications. In numerous countries, classic techniques such as colposuspension have been revived to avoid implants. Except for tapes in the treatment of stress urinary incontinence in women, the literature on randomized controlled studies is insufficient. This review provides an update on pharmacological and surgical treatment options for stress urinary incontinence; it highlights limitations and formulates wishes for the future from a clinical perspective. [ABSTRACT FROM AUTHOR]

Introduction: Post-prostatectomy urinary incontinence (PPUI) has an enormous impact in quality of life (QoL). Transobturator-rethrourethral sling (AdVanceTMXP sling) is a well-established treatment option although there is paucity of data on long-term outcomes. Our objective was to assess the long-term functional outcomes and QoL in a cohort of men undergoing AdVanceTMXP sling surgery. Methods: Retrospective observational study of men undergoing AdVanceTMXP sling in a tertiary referral institution from August 2013 to July 2020. 55 patients met the inclusion criteria, with a minimum follow-up of 12 months. Main outcomes were pre- and post-operative daily pad use and scoring in the ICIQ-SF questionnaire. Post-operative complications were assessed following the Clavien-Dindo classification system. QoL and satisfaction with the procedure were assessed through direct interview. Results: Mean number of pads prior to surgery was 3.1, and mean ICIQ-SF score was 13.5. After surgery, mean daily pads use went to 1.2, and mean ICIQ-SF dropped to 5. With a mean follow-up of 42.36 months, 21.8% patients did not use any pads/day and 76.4% achieved social continence (0–1 pad/day). We found no statistically significant differences in outcomes of patients with follow-up of <36 months, 36–48 months, and >48 months (p = 0.067). Conclusions: AdVanceTMXP sling implantation in men with PPUI improves urinary incontinence and QoL, and their results are sustained over time. [ABSTRACT FROM AUTHOR]

Objective: The artificial urinary sphincter is considered the gold standard for treatment of male stress urinary incontinence (SUI). The male sling is also an option with reasonable utility; however, in some cases the sling may lose efficacy over time. In this video, we demonstrate insertion of an artificial urinary sphincter in a patient who has persistent stress urinary incontinence despite having previously undergone insertion of a male sling twice for male stress urinary incontinence. Patient and surgical procedure: The patient is a 64-year-old male with history of radical retropubic prostatectomy for prostate cancer that resulted in SUI. He underwent male sling twice, but his incontinence persisted.A perineal incision was made, and the mid-bulbar urethra was circumferentially mobilized off its attachments to the tunica albuginea. The previously placed slings were not encountered. One the dorsal plane was sufficiently dissected, the urethral circumference was measured and cuff selected. A transverse lower abdominal incision was used to reach the Space of Retzius to accommodate the pressure regulating balloon, and to make a subdartos pouch in the scrotum for insertion of the control pump. The device components were prepped and inserted and connected. The device was cycled and deactivated prior to closure. Results: This patient had an uneventful recovery and achieved significant improvement in his continence once the AUS was activated. The artificial urinary sphincter can be inserted after a failed sling, with expectation of reasonable efficacy and without significant concern for added complexity from previous surgeries Conclusion: The artificial urinary sphincter is a safe and reliable option for stress incontinence that persists after insertion of male sling.

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. [ABSTRACT FROM AUTHOR]

Purpose of Review: Artificial urinary sphincters and male slings are the primary surgical management options available for male stress incontinence in the USA. In this review, we discuss advances in the assessment of male stress incontinence, the use of artificial urinary sphincters and male slings depending on specific clinical scenarios, and recent research into the use of both treatment options in the irradiated patient. Recent Findings: The standing cough test correlates well with 24-h pad weights and is a low-cost and low-burden assessment that can be conducted on initial consultation. For radiated patients, the artificial urinary sphincter is generally recommended, but limited recent data suggest that male slings may be suitable for motivated, appropriately selected patients. While not yet available in the USA, limited early data comparing adjustable male slings to artificial urinary sphincters found improved continence outcomes for AUS. Summary: Pre-operative evaluation is imperative in stratifying the severity of incontinence and guiding the choice between artificial urinary sphincters and male slings for male stress urinary incontinence. The surgeon must take into consideration patient medical and surgical history, as well as patient preference, in choosing an AUS versus a male sling, but generally, male slings offer good continence outcomes for mild to moderate SUI while AUS offer superior outcomes for men with more severe stress incontinence. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purposes: Little research exists on potential learning curve for male sling procedures. We aimed to perform a learning curve analysis of a single surgeon's experience of sling placement evaluating multiple outcomes and using the cumulative sum failure methodology. Methods: The study included 65 consecutive patients that underwent implantation of a fixed transobturator sling (TiLOOP Male) for post-radical prostatectomy stress incontinence at our institution from January 2013 to December 2018. Dichotomous outcomes evaluated with cumulative sum failure analysis included 12-months continence defined based on Patient Global Impression of Improvement (PGI-I) questionnaire (primary outcome), 24 h pad test and, 24 h pad use, operative time (⩽/>60 min), and complications (yes/no). Univariate and multivariate logistic regression analyses were performed to evaluate the association of the procedures' chronological sequence number with the outcomes. Results: Cumulative sum failure curves revealed a clear and lengthy learning curve effect for most of subjective and quantitative continence outcomes and for operative time. For the primary outcome (at least much improved at PGI-I), 62 procedures were required to overcome the learning curve. Accordingly, multivariate analyses showed that the sequence number was statistically significant for predicting failures based on PGI-I (adjusted OR 0.95; 95% CI: 0.91–0.99; p = 0.02), objective outcomes, and operative time. Conclusions: An evident and lengthy learning curve was observed in our series of male sling placement to achieve the end level of proficiency, independently from case-mix. Individualized structured training on male sling surgery will benefit patients treated in the initial surgeon's experience. Surgical experience should be considered when reporting studies on male slings. [ABSTRACT FROM AUTHOR]

