A narrative review on surgical treatment options for male stress urinary incontinence
Review Article on Surgical Management of Stress Urinary Incontinence in Men

A narrative review on surgical treatment options for male stress urinary incontinence

Zachary J. Prebay, Halle E. Foss^, Kerith R. Wang^, Paul H. Chung

Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA

Contributions: (I) Conception and design: ZJ Prebay, PH Chung; (II) Administrative support: PH Chung; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: ZJ Prebay, HE Foss, KR Wang; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

^ORCID: Halle E. Foss, 0000-0002-7671-5227; Kerith R. Wang, 0000-0003-4389-2734.

Correspondence to: Paul H. Chung, MD. Associate Professor, Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St. Ste. 1100, Philadelphia, PA 19107, USA. Email: paul.chung@jefferson.edu.

Background and Objective: Stress urinary incontinence (SUI) can occur due to a variety of etiologies. For male patients specifically, SUI is typically thought of as iatrogenic secondary to intrinsic sphincter deficiency occurring after prostate surgery. Given the noted negative impact that SUI can have on a man’s quality of life, multiple treatment options have been developed to improve symptoms. However, there is no “One-Size-Fits-All” approach to management of male SUI. In this narrative review, we sought to highlight some of the various procedures and devices available to treat men with bothersome SUI.

Methods: This narrative review gathered primary resources through Medline search, and secondary resources by cross-referencing citations used in articles of interest. We started our investigation by searching for previous systematic reviews on male SUI and treatments for male SUI. Furthermore, we reviewed societal guidelines, such as the American Urological Association and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction guidelines and the recently published European Urological Association guidelines. Our review focused on English-language full-length manuscripts when available.

Key Content and Findings: We present multiple surgical options for men with SUI. This review focuses on surgical options including 5 fixed male slings, 3 adjustable male slings, 4 artificial urinary sphincters (AUS), and an adjustable balloon device. This review includes treatment options from across the globe, although not all included devices are available in the United States.

Conclusions: A great variety of treatment options exist for men with SUI, although not all Federal Drug Administration (FDA) approved. Shared decision making is paramount to generate the greatest satisfaction for patients.

Keywords: Stress urinary incontinence; artificial urinary sphincter; male sling

Submitted Sep 27, 2022. Accepted for publication Jan 29, 2023. Published online Mar 06, 2023.

doi: 10.21037/tau-22-629

Introduction

Stress urinary incontinence (SUI) can occur due to a variety of etiologies. For male patients specifically, SUI is typically thought of as iatrogenic, secondary to intrinsic sphincter deficiency occurring after prostate surgery (1,2). However, SUI can also have a neurogenic etiology or occur after urethral or pelvic surgery (3). There is a wide variation in reported rates of SUI following radical prostatectomy, with rates of persistent SUI as low as 4% and as high as 40% (4). With that said, not every patient experiences the same degree of SUI or bothersome side effects following a prostate procedure, with symptoms ranging from none or quite mild, to severe (4). SUI has a considerably negative impact on quality of life for patients, even for those only needing 1 pad per day (PPD) after surgery (5). The literature states that 3–6% of men will undergo some form of surgical correction for SUI following prostatectomy (6,7). The rate of SUI following a bladder outlet procedure is lower with 1% to 2% of men experiencing persistent SUI but is distressing for those who are affected (8).

Given the noted negative impact that SUI can have on a man’s quality of life, multiple treatment options have been developed to improve symptoms (9). However, there is no “One-Size-Fits-All” approach to management of male SUI. Treatments range from conservative management with lifestyle interventions to surgical procedures. Therefore, it is vital for urologists to know the spectrum of treatment options to properly counsel patients and to minimize treatment regret (10).

In this narrative review, we sought to highlight some of the various procedures and devices available to treat men with bothersome SUI. Previous reviews have tended to focus on certain subsets of treatments for male SUI, such as just reviewing male slings (MS), but we will discuss multiple surgical treatment options. By broadly highlighting the entire spectrum of surgical treatment options, we hope to guide providers counseling patients on which treatment may be the best for them and to educate providers on additional devices that are not available in their country. We present this article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-22-629/rc).

Methods

This narrative review gathered primary resources through Medline search and secondary resources by cross-referencing citations referenced in articles of interest. Our methodology is summarized in Table 1. We started our investigation by searching for previous systematic reviews on male SUI and treatments for male SUI. Then, we reviewed societal guidelines, such as the American Urological Association and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction guidelines and the recently published European Urological Association guidelines on male urinary incontinence (2,3). In this manner, we were able to obtain a broad sample of the previous scientific literature from which we were able to synthesize into the review as presented. Of note, as a narrative review synthesizing the results of various primary studies, the definitions and outcomes of interest may vary between each article. This is a consistent issue within the SUI literature as studies lack standardization in both grading of SUI and in terms of outcome measurement. When applicable, we specify how each study defined success or continence to provide context for the reported results. Further, this review is intended to provide an overview for readers and is not designed to guide or recommend treatment for individual patients as this decision is best left to shared decision making between patient and provider.

