Surgical Management of Male Stress Incontinence: Techniques, Indications, and Pearls for Success

Figures & data

Figure 1 Literature selection criteria.

Figure 2 Standing cough test (SCT) scoring by the Male Stress Incontinence Grading Scale.

Note: Reproduced with permission from Shakir NA, Fuchs JS, McKibben MJ, et al. Refined nomogram incorporating standing cough test improves prediction of male transobturator sling success. Neurourol Urodyn. 2018;37(8):2632–2637. © 2018 Wiley Periodicals, Inc.¹⁶

Table 1 Outcomes after AUS placement

Article	PMID	Device Type	No. Patients	Notes	Definition of Success	Success Rate	Cure Rate	Need for Revision	Complications	Follow-Up
Deruyver et al, 2022^Citation41	34821960	AMS 800	263	Evaluation of long-term (5-year) functional outcomes for patients with AUS	Social continence: 0–1 PPD Cure: 0 PPD	Social continence: at 5 years: 60% at 10 years: 37.9%	29%	5-year explant rate: 25% 5-year revision rate: 38%	Retention: 5 Scrotal hematoma: 12 Wound infection/problem: 3 Hematuria: 2 Erosion (50%) and infection (40%) were primary reason for explant	Mean: 61 mo.
Hebert et al, 2021^Citation42	34401337	AMS 800	1079 – primary 281–1st revision	Authors compared outcomes of primary AUS implantation to first revision	Device survival	5-year device survival: Primary: 74% 1st Revision: 51% (p < 0.001)	5-year device survival: Primary: 74% 1st Revision: 51% (p < 0.001)	Primary: 18.1% 1st Revision: 30.2%	First revision surgery was associated with a significantly increased cumulative incidence of device infection or urethral erosion (p = 0.02) No difference in mechanical failure (p = 0.43) No difference in urethral atrophy rate (p = 0.77)	Median 4.1 years (IQR 0.8–7.9)
Khouri et al, 2020^Citation12*	32289365	AMS 800 vs AdVance	AUS: 65 Sling: 114	Analysis #2: Retrospective comparison of AUS vs Sling for moderate SUI (MSIGS 2–3)	0–1 PPD	AUS: 80% Sling: 63% (p = 0.02)	Not Reported	Complications/revisions reported together	Complications/revisions reported together AUS: 20% Sling: 22%	Median 20.1 mo (IQR 1.6–52.2 mo.)
Linder et al, 2018^Citation43	29154982	AMS 800	309	Authors evaluated the effect of different definitions of success	Pad-based: 0 PPD, ≤ security pad only, ≤ 1 PPD Overall improvement ≥ “much better” (PGI-I) Treatment considered “very successful” Recommend to a friend	14.8%, 43.6%, 69.8% 86.7% 46.7% 73.3%	15%	28.0%	Overall: 28.1% Infection or Erosion: 9.4% Urethral atrophy: 6.1% Mechanical failure: 10.0% Pump malposition/Unknown: 2.6%	Median 24 mo. (IQR 8–40 mo.)
Sacco et al, 2021^Citation44	32744793	AMS 800 vs TiLOOP Retrourethral Transobturator Sling (RTS)	AUS: 35 Sling: 35	Propensity score-matched comparison of AUS vs TiLOOP RTS sling for men with 3–5 PPD incontinence	Outcome of “much improved” according to the Patient Global Impression of Improvement questionnaire and 0–1 pads/day at 12 months	Sling: 68.6% AUS: 94.3%	At 12 months: Sling: 45.8% AUS: 65.7%	Sling: 25.7% AUS: 11%	Sling: Groin pain: 17.1% Perineal numbness: 14.3% De novo LUTS: 8.6% AUS: Explantation: 5.7% Groin pain: 2.9% Erosion: 2.9%	Median Sling: 47.2 mo. AUS: 51.2 mo.
Tutulo et al, 2019^Citation39	30575997	AMS 800	892	Authors evaluated outcomes in patients with and without history of PIS	0 PPD	Overall: 58% No PIS: 57% PIS: 48%	Overall: 58% No PIS: 57% PIS: 48%	30.6%	Overall: 27.8% Erosion: 6.7% Infection: 4.2% Urethral atrophy: 3.5% Mechanical failure: 13.2%	Median 20 mo. (range 12–300 mo.)
Sacomani et al, 2018^Citation45	29211407	AMS 800	121	Retrospective review of patients with >1 yr follow up	0–1 PPD	87.6% adequate continence and no re-implant	67.8% no pads	19.8%	Erosion: 12.4% (12 with hx of RT, 3 no hx of RT)	Median 56 mo. (range 14–139 mo.)
Sayedahmed et al, 2020^Citation46	30980093	AMS 800	105 (28.6% with hx urethroplasty)	Prospective review of AMS patients	Objectively continent: 0–1 PPD	96.2% 0–1 PPD	Not reported	14.3% explanted over long-term due to erosion or infection	Erosion: 12.3%	Mean 76.6 ± 15.9 mo.