Purpose We sought to describe and analyze the adverse events associated with synthetic male slings reported to the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database. Methods We queried the MAUDE database for all entries including the terms “Male Sling,” “InVance,” “Virtue,” or “Advance” from January 1st, 2009 to December 31st, 2018. We collected and analyzed information about the event type, date received, report source, source type, and manufacturer. We reviewed and categorized the event description text for each medical device report (MDR). Results A total of 497 adverse events related to the male sling were identified. The adverse events were classified as injury (95.4%), malfunction (4.2%), and other (0.4%). There were no deaths described. The slings involved were the Advance or Advance XP sling (69.8%), InVance (15.5%), Virtue Quadratic (12.3%), or unknown (2.4%). The 4 most common adverse events described were urinary incontinence (46.7%), sling erosion (9.1%), mechanical malfunction (8.2%), and pain/numbness (8.2%). There was no increase in the number of reports in the years following the FDA warnings for urogynecologic mesh. Conclusions There was an overall modest number of MDRs related to male slings and the majority of them were reported by the manufacturer. The reporting of adverse events for male slings does not seem to be affected by the controversy and scrutiny towards transvaginal mesh and midurethral slings. Further clinical studies and more objective and detailed databases are needed to investigate the safety of these synthetic slings.

Background: Stress urinary incontinence is common in men after prostate surgery and can be difficult to improve. Implantation of an artificial urinary sphincter is the most common surgical procedure for persistent stress urinary incontinence, but it requires specialist surgical skills, and revisions may be necessary. In addition, the sphincter is relatively expensive and its operation requires adequate patient dexterity. New surgical approaches include the male synthetic sling, which is emerging as a possible alternative. However, robust comparable data, derived from randomised controlled trials, on the relative safety and efficacy of the male synthetic sling and the artificial urinary sphincter are lacking. Objective: We aimed to compare the clinical effectiveness and cost-effectiveness of the male synthetic sling with those of the artificial urinary sphincter surgery in men with persistent stress urinary incontinence after prostate surgery. Design: This was a multicentre, non-inferiority randomised controlled trial, with a parallel non-randomised cohort and embedded qualitative component. Randomised controlled trial allocation was carried out by remote web-based randomisation (1 : 1), minimised on previous prostate surgery (radical prostatectomy or transurethral resection of the prostate), radiotherapy (or not, in relation to prostate surgery) and centre. Surgeons and participants were not blind to the treatment received. Non-randomised cohort allocation was participant and/or surgeon preference. Setting: The trial was set in 28 UK urological centres in the NHS. Participants: Participants were men with urodynamic stress incontinence after prostate surgery for whom surgery was deemed appropriate. Exclusion criteria included previous sling or artificial urinary sphincter surgery, unresolved bladder neck contracture or urethral stricture after prostate surgery, and an inability to give informed consent or complete trial documentation. Interventions: We compared male synthetic sling with artificial urinary sphincter. Main outcome measures: The clinical primary outcome measure was men’s reports of continence (assessed from questions 3 and 4 of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) at 12 months post randomisation (with a non-inferiority margin of 15%). The primary economic outcome was cost-effectiveness (assessed as the incremental cost per quality-adjusted life-year at 24 months post randomisation). Results: In total, 380 men were included in the randomised controlled trial (n = 190 in each group), and 99 out of 100 men were included in the non-randomised cohort. In terms of continence, the male sling was non-inferior to the artificial urinary sphincter (intention-to-treat estimated absolute risk difference –0.034, 95% confidence interval –0.117 to 0.048; non-inferiority p = 0.003), indicating a lower success rate in those randomised to receive a sling, but with a confidence interval excluding the non-inferiority margin of –15%. In both groups, treatment resulted in a reduction in incontinence symptoms (as measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form). Between baseline and 12 months’ follow-up, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score fell from 16.1 to 8.7 in the male sling group and from 16.4 to 7.5 in the artificial urinary sphincter group (mean difference for the time point at 12 months 1.30, 95% confidence interval 0.11 to 2.49; p = 0.032). The number of serious adverse events was small (male sling group, n = 8; artificial urinary sphincter group, n = 15; one man in the artificial urinary sphincter group experienced three serious adverse events). Quality-of-life scores improved and satisfaction was high in both groups. Secondary outcomes that showed statistically significant differences favoured the artificial urinary sphincter over the male sling. Outcomes of the non-randomised cohort were similar. The male sling cost less than the artificial sphincter but was associated with a smaller quality-adjusted life-year gain. The incremental cost-effectiveness ratio for male slings compared with an artificial urinary sphincter suggests that there is a cost saving of £425,870 for each quality-adjusted life-year lost. The probability that slings would be cost-effective at a £30,000 willingness-to-pay threshold for a quality-adjusted life-year was 99%. Limitations: Follow-up beyond 24 months is not available. More specific surgical/device-related pain outcomes were not included. Conclusions: Continence rates improved from baseline, with the male sling non-inferior to the artificial urinary sphincter. Symptoms and quality of life significantly improved in both groups. Men were generally satisfied with both procedures. Overall, secondary and post hoc analyses favoured the artificial urinary sphincter over the male sling. Future work: Participant reports of any further surgery, satisfaction and quality of life at 5-year follow-up will inform longer-term outcomes. Administration of an additional pain questionnaire would provide further information on pain levels after both surgeries. Trial registration: This trial is registered as ISRCTN49212975. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 36. See the NIHR Journals Library website for further project information.