Table 1

Search methodology

Items Specification
Date of search 06/01/2022–12/19/2022
Databases and other sources searched PubMed
Search terms used “Male Stress Urinary Incontinence”, specific device names, “review”
Timeframe To present
Inclusion and exclusion criteria Full, English-language manuscripts when available/preferred
Selection process ZJP, HF, KRW evaluated literature
Any additional considerations, if applicable Our search primarily identified societal guidelines or devices familiar to our clinical practice as well as previous reviews on the topic and then expanded based on findings within primary sources

Discussion

Bulking agents

We will begin our discussion with a less invasive procedure, urethral bulking. Urethral bulking agents may be considered for men unfit to undergo or wishing to avoid more invasive surgery. There are currently multiple urethral bulking agents available for use. With this procedure, the agent is administered directly into the periurethral tissue under cystoscopic guidance to coapt the mucosa and provide more resistance against urine flow. In the first decade of the new millennia, bulking agents were performed in around one-quarter to one-third of men with SUI (11). However, following this initial enthusiasm, there has been limited data supporting the efficacy of these treatments (12) and a need for contemporary literature describing their current applications and efficacies. A recent systematic review by Toia et al. noted a wide variability in reported outcomes with moderate to severe risk of bias (12). The review concluded that there is some evidence for short term improvement in men (up to 83% completely dry in one study) but that the data is scarce with a relatively high risk of bias and that durability of success remains a challenge.

For more definitive treatment, we transition our discussion to the various MS and artificial urinary sphincter (AUS) devices. Traditionally, an AUS has been considered the “gold standard” for SUI and is a valid treatment for all degrees of symptoms. MS have typically been reserved for men with mild or moderate incontinence (13). Both AUS and MS are safe, with AUS having a slightly higher rate of postoperative complications (5.1% vs. 2.8%) in an analysis of ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) data (14), which evaluated 608 patients undergoing AUS and 597 patients receiving a MS. However, an AUS requires a minimum level of dexterity to operate the sphincter mechanism, and this important fact may limit its accessibility to some patients.

Fixed MS

MS work by compressing and repositioning the bulbar urethra (13). When on appropriate tension, the sling will relocate the urethral bulb proximally into the pelvis and will also provide support to the dorsal distal portion of the membranous urethra (15). They may be inserted through a transobturator or retropubic approach and come in adjustable or fixed models. For fixed models, Rehder and Gozzi first reported a transobturator tape used in cadavers and later in a pilot of 20 men in 2007 (16). This was followed by a series of 67 patients (17) and shortly thereafter developed into the AdVance Male Sling (Boston Scientific, Marlborough, MA USA) (18). The second-generation AdVance XP entered the market in 2010 (19) with design modifications including a new anchoring mechanism to prevent migration, a liner, and longer mesh arms for easier use in obese patients (13). The interested reader can find links to the companies’ websites in Appendix 1 for photos of the devices. Overall cure rate (0 pad use) has been reported at 80% with a median follow-up of 26 months (19). In comparative work, there are largely no significant differences between the original and XP models, both in terms of outcomes and complications except for higher rates of urinary retention in the XP (20). Adverse events related to these slings include elevated post-void residual, increased bleeding, and decreased satisfaction with a need for subsequent incontinence procedures (21).

Grise and colleagues in France developed a sling similar to the AdVance which is now known as the I-Stop TOMS (originally CL Medical, now DiLo Medical, Lyon, France) (22), with placement of the sling located at the bulbar urethra. It is a 4-arm sling made of monofilament polypropylene. After first performing cadaver studies, they initially tested their device on 50 men with post-prostatectomy incontinence. There were concerns over the durability of success in this device, with lower long term objective cure rates (heterogenous between studies, 40% and 15% at 1- and 5-year follow-up), as summarized by a recent meta-analysis, when compared to other devices (23,24). This device was approved by the Federal Drug Administration (FDA) in 2006. In the available literature, minor adverse events, such as urinary retention or infection, are uncommon, and no serious adverse events were reported (24-26).

From Denmark comes the Virtue quadratic sling (Coloplast, Humlebaek, Denmark) (27), which has been available in the United States since 2008. This “hybrid device” works by achieving both urethral elevation and prepubic compression using a 4-armed polypropylene mesh (28). The Virtue sling attempted to combine the mechanisms of previous bone-anchored and retroluminal slings into a single more effective implant. Crucial to the success of this surgery is the use of retrograde leak point pressure to determine the tension at which to fix the sling. Saline is administered at 60 cm above the pubic symphysis through a catheter in the fossa navicularis and once flow stops, the tension for the sling is correct. If patients have residual bothersome incontinence after the surgery is performed, a second surgery again using leak point pressure can help guide suture placement to increase tension on the sling. Recent data up to 3 years postoperatively notes the Virtue sling shows promising efficacy, reporting that over 70% of patients continued to show objective improvement based on 24-hour pad weight (>50% reduction) and with a 67% subjective satisfaction rate (29). In this same study, many patients had postoperative pain or de novo overactive bladder symptoms; the rate of second procedures was low at 5.1%, and no patients suffered a more serious complication.

