Reconstruction

Male SUI (most often incontinence after prostate therapy, IPT) results from damage to the striated urethral sphincter. After conservative management and time, surgery ranges from bulking and slings for milder leakage to the artificial urinary sphincter (AUS) — the gold standard across severities and the preferred device after radiation or urethral reconstruction.

Causes

SUI develops only with combined internal and external sphincter impairment.

• Internal sphincter impairment: pelvic surgery, bladder-neck injury, sympathetic neuropathy, embryologic disruption.
• External sphincter impairment: radical prostatectomy (most common); TURP (incontinence here usually reflects persistent overactivity, rarely sphincter damage — the Veterans Study found de novo UI no different from watchful waiting); pelvic fracture urethral injuries; myelopathy; congenital disorders (spinal dysraphism, sacral agenesis, exstrophy/epispadias).

Pre-treatment Counseling and Natural History

• Continence is defined as not requiring a pad/protective device (pad-free).
• Risk factors for IPT after RP (5): older age, larger prostate, shorter membranous urethral length, lack of bilateral neurovascular-bundle preservation (bilateral preservation → 26% more likely continent at 6 months), and prior pelvic radiation. Open and robotic RP have similar incontinence rates; radiation is a significant risk factor (warn of possible AUS need).
• Natural history: continence improves over time, with maximum by ~12 months; most men are not continent at catheter removal; ~90% are continent at 6 months after robotic RP (only +4% afterward). Manage conservatively with follow-up during the first year. Patients may also develop sexual-arousal incontinence and climacturia.
• Pelvic-floor muscle training should be offered immediately postoperatively — it improves time to continence (and QoL) but not overall continence at 12 months; preoperative PFMT benefit is inconsistent (though easier to learn before surgery).

Diagnosis and Evaluation

• Recommended: history/physical with bother; urinalysis ± culture; tools to categorize type/severity (voiding diary, pad weights). Optional: PVR (rule out retention/overflow).
• History — distinguish SUI from urgency/mixed; a voiding diary and pad test help. Severity by volume lost; with sphincteric insufficiency, male slings do worse in severe incontinence.
• Exam — abdomen, genitalia, perineum, rectum, neurologic; scrotal exam for pathology affecting pump placement; note prior incisions for AUS reservoir planning.
• Cystoscopy assesses for urethral/bladder pathology; treat symptomatic vesicourethral anastomotic stenosis or bladder-neck contracture before SUI surgery.
• Urodynamics is not required unless the diagnosis is in doubt; during UDS, remove the catheter and repeat stress testing — up to 35% of men with post-prostatectomy SUI will not leak with a catheter in place. Detrusor hypocontractility may favor AUS over a sling; reduced compliance is concerning (high-pressure storage threatens the upper tracts).

Management

Urgency-predominant disease is treated per OAB guidelines. Non-surgical (offered first): PFMT (offer to all; treat ≥3 months and wait 6–12 months after RP before surgery), absorbent pads, penile compression clamps (not overnight; unsuitable with memory deficit, poor dexterity, impaired sensation, or significant OAB), condom catheter, urethral catheter (last resort — note a suprapubic catheter does not solve severe ISD), and duloxetine.

Surgical timing: consider early surgery if no improvement at 6 months with bothersome (especially severe) SUI; otherwise offer at 12 months for persistent bothersome SUI (caution if still improving). Confirm SUI before surgery and perform cystoscopy. Relative contraindications: urinary-tract conditions needing future transurethral management (bladder cancer, refractory anastomotic strictures) and detrusor overactivity (counsel, not absolute).

Surgical Options

• Transurethral bulking agents — least invasive, least effective (cure rare); for those unwilling/unable to undergo more invasive surgery; limited role after prostatectomy.
• Adjustable balloon devices (ProACT) — for mild SUI; more intraoperative complications and explantation within 2 years than slings/AUS.
• Bulbar urethral sling — for mild–moderate SUI (mild = 24-h pad weight <150 g, moderate <400 g); poor vs AUS in severe disease. Contraindicated with radiation, urethral erosion, or severe gravitational UI. Types: InVance (bone-anchored, compresses urethra; no longer available in the US), AdVance (transobturator; repositions/lengthens the membranous urethra without significant compression), Virtue (combined prepubic + transobturator, four-armed). Neither reliably works after pelvic-fracture urethral disruption. Low rates of retention (resolves ~1 week), pain/paresthesia (resolves ~12 weeks), and rare erosion/infection.
• Artificial urinary sphincter (AUS, AMS 800) — the gold standard for male SUI, effective across moderate–severe loss; revision ~16% at 2 years and ~28% at 5 years. Three components: control pump, pressure-regulating balloon (PRB), and a fluid-filled cuff giving a 2-cm zone of circumferential compression (standard bulbar PRB 61–70 cm H₂O; cuff most often 4 or 4.5 cm). Preferred after radiation, urethral reconstruction, or anastomotic stenosis/bladder-neck contracture (slings less effective; complication rates higher). Absolute contraindications (6): inability to operate the pump, repetitive UTIs, urethral diverticulum/poor tissue at the site, complex/recurrent stricture, small-capacity/non-compliant bladder, active infection. Relative: high-grade VUR, recurrent intravesical disease needing repeat instrumentation (a male sling allows a 24-Fr resectoscope), bladder-neck contracture, detrusor overactivity. Radiotherapy itself is not a contraindication.
  • Technique: single-cuff perineal approach (superior to transverse scrotal), cuff as proximal as possible on the bulbar urethra; size to urethral circumference; place the PRB (abdominal route if prior mesh hernia or extensive abdominal surgery) and pump in the anterior scrotum; verify coaptation by urethroscopy. A bladder-neck cuff is an option in neuropathic disorders (lower erosion/atrophy but higher PRB pressures, 4–6-week deactivation) and is contraindicated after radical prostatectomy.
• Bladder neck closure / urinary diversion — for motivated patients without adequate QoL or inadequate tissue for a sling/AUS: bladder-preserving options (Mitrofanoff, incontinent ileovesicostomy, suprapubic tube with bladder-neck closure) or, for a "hostile" bladder, cystectomy with ileal conduit or continent catheterizable pouch.