Urinary incontinence is the most common adverse effects after radical prostatectomy, and it significantly impacts patients' quality of life after surgery. With the discovery of the fine anatomical structure of the prostate and the popularization of the concept of neurovascular bundle-sparing during surgery, the incidence of urinary incontinence after radical prostatectomy has been significantly reduced. Depending on the degree of urinary incontinence, the current treatment strategies include conservative treatment, behavioral therapy, pharmacotherapy, urethral bulking agents injection, male sling and artificial urethral sphincter. This article reviews the current status of treatment of urinary incontinence after radical prostatectomy, summarizes the scope of application, advantages and disadvantages of different treatment options and prospects for new treatment options in the future.

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.

Background: Stress urinary incontinence in men is predominantly iatrogenic after radical prostatectomy or transurethral interventions. Current studies show that there is a deficit in the availability of surgical therapy not only in Germany. The aim of this study is to investigate in more detail the structural health care situation of surgical treatment of male stress incontinence in Germany., Materials and Methods: The evaluation of the surgical therapy of male stress incontinence in Germany is based on the OPS (Operationen- und Prozedurenschlüssel-German procedural classification) codes from hospital quality reports from 2011-2019., Results: From 2012-2019, the number of male incontinence surgeries declined from 2191 to 1445. The number of departments performing incontinence surgeries decreased from 275 to 244. In the multivariate analysis, a high number (≥ 50) of radical prostatectomies/year (RPE/year) is an independent predictor of a high-volume centre (≥ 10 procedures/year; odds ratio [OR] 6.4 [2.3-17.6]; p < 0.001). The most significant decrease was in sling surgery (from 1091 to 410; p < 0.001). Here, the number of cases decreased especially in departments that implanted a high number of slings (≥ 10 slings/year; -69%; -62.4 ± 15.5 surgeries/year; p = 0.007). In addition, the number of departments implanting slings decreased over the investigated time period (from 34 to 10; p < 0.001). This particularly affected departments that also had a low number of RPE/year (from 9 to 0; -100%)., Conclusion: The situation of surgical treatment of male stress urinary incontinence in Germany shows a clear decline in sling implantation, especially in small departments. On the one hand, this reflects the increasingly differentiated indications for sling implantation. On the other hand, it raises the suspicion that a gap in care has developed, as the decline was not compensated for by other surgical therapies., (© 2024. The Author(s).)

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., (© 2024 The Asian Pacific Prostate Society. Published by Elsevier B.V.)