Notes: *Article presented two analyses.

Abbreviations: AUS, Artificial Urinary Sphincter; PPD, Pads per day; IQR, Interquartile Range; AMS, American Medical System; PIS, Previous Incontinence Surgery; SUI, Stress Urinary Incontinence; MSIGS, Male Stress Incontinence Grading Scale; PGI-I, Patient Global Impression of Improvement; RTS, Retrourethral Transobturator Sling; LUTS, Lower Urinary Tract Symptoms.

Table 2 Outcomes of urethral sling placement

Authors	PMID	Device Type	No. Patients	Notes	Definition of Success	Success Rate	Cure Rate	Need for Revision	Complications	Follow-Up
Abdullah et al, 2019^Citation68	31387835	Virtue sling	35	Evaluation of efficacy and quality of life for patients with Virtue sling	Improvement or resolution of symptoms	83%	66%	Not reported	Pain: 48.6% Acute Urinary Retention: 8.6% Urgency: 11.4% Hematoma: 8.6%	Mean 11 mo. (Range: 3–26 mo.)
Ajay et al, 2022^Citation69	35505169	AdVance sling	VLPP ≤70 cmH20: 164 VLPP >70 cmH20: 126	Comparison of success rates for male sling in those with VLPP ≤ 70 cmH20 versus those with VLPP >70 cmH20	0–1 PPD, negative stress test, or pad weight <8g in 24 hours	VLPP ≤ 70cm H20: 83 (51%) VLPP >70cm H20: 85 (68%)	N/A	Not reported	Not reported	Median 5 mo. (IQR 1–15 mo.)
Chua et al, 2019^Citation70	31401219	AdVance sling	215	Retrospective evaluation long-term outcomes for transobturator male slings stratified by pre-op severity	Cure: 0 PPD Improvement: ≥50% reduction in ppd, satisfaction	Mild: 84.7% Moderate: 72.3% Severe: 51.6%	Mild: 67.8% Moderate: 46% Severe: 19.4%	1 required sling explant	Acute Urinary Retention: 15.8% Groin pain: 5.6%	Mean 56.4 ± 41.6 mo.
Giammo et al, 2019^Citation71	30521175	ATOMS system	52	Single-center retrospective review of the ATOMS system	Social continence: 0–1 PPD	73.10%	30.80%	9.6%	Scrotal port displacement: 9.6% Catheterization difficulty: 3.8% Epididimitis: 1.9%	Mean 20.1 mo.
Khouri et al, 2020^Citation12*	32289365	Advance & Advance XP Slings	Mild SUI: 88 Moderate SUI: 114	Analysis #1: Comparison of sling performance for mild SUI (MSIGS 0–1) to moderate SUI (MSIGS 2–3)	0–1 PPD	Mild: 78% Moderate: 63%	Not Reported	Complications/ revisions reported together	Complications/revisions reported together Mild: 15% Moderate: 22%	Median 20.1 mo (IQR 1.6–52.2 mo.)
Marquez-Sanchez et al, 2021^Citation72	34068891	REMEEX System	47	Prospective observational study on device survival and complications with the REMEEX system	Complete dryness: 0–1 PPD Partial dryness: >50% reduction in PPD	89.36%	72.34%	44.44% readjustment rate	Infection: 2.1% Perineal pain: 2.1% Urinary retention: 2.1%	Median 27.7 mo. (Range: 21.4–57.8 mo.)