AUS Adverse Events

• Intraoperative urethral injury — repair, abandon, and delay implantation (infection risk).
• Infection (<1–5%) — skin flora (S. epidermidis most common, then S. aureus); presents with site/scrotal pain, fever, warmth/erythema; urgent explant — not reimplanted for ≥3 months.
• Cuff erosion (up to 5%) — from unrecognized injury or instrumentation; risk factors include radiation, prior erosion/infection, prior urethroplasty, repeat endoscopic treatments, prolonged catheterization, smaller/transcorporal cuffs (no increased risk with age, placement site, prior RP, or prior transobturator sling). Explant + urethral catheter for a few weeks; no reimplant for ≥3 months; confirm healing by urethrography.
• Urethral atrophy — chronic compression; the most common cause of gradual return of incontinence and AUS revision; manage by downsizing, relocating, or adding a tandem cuff.
• Mechanical failure — 7–10-year device life; ~24% at 5 years, ~50% at 10 years; replace an isolated component if revision is <3 years from implant (otherwise replace in entirety).

Special Situations

• Persistent incontinence after AUS/sling — causes: inadvertent deactivation, insufficient compression/oversized cuff, erosion, bladder storage failure, mechanical failure/fluid loss, plugged resistor, kinked tubing. Slow onset suggests atrophy; sudden recurrence suggests mechanical failure/erosion. Cycle the device to exclude deactivation; image the PRB (contrast X-ray/US) to distinguish fluid loss from atrophy; cystoscopy excludes erosion. UDS if storage failure suspected (best OAB predictors: capacity <200 mL, symptomatic OAB before surgery). Revision options: tandem cuff, 3.5-cm cuff, or transcorporeal placement (downsize rather than add a cuff in young patients). After sling failure → AUS recommended; after AUS failure → revision.
• Urethral stricture — safest initial approach is laser incision through a small endoscope (ureteroscope); open reconstruction for refractory cases.
• Climacturia — conservative first (empty bladder before sex, condoms, PFME); imipramine has been used but is generally avoided in men >65; AUS and transobturator slings (placed for SUI) improve climacturia.
• Concomitant IPT and ED — concomitant or staged procedures may be offered.
• Long-term results: ~76% of AUS patients are dry (0–1 pad/day); revision success is comparable to initial surgery (higher infection/erosion); prior adjuvant radiotherapy worsens prognosis.

Self-Test

1. Contraindications to surgery for male SUI — AUS and sling? AUS absolute: inability to operate the pump, repetitive UTIs, urethral diverticulum/poor tissue, complex/recurrent stricture, small/non-compliant bladder, active infection. Sling contraindications: radiation, urethral erosion, severe gravitational UI.

2. Differences between InVance and AdVance slings? InVance — bone-anchored, compresses the urethra (no longer available in the US); AdVance — transobturator, repositions and lengthens the membranous urethra without significant compression.

3. Typical pressure in the PRB? 61–70 cm H₂O for a standard bulbar AUS.

4. Contraindications to scrotal/perineal pump (PRB) placement? Mesh hernia repairs and radical cystectomy/extensive abdominal surgery — use an abdominal approach.

5. Management of urinary retention after AUS insertion? Exclude inadvertent activation; place a small (10–12 Fr) catheter for 24–48 h with the cuff confirmed deactivated; if voiding fails at 48 h, suprapubic drainage; persistent retention suggests cuff undersizing → revision.

6. Most common pathogen in AUS infection? Staphylococcus epidermidis.

7. Risk factors for AUS erosion? Radiation, prior erosion/infection, prior urethroplasty, repeat endoscopic stricture/contracture treatments, prolonged catheterization, smaller/transcorporal cuffs.

8. Causes of persistent incontinence after AUS? Inadvertent deactivation, insufficient compression/oversized cuff, cuff erosion, bladder storage failure, mechanical failure with fluid loss, plugged resistor, kinked tubing.

9. Most common cause of AUS revision? Urethral atrophy.