In this opinion article, the authors attempt to answer the question: 'stress incontinence in men: why we need prospective studies'. We explain that having a gold standard as an operative solution for many years: the sphincter prosthesis, hasty introductions of all kinds of other surgical solutions such as different male slings and the different indications for these procedures, make randomized controlled trials more difficult. We emphasize that in our opinion anamnesis and results should be done in a standardized manner. Only in this way will it be possible in the future to compare results and to make a statement about when which incontinence surgery is indicated and perhaps also by whom in which center. It's not the purpose to describe a clear solution how to proceed in the future, but it is to activate a discussion about it. [ABSTRACT FROM AUTHOR]

Stress urinary incontinence (SUI) is common after radical prostatectomy and likely to persist despite conservative treatment. The sling is an emerging operation for persistent SUI, but randomised controlled trial (RCT) comparison with the established artificial urinary sphincter (AUS) is lacking. To compare the outcomes of surgery in men with bothersome urodynamic SUI after prostate surgery. A noninferiority RCT was conducted among men with bothersome urodynamic SUI from 27 UK centres. Blinding was not possible due the surgeries. Participants were randomly assigned (1:1) to the male transobturator sling (n = 190) or the AUS (n = 190) group. The primary outcome was patient-reported SUI 12 mo after randomisation, collected from postal questionnaire using a composite outcome from two items in validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form questionnaire (ICIQ-UI SF). Noninferiority margin was 15%, thought to be of acceptable lower effectiveness, in return for reduced adverse events (AEs) and easier operation, for the sling. Secondary outcomes were operative and postoperative details, patient-reported measures, and AEs, up to 12 mo after surgery. A total of 380 participants were included. At 12 mo after randomisation, incontinence rates were 134/154 (87.0%) for male sling versus 133/158 (84.2%) for AUS (difference 3.6% [95% confidence interval {CI} –11.6 to 4.6], p NI = 0.003), showing noninferiority. Incontinence symptoms (ICIQ-UI SF) reduced from scores of 16.1 and 16.4 at baseline to 8.7 and 7.5 for male sling and AUS, respectively (mean difference 1.4 [95% CI 0.2–2.6], p = 0.02). Serious AEs (SAEs) were few: n = 6 and n = 13 for male sling and AUS (one man had three SAEs), respectively. Quality of life scores improved, and satisfaction was high in both groups. All other secondary outcomes that show statistically significant differences favour the AUS. Using a strict definition, urinary incontinence rates remained high, with no evidence of difference between male sling and AUS. Symptoms and quality of life improved significantly in both groups, and men were generally satisfied with both procedures. Overall, secondary and post hoc analyses were in favour of AUS. Urinary incontinence after prostatectomy has considerable effect on men's quality of life. MASTER shows that if surgery is needed, both surgical options result in fewer symptoms and high satisfaction, despite most men not being completely dry. However, most other results indicate that men having an artificial urinary sphincter have better outcomes than those who have a sling. The results of this large, high-quality trial allow surgeons to discuss and recommend the use of both the artificial sphincter and the sling procedure for postprostatectomy incontinence, as the results with respect to urine leakage were similar. However, men will wish to know that the majority will have some persistent urinary incontinence, although satisfaction with surgery was high: in the artificial urinary sphincter (AUS) group 91% and 85% were, respectively, completely and fairly satisfied, and 85% would recommend an AUS to a friend; and in the sling group, 72% were completely or fairly satisfied and 72% would recommend a sling to a friend. Similarly, most of the other secondary outcomes favoured the AUS over the sling procedure. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

There is minimal data published on the longevity of the transobturator retrobulbar male sling (AdVance™). We aimed to determine the efficacy, the complication rate and need for salvage SUI surgery in the medium to long term for male sling insertion. We performed a retrospective review of all patients undergoing male sling insertion at a single centre between 2009 and 2018. Data on patient demographics, pre and post-operative International Consultation on Continence Questionnaire – Urinary Incontinence (Short Form) (ICIQ-UI(SF)) scores and 24 h pad usage were collected. Success was calculated as a combination of the cured rate (0–1 security pad use) and the improved rate (>50% reduction in pad usage). Data was also collected on complications, patient satisfaction as well as need for further SUI surgery. A total of 91 patients underwent male sling insertion in the period specified; median follow up was 69 months. Success rates at 3 months in mild SUI, moderate SUI and severe SUI groups were 96, 86 and 80%, respectively. In the medium to long term, this drops to 65, 62 and 47%, respectively. The overall rate of artificial urinary sphincter (AUS) implantation was 15%. Common complications included groin pain (3%), infection (3%), urinary retention (10%) and de novo overactive bladder (OAB) (11%). The only factor predicting success or failure was pre-operative ICIQ-UI(SF) score. AdVance™ male sling success rates deteriorate from 89% at 3 months to 61% at 5 years. The risk of complications is low and, for the most part, transient. Sling insertion remains a reasonable treatment option for male patients suffering with stress urinary incontinence (SUI). [ABSTRACT FROM AUTHOR]

