Improving surgical management of male urinary incontinence

The challenge

Studies have shown that men consider incontinence the most disruptive — but silent — assault on their quality of life and one of their greatest fears associated with prostate surgery. Men with bladder sphincter deficiency grow fearful of coughing, sneezing, laughing or lifting in public, so they stop going out, interacting and enjoying life.

Fortunately, for most patients, the underlying voiding pathophysiology of stress urinary incontinence (SUI) can be well managed. While urinary incontinence is a daily challenge to quality of life, surgical options continue to evolve, with improved outcomes.

Male artificial urinary sphincter

In the year following radical prostatectomy, SUI usually improves. But chronic, severe SUI — requiring three pads a day or more — is estimated to occur in approximately 5 percent of men. For these patients, an artificial urinary sphincter (AUS) is the gold standard of care.

Mayo Clinic has been an international leader in AUS implantation in the United States since the device became available in 1972. Mayo's outcome data show that 75 percent of AUS patients achieve dryness and 25 percent have marked improvement.

Literature reports suggest an eventual failure rate of first-time sphincters of 25 to 30 percent, typically due to erosion, urethral atrophy or infections. For these patients, Mayo Clinic offers a range of advanced options:

Tandem cuff
Two cuffs are placed to increase sphincter control. In patients who have a previously failed single-cuff AUS placement, this procedure results in an average decrease in the number of daily pads used from 4.3 to 1.6, according to a Mayo Clinic study published in 2003.

The study involved 18 patients in whom AUS failed, with a mean follow-up of 3.3 years. Additionally, 56 percent of men required no more than one pad a day after the procedure and 94 percent of patients indicated that they would recommend the procedure.

Transcorporal cuff
In this procedure, part of the corpus cavernosum is cuffed. Results show approximately 65 percent of patients achieve dryness, 30 percent have improved symptoms, and 5 percent have complications such as need for re-operation, device malfunction and infection requiring device explantation.

Collagen-based graft

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Graft wrapped around urethra

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Cuff placed over graft

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Soft tissue graft
In unusually complex cases, Mayo Clinic surgical teams are pioneering use of a collagen-based, nonimmunogenic porcine material that serves as bulk insulation around the urethra. Once this material is wrapped around the urethra, the cuff is placed over it.

In eight Mayo patients who have undergone the procedure since 2008, with an average follow-up of 16.5 months, four (57 percent) have achieved considerable improvement or complete dryness.

Male suburethral sling

Patients with light leakage are generally good candidates for a suburethral sling. The male sling continues to be refined, and the newest generation of compression-based polypropylene mesh male sling was introduced more than five years ago. During a 30-minute, minimally invasive outpatient procedure, the sling is implanted underneath the bulbous urethra to elevate and compress it, thereby preventing leakage.

In carefully selected patients, 60 to 70 percent of patients achieve dryness, 20 percent have markedly improved symptoms and 10 percent have minimal improvement.

The potential for worsening incontinence following this procedure must be emphasized during patient counseling. Patients may not lift more than 10 pounds and should avoid high steps for six weeks after the procedure to avoid stretching and dislodging the sling.

In patients who have had irradiation or transurethral resection of the prostate, the procedure may be less successful. These patients need to be counseled appropriately.

With continued experience placing the male sling, Mayo Clinic urologists are refining the surgical procedure and expect continued improvement of outcomes. Thanks to high patient volumes and opportunities for long-term follow-up, Mayo Clinic urologists have an objective, evidence-based platform for continuous improvement and innovation to relieve patients' incontinence.

Points to remember

• Stress urinary incontinence (SUI) can dramatically affect and decrease quality of life for many men.
• In selected patients with chronic, severe SUI, an artificial urinary sphincter is the gold standard of therapy.
• Patients with light leakage are generally good candidates for a suburethral sling, which is implanted underneath the bulbous urethra to elevate and compress it, thereby decreasing leakage.