Adjustable MS

As innovation continued, adjustable MS were developed in contrast to the traditional fixed models. There is not yet strong evidence to suggest having an adjustable sling provides additional benefit (3), and no adjustable sling has yet been approved for use in men within the United States, although there is a theoretical advantage. Our narration will discuss the ATOMS, Argus, and the Remeex devices. These models likewise provide pressure on the bulbar and membranous urethra and contain adjustable mechanisms to personalize the pressure applied for individual patients and supplement a compressive component to the relocating effect of the sling (30). Consistent with issues throughout SUI research, variable definitions of SUI and cure exist which plagues comparisons between fixed and adjustable slings. The DOMINO (Debates On Male Incontinence) project evaluated the differences between fixed and adjustable slings in a large cohort study. They identified no differences in functional outcomes or quality of life but noted that patients with more risk factors and a higher degree of SUI were more likely to be offered an adjustable sling (30). This analysis included the AdVance and AdVance XP fixed slings as well as the Argus classic, Argus-T, and ATOMS adjustable slings.

The ATOMS (A.M.I, Feldkirch, Austria) sling is well studied with two systematic reviews commenting on outcomes (31,32). This device is composed of a silicone cushion which is anchored to a two-armed mesh attached to both sides of the pubis. The cushion can be filled or emptied via injecting sterile saline into a port, which allows for adjustable compression of the bulbar urethra. The first iteration was introduced in 2008, and the second and third versions were released in 2013 and 2014 respectively. The newer models altered the location and coating of the port and were aimed at reducing the risk of postoperative infections and facilitating easier postoperative device adjustment, specifically involving a pre-attached silicone-covered scrotal port in the 2014 generation. The ATOMS sling resulted in slightly less than a 70% dryness rate, and nearly 90% of patients experienced improvement after adjustment was completed. In a large study of over 200 patients, the device was shown to be most effective in men with mild symptoms resulting in a dryness rate (0–1 safety pads daily) of 96.2% and an overall success rate (completely dry or improved) of 84% at mean 17 months follow-up (33). Between the two systematic reviews, major complications were reported in 3% and 4.2% of patients, and the total complication rate was reported at 16.4% and 17% of patients (31,32). The ATOMS sling is not FDA approved.

Other adjustable slings include the Argus and Argus-T (Promedon SA; Cordoba, Argentina) systems and the Remeex (REgulador MEcánico EXterno—External Mechanical Regulator) (Neomedic, Terrassa, Barcelona, Spain) system. These slings are less studied and have a wide variability in reported patient satisfaction postoperatively. The Argus slings, encompassing both the Argus classic and Argus-T (for transobturator approach) models, has a reported continence rate ranging from 62% to 100% depending on the studies’ definitions of continence (34). One notable concern with the adjustable slings includes postoperative perineal pain (30). Significant perineal pain can be a multifactorial and challenging outcome for patients following sling placement and can lead to explantation (35). In a DOMINO comparison of fixed and adjustable slings, the adjustable slings had significantly more postoperative pain, and the Argus T model in particular had higher pain (43.8% vs. 5.3% Argus classic vs. 4.1% ATOMS) in a subanalysis. A recent study from Márquez-Sánchez et al. in Spain reported complete dryness (0–1 safety pad) in 72.3% of patients receiving a Remeex sling (36), which was higher than previously reported results. The Remeex sling has been available in the United States since 2006. Although Promedon has some options available for female SUI in the US, the Argus slings have not been approved in this country.

AUS

The AMS 800 (American Medical System) (Boston Scientific, Marlborough, MA, USA) has long been an implant of choice since its introduction around 50 years ago and is considered the gold standard for treatment of male SUI. Full details of implantation are described elsewhere, but briefly, the AMS 800 is designed to mimic the natural urinary sphincter with a circumferential urethral cuff that can be inflated and deflated by a scrotal pump and includes a fluid reservoir placed inconspicuously in the abdomen. Given its prevalence, robust long-term follow-up and outcomes data exist. Social continence (0–1 PPD) is reported between 55% and 77% (37-39) and maintains a 90% satisfaction rate even at 15 years of follow-up (40). Despite the well-documented success, one downside to the AMS 800 is a relatively high re-intervention rate of around 25% with the rate of revision and the possibility of device failure increasing over time, important considerations to counsel patients on prior to their index operation (41). If an AUS does need revision, two options are available: downsizing the urethral cuff or placing a tandem cuff, both showing similar outcomes and device survival in one study (42). Alternative options include identifying an alternative location for the cuff on the urethra, like a trans corporal placement.

The Zephyr ZSI 375 (Zephyr Surgical Implants, Geneva, Switzerland) was designed as a one-piece AUS for easier insertion. This device does not require an abdominal reservoir, instead utilizing a pressure-regulating tank and pump placed within the scrotum, and the pre-connected design is intended to both save time and decrease mechanical failure due to poor connection (43). Additionally, the device has an adjustable cuff and an adjustable pressure regulator. An early case series did in fact show decreased operative times and no intraoperative complications. However an explantation rate of over 60% was noted with mean device survival of less than one year (43). Since then, the manufacturer has made iterative updates to improve connections and make the device easier to use. A more recent European multicenter study showed considerable success (cured or improved) in 92.7% of the 109 men recruited with severe SUI and a much lower complication rate with 9 (9.7%) patients requiring explant and 3 (3.2%) requiring revision (44).

Another pre-connected device is the Victo AUS from the same company that created the Argus slings (Promedon SA). This sphincter is also designed to be adjustable, similar to their slings, resulting in a 76.4% dry rate and no explantations after one year in two available studies (45,46). However, these devices have not had FDA clearance but are available in many countries in Latin America, Europe, Asia, and Africa.