Purpose: To evaluate postoperative pain and complications following AdVance™/AdVance™ XP male sling implantation. Materials and Methods: A multi‐center retrospective medical notes review of patients implanted for bothersome post‐prostatectomy incontinence was conducted. All patients were telephoned to provide further information on pain or further complications related to their surgery. Statistical evaluation utilized logistical regression analysis. Additionally, a literature review was conducted reviewing pain outcomes following AdVance™/AdVance™ XP implantation. Results: One‐hundred and twenty‐seven men were reviewed over an 8‐year period. The mean age was 70 years, with mean follow up 52 months. Of those with mild stress urinary incontinence, 45 (79%) had a successful outcome compared to 42 (72%) in the moderate group. Twenty‐nine (23%) men reported postoperative pain, with a mean maximal pain score of 6 (range: 0–10). The majority of pain resolved within 4 weeks (19/29 men). A further seven patients resolved by 3 months. Only three men (2.3%) had chronic pain greater than 3 months, which all resolved by 1 year. Men less than 65 years were more likely to suffer pain (p = 0.009). Acute urinary retention occurred in 23 (18%) men and correlated significantly with postoperative pain (p = 0.04). Overactive bladder symptoms, severity of incontinence or radiotherapy were not correlated with postoperative pain. In our cohort, there were no extrusions, divisions, or explantations. Conclusion: Approximately a quarter of men experience pain in the early postoperative period. However, the severity and rates of chronic pain (>3 months) are low (2.3%) but all settle within a year. [ABSTRACT FROM AUTHOR]

Aims: The use of Argus‐T adjustable sling may be a promising alternative option for the treatment of urinary incontinence after radical prostatectomy, however long‐term data is lacking. The aim of this study is to evaluate the long‐term results of the Argus‐T sling on incontinence rates, patient's quality of life and tape‐related complications. Methods: Patients were eligible if persistent stress incontinence was present ≥12 months after radical prostatectomy. Measurements included 24 h frequency volume micturition list, 24 h pad test, 24 h pad count and quality of life questionnaires. Argus‐T adjustable sling was placed with a single perineal route incision approach. Results: Seventy‐eight patients were included, 69 ± 6 years, pre‐intervention 24 h urinary loss 212 (75–385) g. Directly after surgery, 63.6% of the patients was completely dry, 79.2% of the patients reported greater than 90% improvement of their urinary loss and 92.2% > 50% improvement. Median follow‐up time was 3.2 (2.5–6.1) years. After 5 years of follow‐up, 53.3% of the patients were completely dry, 71.5% reported an improvement greater than 90% and 79.6% reported an improvement of greater than 50%. Patients with preoperative urinary loss less than 250 g reported significantly higher improvement of their urinary loss compared to patients with urinary loss ≥250 g (p =.02). Patients satisfaction was still increased after 5 years follow‐up (70 ± 21 vs.16 ± 9, p <.001) and patients quality of life remained high (85 ± 20 vs. 88 ± 13, p =.1). Complications were mainly observed directly after surgery. Two patients (2.6%) needed reimplantation of the sling. Conclusion: These data indicate that Argus‐T sling is an effective treatment option in obtaining substantial long‐term incontinence relief in patients with invalidating moderate stress urinary incontinence after radical prostatectomy. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of artificial urinary sphincter (AUS) vs retrourethral transobturator sling (RTS) in men with moderate post‐prostatectomy urinary incontinence (PPI) using propensity score‐matching analysis to enhance the validity of the comparison (Canadian Task Force classification II‐2). Patients and methods: Consecutive men with moderate (3–5 pads/day) stress‐prevalent PPI were included if implanted with a RTS (TiLOOP® Male; pfm medical, Köln, Germany) or AUS (AMS800®; Boston Scientific, Boston, MA, USA) since July 2011 to December 2017 and with ≥12 months of follow‐up. Preoperative assessment included 24‐h pad usage, International Consultation on Incontinence Questionnaire‐Short Form (ICIQ‐SF), urethrocystoscopy, and urodynamics if indicated. Propensity score‐matching analysis was based on age, body mass index, Charlson Comorbidity Index, pad usage, previous radiotherapy, and urethrotomy. The primary outcome was at least 'much improved' response at 12‐months according to the Patient Global Impression of Improvement questionnaire, without additional PPI surgery or prosthesis explantation. Results: Of 109 included patients, 70 patients were matched and the study groups were well balanced for the baseline matched variables. The median baseline 24‐h pad usage was four in both groups (P = 0.10), and median follow‐up was 51.2 months for AUS and 47.2 months (P = 0.5) for RTS patients. In the AUS and RTS cohorts, respectively, 33 (94.3%) and 24 (68.6%) patients achieved the primary outcome (P < 0.001), the 0–1 pad/day rates was 94.3% vs 68.6% (P = 0.012) at 12 months, and 91.4% vs 68.6% (P = 0.034) at last follow‐up. At the last follow‐up, the median 24‐h leakage volumes, median ICIQ‐SF scores and satisfaction rates were 0 vs 15 mL (P = 0.017), 4 vs 10 (P = 0.001), and 94.3% vs 68.6% (P = 0.012) in the AUS and RTS cohorts, respectively. There were no significant differences in overall rates of complications and re‐interventions, although Clavien–Dindo Grade III complications (n = 3) occurred only in the AUS group. At sensitivity analysis, the study was reasonably robust to hidden bias. Conclusion: We found that AUS implantation significantly outperformed RTS in patients with moderate PPI for both subjective and objective outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Stress urinary incontinence (SUI) is a frequent adverse effect for men undergoing prostate surgery. A large proportion (around 8% after radical prostatectomy and 2% after transurethral resection of prostate (TURP)) are left with severe disabling incontinence which adversely effects their quality of life and many are reliant on containment measures such as pads (27% and 6% respectively). Surgery is currently the only option for active management of the problem. The overwhelming majority of surgeries for persistent bothersome SUI involve artificial urinary sphincter (AUS) insertion. However, this is expensive, and necessitates manipulation of a pump to enable voiding. More recently, an alternative to AUS has been developed – a synthetic sling for men which elevates the urethra, thus treating SUI. This is thought, by some, to be less invasive, more acceptable and less expensive than AUS but clear evidence for this is lacking. The MASTER trial aims to determine whether the male synthetic sling is non-inferior to implantation of the AUS for men who have SUI after prostate surgery (for cancer or benign disease), judged primarily on clinical effectiveness but also considering relative harms and cost-effectiveness. Methods/design Men with urodynamic stress incontinence (USI) after prostate surgery, for whom surgery is judged appropriate, are the target population. We aim to recruit men from secondary care urological centres in the UK NHS who carry out surgery for post-prostatectomy incontinence. Outcomes will be assessed by participant-completed questionnaires and 3-day urinary bladder diaries at baseline, 6, 12 and 24 months. The 24-h urinary pad test will be used at baseline as an objective assessment of urine loss. Clinical data will be completed at the time of surgery to provide details of the operative procedures, complications and resource use in hospital. At 12 months, men will also have a clinical review to evaluate the results of surgery (including another 24-h pad test) and to identify problems or need for further treatment. Discussion A robust examination of the comparative effectiveness of the male synthetic sling will provide high-quality evidence to determine whether or not it should be adopted widely in the NHS. Trial registration International Standard Randomised Controlled Trial Registry: Number ISRCTN49212975. Registered on 22 July 2013. First patient randomised on 29 January 2014.

