The most common cause of stress urinary incontinence (SUI) in men is iatrogenic injury during prostate surgery. The rate of incontinence following surgery for benign prostatic hyperplasia is approximately 2% (1). In contrast, the risk of urinary incontinence is significantly higher following surgery for prostate cancer. In a questionnaire-based study by Stanford et al. (2), postprostatectomy patients were evaluated using a selfadministered questionnaire. Only 32% claimed total urinary control, 40% had occasional leakage, 7% had frequent leakage, and 2% suffered from no control at 2 years postoperatively (2). Although reports of postprostatectomy incontinence (PPI)
vary, contemporary cohort studies demonstrate that 1% to 5% of patients will ultimately undergo surgery for the management of their incontinence after radical prostatectomy (2,3,4,5).

The surgical technique for radical prostatectomy (RP) has become relatively standardized, with improved instrumentation and visualization, especially following the adoption of robotic assistance. There are, however, recognized risk factors for PPI. These risk factors include age, preoperative continence status, preoperative voiding dysfunction, tumor stage, obesity, prior radiation or transurethral resection of the prostate, vascular disease, preoperative membranous urethral length, and postoperative radiation or cryotherapy (6,7,8,9,10,11,12,13,14). Although many of these risks may not be modifiable, they may alter cancer treatment choice.

The most predictive risk factors for PPI are preoperative urinary incontinence and voiding dysfunction. Stress incontinence in men who have not had prostate cancer surgery occurs at a baseline prevalence of 1.3% to 4.8% (15). Whereas urgency and overflow incontinence associated with bladder outlet obstruction may indeed resolve following surgery for this condition, preoperative SUI typically will not improve postoperatively (6). Rather, baseline intrinsic sphincteric deficiency (ISD), demonstrated either by the preexisting clinical sign of SUI or the urodynamic finding of low maximal urethral closure pressure, strongly predicts postoperative SUI (13,14). Preoperative bladder dysfunction also increases the risk of PPI, especially in those with neurogenic detrusor overactivity secondary to Parkinson disease, dementia, or spinal cord injury (7).

Surgical intervention is indicated for treating bothersome SUI due to ISD that fails to adequately improve following 12 months of conservative management. Most patients will experience improvement in leakage for up to 1 year following surgery, regardless of active (pelvic floor physiotherapy) or passive (observation) management (20).

Severity, effect on quality of life, and the ability of the patient to conservatively manage incontinence must be balanced against the risks of surgery. In addition, reasonable physician and patient expectations based on clinical efficacy, acceptable morbidity (severity, duration, and need for additional therapy), and the avoidance of serious complications are essential. Implantation of a surgical device should be undertaken with caution in patients with uncontrolled detrusor overactivity or decreased bladder compliance. In addition, those conditions that may require future transurethral management (i.e., urethral stricture or bladder neck contracture) are relative contraindications to outlet surgery because repeated instrumentation may put the patient at risk for device infection or erosion.

Due to lack of U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for ISD, and generally poor efficacy of periurethral bulking agents (21), surgery remains the primary treatment modality for the management of PPI. Surgical approaches include implantation of an artificial urinary sphincter (AUS), or placement of a male sling (MS). This chapter will focus on the surgical technique of the most popular MS surgeries.

In contrast to the low-pressure coaptation of periurethral bulking, the AUS relies on circumferential occlusion of the urethra using a pressurized inflatable cuff. For more than three decades, the AUS has represented the most efficacious treatment for male SUI treatment, with satisfaction rates typically greater than 80%, regardless of the degree of incontinence. The majority of men with PPI are appropriate candidates for AUS placement, with exception of those who may lack the mental faculties and manual dexterity to cycle the scrotal pump and properly work the system.

The AUS has been reported to have a predictably high success rate regardless of the degree of incontinence, even in the setting of detrusor dysfunction such as overactivity, or diminished vesical compliance (22). In men who had presumably normal storage function prior to RP, the urodynamic findings of detrusor overactivity or diminished compliance are most likely due to a supraphysiologic infusion rate of filling medium into a bladder that has experienced a prolonged underfilled state secondary to continual urinary leakage. Preoperative detrusor overactivity does not adversely affect resolution of SUI following AUS implantation, but persistent overactive bladder symptoms are common, and patients must be counseled accordingly (22). Detrusor hypocontractility does not adversely affect surgical success because the AUS is cycled to an “open” phase during voiding, with relief of urethral occlusion.

The AUS, however, has a nontrivial complication rate. It has revision rates of 8% to 45% and explantation rates of 7% to 17% due to mechanical failure, urethral atrophy, infection, and erosion (23,24). Despite high success rates, the high cost and high revision rates have inspired the search for less expensive, less invasive, and less complicated devices. In addition, patients are often apprehensive about a mechanical device that requires manipulation prior to voiding. The modern MS has been actively studied and refined over the past decade in an effort to minimize invasiveness and overcome these hurdles.

Various slings are currently available for the treatment of PPI. With the recent withdrawal of the bone-anchored sling from the market, the most commonly used devices are the retrourethral transobturator sling (RTS), the quadratic sling, and the adjustable pubourethral sling.

The impetus for the design of the modern MS was to decrease the risk of device infection, urethral erosion, and urethral atrophy that can be associated with a circumferential urethral compression and to allow for spontaneous voiding without the need for device manipulation. The MS is a noncircumferential suburethral device that is placed with the aim of applying sufficient urethral occlusive pressure to prevent leakage yet permit normal spontaneous voiding without the need for device manipulation. Recent experience with the MS has taught several lessons regarding the management of PPI with sling surgery: (a) Adequate but not excessive tension is necessary for urethral compression and continence; (b) welldesigned synthetic materials have an acceptably low rate of infection and erosion; (c) adequate detrusor contractility is necessary to overcome the fixed resistance of certain slings; (d) various methods of sling fixation can achieve successful urethral compression; (e) there is no “best” sling for all patients—rather different patient types may be best treated with different slings; and (f) patients with more severe or total urinary incontinence appear to have a lower success rate with the MS than do patients with more mild to moderate degrees of incontinence (25,26).