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  • Review Article
  • Published:

Surgery for postprostatectomy incontinence: which procedure for which patient?

Nature Reviews Urology volume 12, pages 91–99 (2015)Cite this article

Subjects

Key Points

  • Intrinsic sphincter dysfunction (which can be confirmed using urodynamics) is the most common cause of postprostatectomy incontinence

  • Quantifying the degree of urine leakage using incontinence pad weight or pad use is important for determining the optimal surgical treatment

  • Implanted slings are generally effective in men with mild-to-moderate postprostatectomy incontinence

  • Adequate sling tensioning during surgery and postprocedural maintenance of sling tension are necessary for sustained device performance

  • Different sling designs suit different patients, and device selection should be based on the degree of leakage, residual sphincter function and bladder contractility

  • Sling effectiveness is lowest in men with severe incontinence and a history of radiation exposure; implantation of an artificial urinary sphincter remains the procedure of choice in this group

Abstract

Surgery remains the most effective treatment for postprostatectomy incontinence. Over the past two decades, this surgery has evolved with respect to both operative technique and sling design, and various devices are now available that have different mechanisms of action, such as the artificial urinary sphincter, retroluminal sling or quadratic sling. The choice of device, however, should be individualized according to the circumstances of each patient. The optimal surgical treatment depends on a variety of patient-related factors, including the degree of urine leakage as assessed by incontinence pad weight test results, bladder contractility, urethral compliance, history of radiation exposure or prior incontinence surgery, and patient preference—given the choice, most patients opt for a sling procedure over an artificial sphincter to avoid implantation of a mechanical device. Athorough urodynamic evaluation is, therefore, necessary for the majority of patients. An artificial urinary sphincter, retroluminal sling or quadratic sling might be the most appropriate choice for a particular patient, depending on their specific urodynamic findings. Progress in this field continues, and several new devices are in development.

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Figure 1: Urodynamic measurements of detrusor contractility during the mechanical stop test.
Figure 2: Fluoroscopic determination of proximal urethral mobility.
Figure 3: Implantation of a retroluminal sling.
Figure 4: The quadratic sling.
Figure 5: Partial explantation of the quadratic sling before artificial urethral sphincter placement.

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    Craig Comiter

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C.C. declares that he has acted as a consultant for Coloplast.

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Comiter, C. Surgery for postprostatectomy incontinence: which procedure for which patient?. Nat Rev Urol 12, 91–99 (2015). https://doi.org/10.1038/nrurol.2014.346

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