Balloon device

Lastly, the ProACT (Uromedica Inc., Plymouth, MN, USA) device differs from our previous implants in that it provides a non-circumferential compression on the urethra. This system is placed transperineally under fluoroscopic guidance, endoscopic assistance, or ultrasound and consists of two balloons placed on either side of the bladder neck and adjustment ports within the scrotum (47). The ports can be accessed percutaneously in the outpatient setting to further inflate or deflate the balloons based on the patient’s response to treatment. Studies have shown a significantly positive impact on quality of life with a meta-analysis of 1,264 patients and 4,517 patient-years reporting a decrease of 4 to 1.1 PPD (47). In this study, the most common complications were erosions of the bladder or urethra and approximately 1 out of 5 patients needed revision with an average follow-up of 3.6 years. Further, these devices have the known long-term complication of balloon migration occurring in an estimated 6.5% of patients, which can lead to device explant.

Newer devices

In addition to the devices mentioned above, new devices are being brought to market, such as the Rigicon ContiClassic and ContiReflex systems (Rigicon—Innovative Urological Solutions, Ronkonkoma, NY, USA) which was granted approval in Europe in 2020 and is still in its first trial of patients (48). The company was targeting a US approval in 2022, thus the first availability in the States may occur shortly.

Historical devices

In contrast, older models have since been taken off the market. A historical mention will be made of the InVance male sling (American Medical Systems, Minnetonka, MN, USA) (49). This sling was anchored to bone, but given associations with bone infection and a high failure rate (50), it is no longer available for use. Similarly, the TiLOOP Male (pfm medical, Cologne, Germany) sling uniquely had a titanium coating designed with the theory that the titanium coating would limit cellular reactions (51-53), like apoptosis and proliferation. This carried the apparent advantage of minimizing inflammation, shrinkage, and sling migration. In a study of 44 patients with midterm follow-up, objective and subjective improvement were nearly consistent at 77% and 75% with a median follow-up of 25 months (54). Although this device is no longer available on the company website, some argue perhaps it was prematurely disregarded (55). Finally, another fixed sling includes the Surgimesh M-Sling (Aspide Medical, La Talaudière, France), with one study from France available in the literature (56). This sling was designed for direct implantation over the urethral bulb and includes two transobturator and two prepubic arms with divergent traction axes to provide adequate tension. In a study of 77 patients, 34.4% reported a cure (0 pad or daily pad weight <2 g) and 71% reported being either “satisfied” or “very satisfied” after 24 months (56). The M-Sling is no longer available on the company website.

The various treatment options above are summarized in Tables 2-4 separated into fixed slings, adjustable slings, AUS, and ProACT. If all else fails, offering a urinary diversion to patients unable to achieve satisfactory improvements in their quality of life from other treatments is in line with national guidelines (2). However, this decision must not be taken lightly given the well-known morbidity of diversions, especially if a cystectomy is included.

Table 2

Comparison of available fixed sling options for male stress urinary incontinence

Treatment Study Measure of success Infection rate Complications Country (year) of approval
AdVance XP Fixed Sling (19,57-59) Chung et al. 2016 84% (16/19) achieved social continence (<1 PPD) FDA approved Nov 27, 2018
Collado Serra et al. 2013 Urinary retention
Perineal numbness
De novo storage symptoms (urgency)
Perineal hematoma
Bauer et al. 2010 0.4% (1/230) local wound infection 1.3% (3/230) required surgical intervention for complications
0.4% (1/230) urinary infection 21% postoperative urinary retention, managed with temporary catheterization
Rehder et al. 2010 73.7% (87/118) cured (0 or occasional security pad)
I-Stop TOMS Fixed Sling (25,26) Galiano et al. 2016 82.4% (28/34) were dry or showed improvement (50% reduction in PPD) 2.9% (1/34) wound infection 14.7% (5/34) required re-implantation
Retention
Ecchymosis
Low perineal pain
Grise et al. 2012 87% improved to 0–1 PPD
Virtue Quadratic Fixed Sling (60) McCall et al. 2016 32% (10/31) were successes (see failure) None 68% (21/31) were procedure failures (no change in postoperative pad use, failure to reduce leakage <2 PPD, need for placement of an artificial genitourinary sphincter, and/or sling explant) FDA approved Aug 17, 2011
22% (7/31) underwent sling explant, 20% (6/31) had a subsequent AUS placement
Chronic pain
Failure more likely in patients who received EBRT
More subsequent procedures than other slings

FDA, United States Food and Drug Administration; PPD, pads per day; AUS, artificial urinary sphincter; EBRT, external beam radiation therapy.

Table 3

Comparison of adjustable sling options for male stress urinary incontinence

Treatment Study Measure of success Infection rate Complications Country (year) of approval
ATOMS Adjustable Sling (32,33) Esquinas et al. 2019 Mean 67% and 90% improvement between 20 studies 5.75% needed device removal Europe
16% complications, 3% major complications
Transient postoperative dysesthesia
Angulo et al. 2018 3/215 patients with mean 24 months follow-up
Argus Adjustable Sling (61,62) Hübner et al. 2011 79.2% (80/101) dry with 0–1 PPD in moderate to severe SUI 15.8% (16/101) needed removal
38.6% (39/101) required adjustment
Romano et al. 2009 66% (31/48) dry and 12.8% (6/48) 1 PPD 6.3% (3/48) infection Erosions through urethra, bladder, and abdominal wall
Perineal pain
Acute urinary retention, spontaneously resolving
Remeex Adjustable Sling (63) Sousa-Escandón et al. 2007 64.7% (33/51) cured (no or safety pad) 3.9% (2/51) removed due to infection Intraoperative bladder perforation Many European countries
Perineal hematoma FDA approved Nov 02, 2006
Transient perineal discomfort and pain

PPD, pads per day; FDA, United States Food and Drug Administration.

