Suburethral Slings

Abstract

Male stress urinary incontinence (UI) after radical prostatectomy (RP) is still one of the most common complications and the one that has a higher impact in quality of life (QoL) (Bauer et al., Eur Urol 59(6):985–96, 2011). Although new minimally invasive techniques for RP have been developed such as nerve-sparing surgery or robot-assisted radical prostatectomy (RARP), post-prostatectomy stress urinary incontinence (PPI) rates still vary between 9 and 69% (Kretschmer et al., Eur Urol Focus 2(3):245–59, 2016). This wide difference in reported data is mostly due to a lack of standardization of definition of PPI itself and severity of the stress urinary incontinence (Burkhard, EAU Guidelines on Urinary Incontinence in Adults [Internet], 2020; AUA Guidelines on Incontinence after prostate treatment [Internet], 2020), and also there are significant differences regarding the methods of data acquisition (Wei and Montie, Semin Urol Oncol 18(1):76–80, 2000). There are numerous factors that favor the development of PPI, such as patient’s age, the surgeon’s experience, nerve-sparing surgery, or treatment with radiation therapy (RT) (Burkhard, EAU Guidelines on Urinary Incontinence in Adults [Internet], 2020; Wei et al., J Urol 164(3 Pt 1):744–8, 2000).

The treatment of PPI should seek the maximum gain in QoL for the patient. Although there is a consensus that the treatment will be chosen based on the severity of urinary losses, management should be started conservatively. This should be done through rehabilitation of the pelvic floor both pre- and postoperatively (Burkhard, EAU Guidelines on Urinary Incontinence in Adults [Internet], 2020; AUA Guidelines on Incontinence after prostate treatment [Internet], 2020) and lifestyle changes such as voiding programming, reduction of fluid intake, reduction of bladder irritants (caffeine, tobacco, hot spices) (Goode et al., JAMA 305(2):151–9, 2011). Recommendations for lifestyle interventions are still mainly based on expert opinions but still strongly recommended by the guidelines (Burkhard, EAU Guidelines on Urinary Incontinence in Adults [Internet], 2020).

The standard surgical treatment for PPI is the artificial urinary sphincter (AUS) which can be used for all degrees of severity of PPI and in patients who have received RT. However, in the 2000s a new device emerged for the surgical treatment of PPI: the fixed male slings or retrourethral transobturator slings (RTS). This devices are positioned under the urethra by a transperineal access and fixed by a retro-pubic or transobturator approach (Burkhard, EAU Guidelines on Urinary Incontinence in Adults [Internet], 2020). These devices are advocated for mild-to-moderate PPI and no previous RT, as there is evidence that the efficacy of retrourethral transobturator slings is reduced in patients previously treated with RT (Kretschmer et al., Eur Urol Focus 2(3):245–59, 2016; Rehder et al., Eur Urol 62(1):140–5, 2012; Herschorn et al., Neurourol Urodyn 29(1):179–90, 2010; Hoffman et al., Urology 125:58–63, 2019).