Background: Stress urinary incontinence (SUI) is a major component of the post radical prostatectomy (RP) trifecta. Surgical treatments are sub‐urethral slings, artificial urinary sphincter (AUS) and adjustable peri‐urethral balloons (PUB) ProACT. All options are imperfect at best and persistent SUI is challenging when AUS is not manageable. Aims: This study analyzed the cumulate experience of our 2 centers with offering PUB implantation for SUI post RP in patients with insufficient improvement from slings. Materials & Methods: This retrospective study reviewed all patients implanted with second line ProACT. The primary endpoint was continence, defined as 0 pads per day (PPD). The secondary endpoints were 50% decrease in PPD and increases in the Incontinence Quality of Life score (IQOL). Refilling and complications were reported. Results: Between 2007 and 2016, 26 patients were implanted. Five patients have had adjuvant radiotherapy (18%). The mean follow‐up was 36 months (±20; min 14‐max 128). All patient presented with persistent SUI, using 2.3 PPD (±1; min 1–max 6), and only one sling was removed due to infection. After ProACT with an average 3 mL refilling (±1.2 min 2–max 6), 18 patients (66.7%) were continent. Eight of the remaining patients (29.6%) were improved; their number of PPD decreased from 2.6 to 1. The average IQOL score of those 8 patients increased by 20 points, from 53.4 up to 74.2 (P =.005). Overall 26 patients (96.3%) were improved. The remaining patient was not implanted because of an intraoperative urethral injury and is considered a failed case (3.7%). He had instead an AUS implantation. Three patients (14.8%) needed PUB replacement. Conclusion: The limited population of patients from both our centers who presented with persistent SUI after RP, despite sling placement, improved with PUB ProACT implantations without significant complications. [ABSTRACT FROM AUTHOR]