Table 4

Comparison of artificial urinary sphincter and balloon device option(s) for male stress urinary incontinence

Treatment Study Measure of success Infection rate Complications Country (year) of approval
AMS 800 Artificial Urinary Sphincter (64) Queissert et al. 2020 45.5% vs. 24.2% achieved social continence (0–1 PPD) at low-volume vs. high-volume centers 8 (1.9%) Revision rate 38.5% vs. 26.7% at low-volume and high-volume centers FDA approved Jun 14, 2001
Erosion
Mechanical failure
Zephyr ZSI 375 Artificial Urinary Sphincter (44,65) Ostrowski et al. 2019 8.25% urethral erosion Many countries in Europe, Latin America, Near East, Southeast Asia
2.75% mechanical complications requiring re-implantation
Ostrowski et al. 2018 58% (29/50) achieved social continence (0–1 PPD) from severe SUI (≥3 PPD) 0% (0/50) at 4 years 24% (12/50) required revision or permanent device removal
Failure in 12% (6/50) of patients
Victo Artificial Urinary Sphincter (45,46) Giammò et al. 2021 1-year dry rate 76.4% None reported 17.6% (all Clavien-Dindo I) Many countries in Europe, Asia, Africa, and Latin America
Social continence (0–1 PPD) 94%
Weibl et al. 2018 No 1-year explants
Rigicon ContiClassic Artificial Urinary Sphincter No studies yet European approval 2020
ProACT Adjustable Continence Therapy (47,66,67) Larson et al. 2019 4.0 PPD reduced to 1.1 PPD 14% infection Revisions ranging from 21.7–72.7% mostly due to device leakage In European market since 2002
Device leakage FDA approved Nov 24, 2015
Intraoperative urethral perforation
Urinary retention
Venturino et al. 2015 4.5% (1/22) continent immediately 73% revision rate
Mean 5.9 PPD reduced to 1.7 PPD 55% explantation rate
Rouprêt et al. 2011 PPD decreased from 4.2 to 1.5 18% explantation rate
Significantly more urethral and bladder erosion than radiotherapy

PPD, pads per day; FDA, United States Food and Drug Administration; SUI, stress urinary incontinence.

The landscape of treatment options for SUI is constantly changing, with innovative research being published daily. Many opportunities for research to improve our care of patients remains. One of the pitfalls when studying SUI is the lack of standardization across studies. This can make comparisons between devices difficult as definitions of “success” are not uniform. Future directions to standardize how we communicate and evaluate SUI and treatment of SUI will benefit providers and more importantly patients. Other areas of future research include more multi-institutional and registry-based studies. Much literature regarding SUI comes from single institutional studies or studies only including a few institutions. Multi-institutional initiatives such as the DOMINO project are applauded, and even larger registry-based studies would be strongly welcomed as this can capture more real-world outcomes in a way that has been lacking. Additionally, we would like to highlight the continued efforts and innovative work being done by contributors to the International Consultation on Incontinence, with the 7th consultation occurring in November 2021. We look forward to Abrams and colleagues’ updated edition of “Incontinence”, which will provide a far more comprehensive overview of male SUI than a review article could hope to accomplish. And finally, with all of the available devices on the market, continued efforts to refine patient selection and to individualize treatment will improve patient care.