Mumm et al, 2021^Citation73	33517334	AdVance XP sling	115 (59 with 5-year follow-up)	Prospective, multicenter evaluation of AdVance XP with longterm follow-up	Cure: 0 ppd, ≤ 5g 24-hr pad weight Improvement: ≥ 50% reduction in 24-hr pad weight	Improvement: 24 months: 92.8% 60 months: 83%	24 months: 64% 60 months: 57.6%	Incision of one sling arm due to retention or urge: 7.8% Salvage AUS: 0.9%	De novo OAB: 4.3% UTI: 0.9%	Minimum 5 years
Queissert et al, 2021^Citation74	35011821	ATOMs system	88	Multicenter cohort analysis of patients undergoing second-line ATOMS implantation after failure of AdVance sling	Cure: 0 PPD Success: social continence	76.10%	56.80%	9% required revision	Postoperative complications: 7.95%	Mean 42.5 mo. (Range 7–108 mo.)
Rizvi et al, 2021^Citation63	33517819	AdVance sling	91	Median and long-term follow-up of patients undergoing AdVance sling	0–1 ppd and >50% pad reduction	3 Months: Mild: 96% Moderate: 86% Severe: 80% Medium/long term: Mild: 65% Moderate: 62% Severe: 47%	3 Months: Mild: 96% Moderate: 84% Severe: 73% Medium/long term: Mild: 65% Moderate: 56% Severe: 47%	Salvage AUS: 15%	Groin pain: 3% Infection: 3% Retention: 10% OAB: 11%	Median 69 mo. (range: 15–130 mo.)
Valenzuela et al, 2019^Citation75	31109775	Male Urethral Mini-Sling (MUMS)	36	Retrospective review of those with history of IPP and MUMS placement for climacturia (9), SUI (6) or both (21)	Subjective improvement in SUI, Changes in pre-op vs post-op pads per day	Subjective success: 85% Mean # of pads decreased from 1.4 (pre-surgery) to 0.4 (post-surgery) (p = 0.02)	59%	Explant for erosion: 1 (2.8%)	Transient urinary retention: 5.6%	Mean 5.9 ± 3.7 mo.
Ye et al, 2018^Citation65	30404760	AdVance Sling	113	Prospective multicenter study on post-prostatectomy patients	Cure: 0 pads and no urinary leakage Improvement: >50% leakage reduction and no more than 1 pad	80.6%	22.6%	No direct device removal/revision	Clavien IIIb complications: 2.7% (1 perineal hematoma, 1 perineal abscess, 1 urethral perforation)	93 attended all post-op visits (1.5, 3, 6, 12, 24 mo.)
Wright et al, 2017^Citation76	28971786	AdVance Sling	52	Chart review based on current Procedural Terminology (CPT) search	Incontinence: Expanded Prostate Cancer Index Composite (EPIC) Satisfaction: willing to recommend procedure to a friend	EPIC incontinence score improvement: 39.1, p < 0.001 PPD: 3.2 to 1.4, p<0.001	N/A	Not Reported	Not Reported	36 pts short term (19.4 months) 16 long term (61.5 months) follow up
Bauer et al, 2017^Citation77	27862836	AdVance Sling	115	Prospective multicenter study on patients after radical prostatectomy	24-h pad test, Quality of Life Score, Visual Analogue Scale for Pain, International prostate Symptoms Score, and Patient Global impression of Improvement PGI-	31.6% improved continence	64.9% after 3 months 68% after 24 months	Not reported	No intraoperative complications reported, no erosions or explanations	Mean: 29 mo. (5–209)

Note: *Article presented two analyses.

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