Background: The impact of obesity on AdVance male urethral sling outcomes has been poorly evaluated. Anecdotally, male urethral sling placement can be more challenging due to body habitus in obese patients. The objective of this study was to evaluate the impact of obesity on surgical complexity using operative time as a surrogate and secondarily to evaluate the impact on postoperative pad use. Methods: A retrospective cohort analysis was performed using all men who underwent AdVance male urethral sling placement at a single institution between 2013 and 2019. Descriptive statistics comparing obese and non-obese patients were performed. Results: A total of 62 patients were identified with median (IQR) follow up of 14 (4-33) months. Of these, 40 were non-obese and 22 (35.5%) were obese. When excluding patients who underwent concurrent surgery, the mean operative times for the non-obese versus obese cohorts were 61.8 min versus 73.7 min (p = 0.020). No Clavien 3-5 grade complications were noted. At follow up, 47.5% of the non-obese cohort and 63.6% of the obese cohort reported using one or more pads daily (p = 0.290). Four of the five patients with a history of radiation were among the patients wearing pads following male urethral sling placement. Conclusion: Obese men undergoing AdVance male urethral sling placement required increased operative time, potentially related to operative complexity, and a higher proportion of obese compared with non-obese patients required postoperative pads for continued urinary incontinence. Further research is required to better delineate the full impact of obesity on male urethral sling outcomes. [ABSTRACT FROM AUTHOR]

Purpose of Review: To review the most recent literature on the treatment of post-prostatectomy incontinence. Recent Findings: New technology and implementation of surgical devices have resulted in a myriad of treatment options for men suffering post-prostatectomy incontinence. However, many of these have widely varied results. Summary: The treatment of post-prostatectomy incontinence is consistent and continues to expand with more devices being introduced in the market. However, optimization of patient outcomes and determination of which devices work best will be required. To date, there are few randomized controlled trials for the treatment of post-prostatectomy incontinence. [ABSTRACT FROM AUTHOR]

Purpose of Review: With increasing rates of radical prostatectomy, post prostatectomy incontinence represents a growing challenge for urologists. The artificial urinary sphincter is a highly effective treatment but is invasive, expensive and associated with mechanical failure. Over the past two decades, a plethora of minimally invasive sling devices to treat post prostatectomy incontinence have become available. This review aims to describe the various male slings available and the evidence supporting their use. Recent Findings: Various sling devices are available, each with limited generally low quality evidence reporting their efficacy and safety. Few comparative studies are available. Summary: Evolving mid-term data suggest that male slings are an effective alternative to artificial urinary sphincter for well-selected patients. Further study is needed to provide higher quality particularly comparative evidence to support the continued use of male sling devices. [ABSTRACT FROM AUTHOR]

Previous worked showed that the Andrianne Mini-Jupette (AMJ) procedure with inflatable penile prosthesis (IPP) significantly improves climacturia or stress urinary incontinence (SUI) that may accompany erectile dysfunction (ED) after radical prostatectomy. However, with the AMJ procedure, the graft is incorporated into the medial aspect of the corporotomy, thereby requiring a more complex closure. Moreover, in the original report, multiple graft materials were used. To describe our technique for "male urethral mini-sling" (MUMS) with a Virtue sling mesh, which is a modified approach to the AMJ, and to assess early postoperative outcomes. A retrospective chart review was performed for men who underwent IPP and MUMS placement with a modified Virtue mesh by 2 high-volume prosthetic urologic surgeons using the same technique. After proximal urethral exposure, the MUMS is sutured to the latera corpora over the bulbar urethra, proximal to and separate from the planned corporotomy, with care taken to avoid excessive urethral tension. The IPP is then placed in standard fashion. Changes in patient-reported climacturia and pads per day for SUI were assessed before and after surgery. 36 men underwent both IPP and MUMS placement between January 2016–October 2018. Mean patient age was 68 years. Etiology for ED and urinary symptoms was prostatectomy alone in 30 of 36 (83%) and prostatectomy plus radiation in 6 of 36 (17%). Preoperative urinary symptoms included climacturia in 30 of 36 (83%) and SUI in 27 of 36 (75%). Mean (SD) follow-up was 5.9 (3.7) months. Climacturia resolved in 28 of 30 (93%), and SUI improved in 23 of 27 (85%). The mean (SD) number of pads per day for those patients with SUI decreased significantly from 1.4 (1.1) before surgery to 0.4 (0.6) after surgery (P =.02). 1 patient required MUMS explantation for urethral erosion after prolonged postoperative catheterization. The MUMS with modified Virtue mesh at the time of IPP placement can be used to treat ED with climacturia or mild SUI after radical prostatectomy. Strengths include the use of a consistent operative technique with a single graft material by 2 experienced prosthetic urologic surgeons. Limitations include the retrospective study design, use of subjective postoperative outcomes, lack of comparison group, and relatively moderate follow-up duration. Our early results suggest that the MUMS significantly improves bothersome climacturia and mild SUI in addition to treating ED, with little added morbidity. Although further study, including longer-term follow-up, is needed, this approach may be considered in the appropriately counseled patient. Valenzuela RJ, Ziegelmann MJ, Hillelsohn JH, et al. Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence. J Sex Med 2019;16:1310–1317. [ABSTRACT FROM AUTHOR]