Conclusions

In conclusion, a great variety of treatment options exist for men with SUI although not all are FDA approved. Shared decision making is paramount in generating the greatest satisfaction for patients (10). An AUS has long been considered the gold standard for SUI, but for men wishing to avoid a surgery or without the dexterity to manipulate a scrotal pump, alternatives exist and can be attempted. We discuss a wide variety of treatments from multiple countries of origin capturing the majority of devices and procedures utilized worldwide. The most recognized surgical treatments for SUI were presented and serve as a framework and quick reference for urologists wishing to better guide patients looking for treatment of their SUI.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology for the series “Surgical Management of Stress Urinary Incontinence in Men”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-22-629/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-22-629/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-22-629/coif). The series “Surgical Management of Stress Urinary Incontinence in Men” was commissioned by the editorial office without any funding or sponsorship. PHC served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Translational Andrology and Urology from April 2019 to November 2023. PHC received grants, consulting fees and honoraria for lectures from Boston Scientific and Coloplast. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. Das AK, Kucherov V, Glick L, et al. Male urinary incontinence after prostate disease treatment. Can J Urol 2020;27:36-43. [PubMed]
  2. Sandhu JS, Breyer B, Comiter C, et al. Incontinence after Prostate Treatment: AUA/SUFU Guideline. J Urol 2019;202:369-78. [Crossref] [PubMed]
  3. Gacci M, Sakalis VI, Karavitakis M, et al. European Association of Urology Guidelines on Male Urinary Incontinence. Eur Urol 2022;82:387-98. [Crossref] [PubMed]
  4. Crivellaro S, Morlacco A, Bodo G, et al. Systematic review of surgical treatment of post radical prostatectomy stress urinary incontinence. Neurourol Urodyn 2016;35:875-81. [Crossref] [PubMed]
  5. Cooperberg MR, Master VA, Carroll PR. Health related quality of life significance of single pad urinary incontinence following radical prostatectomy. J Urol 2003;170:512-5. [Crossref] [PubMed]
  6. Kim PH, Pinheiro LC, Atoria CL, et al. Trends in the use of incontinence procedures after radical prostatectomy: a population based analysis. J Urol 2013;189:602-8. [Crossref] [PubMed]
  7. Nelson M, Dornbier R, Kirshenbaum E, et al. Use of Surgery for Post-Prostatectomy Incontinence. J Urol 2020;203:786-91. [Crossref] [PubMed]
  8. Castellani D, Rubilotta E, Fabiani A, et al. Correlation Between Transurethral Interventions and Their Influence on Type and Duration of Postoperative Urinary Incontinence: Results from a Systematic Review and Meta-Analysis of Comparative Studies. J Endourol 2022;36:1331-47. [Crossref] [PubMed]
  9. Clark CB, Kucherov V, Klonieck E, et al. Management of urinary incontinence following treatment of prostate disease. Can J Urol 2021;28:38-43. [PubMed]
  10. Hampson LA, Suskind AM, Breyer BN, et al. Predictors of Regret among Older Men after Stress Urinary Incontinence Treatment Decisions. J Urol 2022;207:885-92. [Crossref] [PubMed]
  11. Chughtai B, Sedrakyan A, Isaacs AJ, et al. National study of utilization of male incontinence procedures. Neurourol Urodyn 2016;35:74-80. [Crossref] [PubMed]
  12. Toia B, Gresty H, Pakzad M, et al. Bulking for stress urinary incontinence in men: A systematic review. Neurourol Urodyn 2019;38:1804-11. [Crossref] [PubMed]
  13. Bole R, Hebert KJ, Gottlich HC, et al. Narrative review of male urethral sling for post-prostatectomy stress incontinence: sling type, patient selection, and clinical applications. Transl Androl Urol 2021;10:2682-94. [Crossref] [PubMed]
  14. Alwaal A, Harris CR, Awad MA, et al. Comparison of complication rates related to male urethral slings and artificial urinary sphincters for urinary incontinence: national multi-institutional analysis of ACS-NSQIP database. Int Urol Nephrol 2016;48:1571-6. [Crossref] [PubMed]
  15. Chung ASJ, Suarez OA, McCammon KA. AdVance male sling. Transl Androl Urol 2017;6:674-81. [Crossref] [PubMed]
  16. Rehder P, Gozzi C. Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol 2007;52:860-6. [Crossref] [PubMed]
  17. Gozzi C, Becker AJ, Bauer R, et al. Early results of transobturator sling suspension for male urinary incontinence following radical prostatectomy. Eur Urol 2008;54:960-1. [Crossref] [PubMed]
  18. Cornel EB, Elzevier HW, Putter H. Can advance transobturator sling suspension cure male urinary postoperative stress incontinence? J Urol 2010;183:1459-63. [Crossref] [PubMed]
  19. Collado Serra A, Resel Folkersma L, Domínguez-Escrig JL, et al. AdVance/AdVance XP transobturator male slings: preoperative degree of incontinence as predictor of surgical outcome. Urology 2013;81:1034-9. [Crossref] [PubMed]
  20. Hüsch T, Kretschmer A, Thomsen F, et al. The AdVance and AdVanceXP male sling in urinary incontinence: is there a difference? World J Urol 2018;36:1657-62. [Crossref] [PubMed]
  21. Del Favero L, Tasso G, Deruyver Y, et al. Long-term Functional Outcomes and Patient Satisfaction After AdVance and AdVanceXP Male Sling Surgery. Eur Urol Focus 2022;8:1408-14. [Crossref] [PubMed]
