Treatment of postprostatectomy urinary incontinence: the case against the male sling

Drogo K Montague* and Kenneth W Angermeier  About the authors

For the man suffering from urinary incontinence following prostatectomy, two surgical options are currently available: the bulbous urethral sling (BUS) and the artificial urinary sphincter (AUS). Is one of these options preferable? To answer this question, we reviewed the literature looking at results for both treatment modalities.

In our review of the literature for BUS implantation following prostatectomy, we found 20 papers, with publication years ranging from 1997 to 2005. Review papers, papers describing techniques or urodynamic evaluations but not results, duplicate contemporaneous reports by the same authors, and early reports which were subsequently updated were excluded; nine papers were excluded for these reasons. A further seven papers were excluded because they had a mean follow-up of less than 1 year, or a patient number of less than 20; this left four case series for evaluation.

Castle et al.¹ reported their experience with 38 patients treated with bone-anchored male slings. The mean follow-up for this series was 18 months (range 6–26 months). Success was defined as the use of one pad or less daily, and was achieved in 15 patients (39%). Rajpurkar et al.² reported the results of 46 patients treated with bone-anchored slings with a mean follow-up of 24 months. During follow-up, 17 patients (37%) were using no pads, and 17 (37%) were using one to two pads daily. Ullrich and Comiter³ reported outcomes of 36 patients implanted with bone-anchored male slings, with a median follow-up of 25 months (range 12–42 months). At follow-up, 24 (67%) patients were using no pads, 5 (14%) were using one pad daily, and 4 (11%) were using two pads daily.

Only one study had a considerably longer follow-up than those cited thus far, and this study will be reviewed in more detail. Stern and associates⁴ treated 71 patients with BUSs that consisted of three tetrafluoroethylene bolsters, placed beneath the bulbous urethra. Nonabsorbable sutures were passed from the perineal incision to a suprapubic incision, where they were tied over the rectus fascia in the midline. This is in contrast to bone-anchored male sling procedures, where a single, flat sling is placed against the ventral aspect of the bulbous urethra, and anchored with bone screws inserted into the pubic rami. Seven patients (10%) had their BUSs removed because of erosion, infection, or nonfunction. The 64 remaining patients were divided into two groups: those who had not received any previous radiation therapy (n = 57), and those who had received prior radiation therapy (n = 7). Mean follow-up was 4 years (range 0.27–6.55 years).

Among patients with no history of radiation therapy, nine (16%) required a suture-retightening procedure, and three of these required a second suture-retightening procedure; overall, 46 patients (81%) in this group had no pain, four (7%) had minimal perineal discomfort, six (10%) had moderate discomfort, and one (2%) had severe discomfort. Among patients who had previously received radiation therapy, six (86%) required a suture-retightening procedure, and two of these required a second suture-retightening procedure; overall, six patients (86%) in this group had no discomfort, and one (14%) had severe perineal discomfort. Including those who underwent retightening procedures, 68% of all patients (72% of those without, and 4% of those with, a history of radiation therapy) required two pads or less daily, and 36% of patients (42% of those without, and 14% of those with, a history of radiation therapy) used no pads. Of the 71 patients implanted with the sling, 49 (69%) reported that they were willing to undergo sling implantation again (46 patients with, and three patients without, a history of radiation therapy).

How do male slings work? In contrast to stress urinary incontinence in females, where urethral hypermobility is usually present and a sling can be expected to stabilize the urethra, urethral hypermobility is not present in males with urinary incontinence after prostatectomy. Presumably, the male sling works by producing enough obstruction in the bulbous urethra to lessen incontinence, while still permitting voiding.

Before the AUS was introduced, a variety of bulbous-urethral-compression procedures were employed in an attempt to control urinary incontinence. Most notable were the Kaufman procedures, which culminated in a prosthetic sling-like perineal implant with bone anchors.⁵ These procedures sometimes resulted in short-term cure or improvement, but urinary incontinence invariably recurred, presumably as pressure against the bulbous urethra lessened with time.

The AUS was introduced in 1973.⁶ Between 1973 and 1983, numerous design changes were introduced.⁷ The device used today, the American Medical Systems^® sphincter 800 urinary prosthesis (AMS 800), was introduced in 1983. Other than various improvements in the components of this device, its basic design and operation have remained unchanged. Unlike the BUS, the AUS permits voiding with no added resistance, when the small scrotal pump is employed to open the AUS cuff. When the cuff closes, pressure within it is controlled by the AUS.

In 2000 we published an editorial comparing AUS implantation to collagen injection for the treatment of postprostatectomy incontinence.⁸ We identified five case series with a total of 286 AUS patients, with mean follow-ups of 18, 23, 37, 41, and 44 months. With success defined as the use of one pad or less daily, 216 (76%) of the 286 patients were dry. In a later publication, we reported on 113 men who underwent AUS implantation for postprostatectomy incontinence, and had a mean follow-up of 73 months (range 20–170 months). During this long-term follow-up, 64% of patients remained dry (1 pad or less used daily).⁹

In summary, we believe that AUS implantation is superior to BUS procedures in men who have postprostatectomy incontinence. With the exception of one study, follow-up for sling procedures is still quite short. The single study with longer follow-up⁴ uses a type of sling not reported by others. This study needs to be corroborated by other groups, and the bone-anchored slings using synthetic material need longer follow-ups. Finally, AUS implantation represents a more physiologic approach to the treatment of this significant complication of prostatectomy.

Competing interests

Both authors have received honoraria as consultants and speakers for American Medical Systems (AMS) Minnesota, MN, USA.

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