As the rate of prostate cancer detection increases, so does the rate at which radical prostatectomy is performed. Post-prostatectomy incontinence (PPI) or urine leakage affects around 20% of men who undergo this procedure. Although affected individuals must be supported in maintaining hygiene with the use of urine capture devices, definitive treatment should also be offered if appropriate. A range of management options are available, from incontinence pads to artificial urinary sphincters. However, an understanding of the aetiology of the leak as well as patient factors is vital if the correct treatment option is to be selected. This article describes the potential causes of PPI and explores management options for this condition. [ABSTRACT FROM AUTHOR]

Objective: The Argus perineal sling is a minimally invasive surgical option to treat post‐prostatectomy stress urinary incontinence (PPSUI). This study retrospectively evaluated the short‐term clinical outcomes with the Argus sling for PPSUI management and determined the effects of potential preoperative parameters on intraoperative retrograde leak point pressure (RLPP). Methods: In this retrospective review of 16 men with various degrees of stress incontinence after prostatic surgery who underwent Argus sling, PPSUI was evaluated by pad usage, urodynamics, 24‐hour pad weight, and validated questionnaires. Findings before and a minimum of 6 months after sling placement were compared. "Cure" was defined as no pad usage or the use of 1 pad for security; "improvement" was defined as a reduction in daily pad use by >50%. Results: After a mean (±SD) follow‐up of 9.75 ± 3.51 months, 62.5% of patients were cured, 18.75% were improved, and 18.75% were still incontinent. Preoperative 24‐hour pad weight was positively correlated with RLPP (P = .0121, r = 0.6286). Mean RLPP was 37.93 ± 3.45 cmH2O. During follow‐up, 44% of men had transient perineal or scrotal pain managed conservatively. Sling explantation, reported in 3 of 16 patients, was associated with urethral erosion or previous radiation therapy. Conclusion: The Argus male sling can lead to satisfactory results in carefully selected patients. Increased stress urinary incontinence severity based on 24‐hour pad weight required higher RLPP to achieve continence. Favorable satisfaction variables and quality of life scores are affected by appropriate intraoperative tensioning pressure. [ABSTRACT FROM AUTHOR]

Objective: Artificial urinary sphincter (AUS) device failure or revision can be due to multiple etiologies including erosion, infection, mechanical malfunction, and urethral atrophy. However, few studies have evaluated factors that predispose patients to urethral atrophy. Here, we sought to identify preoperative and perioperative risk factors associated with urethral atrophy in men undergoing primary artificial urinary sphincter (AUS) placement for stress urinary incontinence. Material and methods: From 1987 to 2013, 1829 AUS procedures were performed at our institution. A total of 1068 patients underwent primary AUS placement and were the focus of our study. Multiple clinical and surgical variables were evaluated for a potential association with revision for atrophy. Those found to be associated with atrophy and relevant competing risks were further evaluated on multivariable analysis. Results: With a median follow-up of 4.2 years (IQR 1.3-8.1), 89 men (8.3%) had urethral atrophy requiring reoperation. Median time to revision was 4.5 years (IQR 1.9-7.6). On univariable analysis, only smaller cuff size (4.0-cm versus 4.5-cm; HR 3.1, p=0.04) was associated with an increased rate of urethral atrophy. Notably, patient age at the time of surgery (p=0.62), body mass index (0.22), and smoking status (p=1.00) were not associated with a risk of atrophy. On multivariable analysis smaller urethral cuff size remained significant (HR 2.8, 95% CI 1.1-7.1; p=0.01). Conclusion: Revision surgery for urethral atrophy was performed in approximately 8% of men undergoing primary AUS placement. Utilization of a smaller AUS cuff size appears to be an independent factor associated with increased rate of urethral atrophy. [ABSTRACT FROM AUTHOR]

Purpose of Review: Despite limited evidence and efficacy, urethral bulking remains a common treatment for post-prostatectomy stress urinary incontinence (PP-SUI). Herein we provide an overview of the existing evidence for synthetic bulking agents and emerging evidence for stem cell-based sphincter rejuvenation in this setting. We also touch upon salvage techniques for management of PP-SUI after failed anti-incontinence interventions.Recent Findings: Autologous stem cell (ASC) therapies are currently undergoing phase III trials for use in female SUI and are poised to enter the market within the next decade. Early data suggests that they may have a future role in PP-SUI management as well. The artificial urinary sphincter (AUS) has emerged as the standard of care for salvage PP-SUI treatment.Summary: Treatment paradigms for PP-SUI continue to evolve. Synthetic bulking remains common while autologous bulking looms as a potential future therapy. The AUS remains the last line of defense. [ABSTRACT FROM AUTHOR]