  22. Grise P, Geraud M, Geraud M, et al. Transobturator male sling TOMS for the treatment of stress post-prostatectomy incontinence, initial experience and results with one year’s experience. Int Braz J Urol 2009;35:706-13; discussion 714-5. [Crossref] [PubMed]
  23. Meisterhofer K, Herzog S, Strini KA, et al. Male Slings for Postprostatectomy Incontinence: A Systematic Review and Meta-analysis. Eur Urol Focus 2020;6:575-92. [Crossref] [PubMed]
  24. Malval B, Rebibo JD, Baron M, et al. Long-term outcomes of I-Stop TOMS™ male sling implantation for post-prostatectomy incontinence management. Prog Urol 2017;27:1084-90. [Crossref] [PubMed]
  25. Galiano M, Guillot-Tantay C, Sivaraman A, et al. Superficial Implantation of the I-Stop TOMS Transobturator Sling in the Treatment of Postprostatectomy Urinary Incontinence: Description of a Novel Technique and 1-Year Outcomes. Urology 2016;90:195-8. [Crossref] [PubMed]
  26. Grise P, Vautherin R, Njinou-Ngninkeu B, et al. I-STOP TOMS transobturator male sling, a minimally invasive treatment for post-prostatectomy incontinence: continence improvement and tolerability. Urology 2012;79:458-63. [Crossref] [PubMed]
  27. Comiter CV, Rhee EY, Tu LM, et al. The virtue sling–a new quadratic sling for postprostatectomy incontinence–results of a multinational clinical trial. Urology 2014;84:433-8. [Crossref] [PubMed]
  28. Rubin RS, Xavier KR, Rhee E. Virtue Quadratic Male Sling for stress incontinence-surgical guide for placement and delayed revision. Transl Androl Urol 2017;6:666-73. [Crossref] [PubMed]
  29. Roumeguère T, Elzevier H, Wagner L, et al. The Virtue quadratic male sling for postradical prostatectomy urinary incontinence: 3-Year outcome measurements and a predictive model of surgical outcome from a European prospective observational study. Neurourol Urodyn 2022;41:456-67. [Crossref] [PubMed]
  30. Hüsch T, Kretschmer A, Obaje A, et al. Fixed or adjustable sling in the treatment of male stress urinary incontinence: results from a large cohort study. Transl Androl Urol 2020;9:1099-107. [Crossref] [PubMed]
  31. Angulo JC, Schönburg S, Giammò A, et al. Systematic review and meta-analysis comparing Adjustable Transobturator Male System (ATOMS) and Adjustable Continence Therapy (ProACT) for male stress incontinence. PLoS One 2019;14:e0225762. [Crossref] [PubMed]
  32. Esquinas C, Angulo JC. Effectiveness of Adjustable Transobturator Male System (ATOMS) to Treat Male Stress Incontinence: A Systematic Review and Meta-Analysis. Adv Ther 2019;36:426-41. [Crossref] [PubMed]
  33. Angulo JC, Cruz F, Esquinas C, et al. Treatment of male stress urinary incontinence with the adjustable transobturator male system: Outcomes of a multi-center Iberian study. Neurourol Urodyn 2018;37:1458-66. [Crossref] [PubMed]
  34. Siracusano S, Visalli F, Favro M, et al. Argus-T Sling in 182 Male Patients: Short-term Results of a Multicenter Study. Urology 2017;110:177-83. [Crossref] [PubMed]
  35. Kretschmer A, Hüsch T, Thomsen F, et al. Targeting Moderate and Severe Male Stress Urinary Incontinence With Adjustable Male Slings and the Perineal Artificial Urinary Sphincter: Focus on Perioperative Complications and Device Explantations. Int Neurourol J 2017;21:109-15. [Crossref] [PubMed]
  36. Márquez-Sánchez GA, Padilla-Fernández BY, Perán-Teruel M, et al. Remeex® System Effectiveness in Male Patients with Stress Urinary Incontinence. J Clin Med 2021;10:2121. [Crossref] [PubMed]
  37. Suh YS, Ko KJ, Kim TH, et al. Long-term outcomes of primary implantation and revisions of artificial urinary sphincter in men with stress urinary incontinence. Neurourol Urodyn 2017;36:1930-7. [Crossref] [PubMed]
  38. Collado Serra A, Domínguez-Escrig J, Gómez-Ferrer Á, et al. Prospective follow-up study of artificial urinary sphincter placement preserving the bulbospongiosus muscle. Neurourol Urodyn 2017;36:1387-94. [Crossref] [PubMed]
  39. Viers BR, Linder BJ, Rivera ME, et al. Long-Term Quality of Life and Functional Outcomes among Primary and Secondary Artificial Urinary Sphincter Implantations in Men with Stress Urinary Incontinence. J Urol 2016;196:838-43. [Crossref] [PubMed]
  40. Léon P, Chartier-Kastler E, Rouprêt M, et al. Long-term functional outcomes after artificial urinary sphincter implantation in men with stress urinary incontinence. BJU Int 2015;115:951-7. [Crossref] [PubMed]
  41. Cordon BH, Singla N, Singla AK. Artificial urinary sphincters for male stress urinary incontinence: current perspectives. Med Devices (Auckl) 2016;9:175-83. [Crossref] [PubMed]
  42. Linder BJ, Viers BR, Ziegelmann MJ, et al. Artificial urinary sphincter revision for urethral atrophy: Comparing single cuff downsizing and tandem cuff placement. Int Braz J Urol 2017;43:264-70. [Crossref] [PubMed]
  43. Kretschmer A, Hüsch T, Thomsen F, et al. Efficacy and safety of the ZSI375 artificial urinary sphincter for male stress urinary incontinence: lessons learned. World J Urol 2016;34:1457-63. [Crossref] [PubMed]
  44. Ostrowski I, Golabek T, Ciechan J, et al. Preliminary outcomes of the European multicentre experience with the ZSI 375 artificial urinary sphincter for treatment of stress urinary incontinence in men. Cent European J Urol 2019;72:263-9. [PubMed]
  45. Giammò A, Falcone M, Blecher G, et al. A Novel Artificial Urinary Sphincter (VICTO®) for the Management of Postprostatectomy Urinary Incontinence: Description of the Surgical Technique and Preliminary Results from a Multicenter Series. Urol Int 2021;105:414-20. [Crossref] [PubMed]
  46. Weibl P, Hoelzel R, Rutkowski M, et al. VICTO and VICTO-plus - novel alternative for the mangement of postprostatectomy incontinence. Early perioperative and postoperative experience. Cent European J Urol 2018;71:248-9. [PubMed]
  47. Larson T, Jhaveri H, Yeung LL. Adjustable continence therapy (ProACT) for the treatment of male stress urinary incontinence: A systematic review and meta-analysis. Neurourol Urodyn 2019;38:2051-9. [Crossref] [PubMed]
  48. Rigicon. Artificial Urinary Sphincter. 2021. Available online: https://www.rigicon.com/artificial-urinary-sphincter-conticlassic/
  49. Carmel M, Hage B, Hanna S, et al. Long-term efficacy of the bone-anchored male sling for moderate and severe stress urinary incontinence. BJU Int 2010;106:1012-6. [Crossref] [PubMed]
  50. Lanoe M, Saussine C, Mouracade P, et al. Male stress urinary incontinence by InVance bone anchored sub-urethral sling: Predictive factors of treatment failure: Multicentric study by the CTMH-AFU. Prog Urol 2009;19:839-44. [Crossref] [PubMed]
  51. Sacco E, Gandi C, Marino F, et al. Artificial urinary sphincter significantly better than fixed sling for moderate post-prostatectomy stress urinary incontinence: a propensity score-matched study. BJU Int 2021;127:229-37. [Crossref] [PubMed]
  52. Scheidbach H, Tannapfel A, Schmidt U, et al. Influence of titanium coating on the biocompatibility of a heavyweight polypropylene mesh. An animal experimental model. Eur Surg Res 2004;36:313-7. [Crossref] [PubMed]
  53. Scheidbach H, Tamme C, Tannapfel A, et al. In vivo studies comparing the biocompatibility of various polypropylene meshes and their handling properties during endoscopic total extraperitoneal (TEP) patchplasty: an experimental study in pigs. Surg Endosc 2004;18:211-20. [Crossref] [PubMed]
  54. Sacco E, Gandi C, Vaccarella L, et al. Titanized Transobturator Sling Placement for Male Stress Urinary Incontinence Using an Inside-out Single-incision Technique: Minimum 12-Months Follow-up Study. Urology 2018;115:144-50. [Crossref] [PubMed]
  55. Hüsch T, Kretschmer A, Thomsen F, et al. The TiLOOP® Male Sling: Did We Forejudge. Urol Int 2018;100:216-21. [Crossref] [PubMed]
  56. Le Portz B, Haillot O, Brouziyne M, et al. Surgimesh M-SLING(®) transobturator and prepubic four-arm urethral sling for post-prostatectomy stress urinary incontinence: clinical prospective assessment at 24 months. BJU Int 2016;117:966-75. [Crossref] [PubMed]
  57. Chung E, Smith P, Malone G, et al. Adjustable versus non-adjustable male sling for post-prostatectomy urinary incontinence: A prospective clinical trial comparing patient choice, clinical outcomes and satisfaction rate with a minimum follow up of 24 months. Neurourol Urodyn 2016;35:482-6. [Crossref] [PubMed]
  58. Bauer RM, Mayer ME, May F, et al. Complications of the AdVance transobturator male sling in the treatment of male stress urinary incontinence. Urology 2010;75:1494-8. [Crossref] [PubMed]
  59. Rehder P, Mitterberger MJ, Pichler R, et al. The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence. BJU Int 2010;106:1668-72. [Crossref] [PubMed]
  60. McCall AN, Rivera ME, Elliott DS. Long-term Follow-up of the Virtue Quadratic Male Sling. Urology 2016;93:213-6. [Crossref] [PubMed]
  61. Romano SV, Metrebian SE, Vaz F, et al. Long-term results of a phase III multicentre trial of the adjustable male sling for treating urinary incontinence after prostatectomy: minimum 3 years. Actas Urol Esp 2009;33:309-14. [PubMed]
  62. Hübner WA, Gallistl H, Rutkowski M, et al. Adjustable bulbourethral male sling: experience after 101 cases of moderate-to-severe male stress urinary incontinence. BJU Int 2011;107:777-82. [Crossref] [PubMed]
  63. Sousa-Escandón A, Cabrera J, Mantovani F, et al. Adjustable suburethral sling (male remeex system) in the treatment of male stress urinary incontinence: a multicentric European study. Eur Urol 2007;52:1473-9. [Crossref] [PubMed]
  64. Queissert F, Hüsch T, Kretschmer A, et al. High/low-volume center experience predicts outcome of AMS 800 in male stress incontinence: Results of a large middle European multicenter case series. Neurourol Urodyn 2020;39:1856-61. [Crossref] [PubMed]
  65. Ostrowski I, Ciechan J, Sledz E, et al. Four-year follow-up on a Zephyr Surgical Implants 375 artificial urinary sphincter for male urinary incontinence from one urological centre in Poland. Cent European J Urol 2018;71:320-5. [PubMed]
  66. Venturino L, Dalpiaz O, Pummer K, et al. Adjustable Continence Balloons in Men: Adjustments Do Not Translate Into Long-term Continence. Urology 2015;85:1448-52. [Crossref] [PubMed]
  67. Rouprêt M, Misraï V, Gosseine PN, et al. Management of stress urinary incontinence following prostate surgery with minimally invasive adjustable continence balloon implants: functional results from a single center prospective study. J Urol 2011;186:198-203. [Crossref] [PubMed]
Cite this article as: Prebay ZJ, Foss HE, Wang KR, Chung PH. A narrative review on surgical treatment options for male stress urinary incontinence. Transl Androl Urol 2023;12(5):874-886. doi: 10.21037/tau-22-629

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