EUF-100; No.

of Pages 15

EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX

available at www.sciencedirect.com
journal homepage: www.europeanurology.com/eufocus

Review – Incontinence

Evaluation and Management of Postprostatectomy Incontinence:

A Systematic Review of Current Literature

Alexander Kretschmer a,*, Wilhelm Hübner b, Jaspreet S. Sandhu c, Ricarda M. Bauer a

a b
Ludwig-Maximilians-Universität, Urologische Klinik und Poliklinik, Campus Großhadern, Munich, Germany; Landesklinikum Weinviertel Korneuburg,
Klinik für Urologie, Kornneuburg, Austria; c Department of Surgery/Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA

Article info Abstract

Article history: Context: Radical prostatectomy is the most common reason for male stress urinary
Accepted January 3, 2016 incontinence. There is still uncertainty about its diagnostic and therapeutic manage-
ment.
Associate Editor: Objective: To evaluate current evidence regarding the diagnosis and therapy of post-
James Catto prostatectomy incontinence (PPI).
Evidence acquisition: A systematic review of the literature was performed in October
2015 using the Medline database.
Keywords: Evidence synthesis: Diagnosis and conservative treatment of PPI are currently mostly
Male urinary stress incontinence based on expert opinions. Pelvic floor muscle training is the noninvasive treatment of
choice of PPI. For invasive management of moderate to severe PPI, the artificial urinary
Postprostatectomy incontinence
sphincter is still the treatment of choice, but an increasing number of adjustable and
Conservative treatment nonadjustable, noncompressive as well as compressive devices are used more frequent-
Surgical treatment ly. However, no randomized controlled trial has yet investigated the outcome of one
Pelvic floor muscle training specific surgical treatment or compared the outcome of different surgical treatment
Artificial urinary sphincter options.
Conclusions: The level of evidence addressing the surgical management of PPI is still
Male slings unsatisfactory. Further research is urgently needed.
Efficacy Patient summary: Incontinence after the removal of the prostate (postprostatectomy
Safety incontinence) is the most common cause of male stress urinary incontinence. First-line
therapy is physiotherapy and lifestyle changes. If no satisfactory improvement is
obtained, various surgical treatment options are available. The most commonly used
is the artificial urinary sphincter, but other treatment options like male slings are also
available.
# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Ludwig-Maximilians-University - Department of Urology, Marchioninis-

trasse 15, 81377 Munich, Germany. Tel. +49 89 4400 0; Fax: +49 89 4400 5444.
E-mail address: Alexander.kretschmer@med.uni-muenchen.de (A. Kretschmer).

1. Introduction activities [1]. Recent findings indicate a multicausal

Radical prostatectomy (RP) is the most common cause of
stress urinary incontinence (SUI) in male patients. Post-
prostatectomy incontinence (PPI) has a major impact on
patient’s quality of life (QoL) and may affect various daily
pathology including de novo detrusor hypocontractility,
intrinsic sphincter deficiency, and decreased membranous
urethral length and venous sealing effect [2,3]. Despite
notable improvements regarding the pathologic etiology of
PPI as well as the surgical technique, reported PPI rates are

http://dx.doi.org/10.1016/j.euf.2016.01.002
2405-4569/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
EUF-100; No. of Pages 15

2 EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX

still high and vary between 6% and up to 69% [4]. This
variation is mostly due to a missing standardization of
definition either of PPI itself or of the severity of the
respective incontinence [5], and also because of significant
differences in data acquisition [6]. However, there is
evidence for certain risk factors that accompany an
increased risk of PPI. These risk factors include patient-
derived factors such as age and body mass index as well as
technical features and experience of the surgeon [4,7–
9]. Confronted with an increasing number of patients with
PPI, urologists can currently choose from a variety of
different conservative as well as invasive treatment options.
We provide current evidence regarding the diagnosis
and management of PPI and offer expert opinions regarding
the surgical management of PPI.
2. Evidence acquisition
In October 2015, we conducted a literature search in the
PubMed/Medline database using the keywords post-pros-
tatectomy incontinence (Medical Subject Headings [MeSH])
OR postprostatectomy incontinence [MeSH], and an addi-
tional PubMed/Medline database search was conducted
using the keywords urinary incontinence [MeSH] AND male
[MeSH] AND artificial urinary sphincter male sling/male
adjustable sling/Argus/ArgusT/ATOMS/Pro-ACT/AdVance/
AdVanceXP/Remeex/ pelvic floor muscle training/duloxetine
[MeSH], respectively. Our search was restricted to articles
published in English in the last 20 yr. The respective
reference lists were also screened for relevant articles.
Initially, articles were screened and selected based on their
abstracts and then studied in detail. All original articles
addressing the diagnosis and conservative as well as
surgical management of PPI were included. In total,
>1200 articles were screened and consequently >100 were
systematically reviewed for evidence (Fig. 1).
3. Evidence synthesis
3.1. Diagnosis
To guarantee a sophisticated therapeutic approach, mean-
ingful diagnosis is crucial. However, evidence regarding the
diagnosis is currently based on expert opinions. The current
European Association of Urology (EAU) guidelines support a
two-step assessment of patients seeking help for urinary
incontinence [10]. The first step includes a medical history,
physical examination, and an objective assessment of
symptoms. The medical history can be particularly helpful
in specifying the diagnosis of PPI. The ability to disrupt the
urine flow, the severity of incontinence over the day (eg, is
there worsening in the afternoon/evening?), the presence or
absence of nighttime incontinence, and the existence of
incontinence-triggering situations (eg, coughing, moving to
an upright position, running, sports, in a horizontal position,
fatigue) [11].
These expert recommendations highlighting the value of
a sophisticated medical history are based on current

Fig. 1 – Summary of evidence acquisition.

Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
EUF-100; No. of Pages 15
EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX
findings regarding the pathophysiology of male SUI. It has
been shown that the external sphincter complex consists of
slow and fast twitch fibers that allow a tonic contraction for
baseline continence, on the one hand, and rapid recruitment
following rapid pressure increase and/or voluntary disrup-
tion of the urine flow, on the other. Baseline continence is
additionally sustained by a combination of smooth muscle
fibers and the slow-twitch striated muscle fibers
[12,13]. PPI is usually caused by an impaired function of
smooth muscle fibers and therefore is primarily a problem
of reduced baseline continence. This is why men with so-
called model PPI usually report incontinence episodes after
exhausting the striated muscle fiber complex (eg, during
longer physical activity like sports or longer walks with
worsening over the day and no urine loss during coughing
[14]).
According to the EAU guidelines, basic diagnostics
should also include a urinalysis and an ultrasound of the
bladder including measurement of postvoid residual urine
(grade of recommendation [GR]: A) [10]. To assess
concomitant voiding and storage disorders, voiding diaries
should be used (GR: A) [10]. According to current EAU
guidelines, standardized questionnaires do not have to be
used regularly but offer useful additional information in
standardized clinical settings such as clinical trials (GR: B)
[10].
Various validated testing tools are available; the most
frequently used ones include the International Consultation
on Incontinence-Short Form [15], the Patient’s Global
Impression of Improvement Score [16], and the UCLA/
RAND-Prostate Cancer Index Urinary Function Score
[17]. Strong evidence indicates that the number of pads
per day correlates well with the weight that can be
measured during a standardized pad test [18]. This
indicates that grading of a patient’s incontinence based
on daily pad usage is sufficient for a daily routine. In clinical
trials, standardized pad tests are useful to objectify the
patient’s urine loss [19]. However, there is still insufficient
evidence about the optimal length of standardized pad
testing. Evidence indicates that a 24-h pad test is the most
accurate one [20]. However, a 1-h pad test seems more
feasible in daily practice and is therefore the most widely
used.
Since 2003, the International Continence Society has
provided a classification of SUI based on the 1-h pad test:
grade 1, urine loss <10 g; grade 2, urine loss 11–50 g; grade
3, urine loss 51–100 g; grade 4, urine loss >100 g [19]. It has
to be kept in mind, however, that usually a retrograde
bladder filling is needed to perform a proper 1-h pad test.
Current guidelines indicate that an initial conservative
treatment attempt should be performed after basic
diagnostics [10]. If this attempt fails and a surgical approach
is initialized, a more invasive diagnosis should be
performed [10]. Urethrocystoscopy aims to detect potential
urethral pathologies such as bladder neck stenosis or
urethral stricture that might contribute to current symp-
toms or complicate a future surgical approach. Urethro-
scopy can also be used to perform a so-called repositioning
test and thereby evaluate the patient’s residual sphincter
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
3
function including the functional sphincter length (‘‘coap-
tive zone’’) and determine suitability for a potential
retrourethral transobturator male sling implantation
[21]. If the patient has any indication of concomitant
overactive bladder (OAB) symptoms or neurogenic dis-
orders, a multichannel urodynamic testing is mandatory.
Regarding the urodynamic evaluation of the residual
internal sphincter function, the use of abdominal leak point
pressure via transrectal catheterization seems to be more
accurate than the measurement of the Valsalva leak point
pressure (VLPP) [22]. Debate is still ongoing regarding the
use of urodynamics in general and the VLPP in particular in
terms of therapeutic decision making. Barnard et al.
analyzed the preoperative urodynamic findings of
46 patients undergoing AdVance male sling implantation
and found a VLPP >100 cm H2O having a high predictability
for postoperative success (defined as no pads or one safety
pad) [23]. In contrast, Han et al. found no negative impact of
an impaired preoperative VLPP on functional outcome after
male sling implantation [24]. Trigo Rocha et al. analyzed
preoperative urodynamic findings of 40 consecutive
patients undergoing artificial urinary sphincter (AUS)
implantation due to intrinsic sphincter deficiency and
found no correlation between preoperative urodynamic
findings and the surgical outcome [25].
Thus currently no evidence shows that the preoperative
VLPP might play a similar important role in predicting
postoperative success as it does in female patient cohorts
[26]. Cornu et al. concluded in a recent review article that
urodynamic studies might not be relevant in all PPI patients
[27].
In summary, a correct diagnosis should be performed to
objectify the patient’s symptoms, to reveal any contra-
indications regarding potential surgical treatment options,
and to detect and objectify any concomitant comorbidities
and complicating factors. Based on the findings during
diagnosis, one should be able to classify among mild,
moderate, and severe sphincter impairment and plan
further treatment accordingly [10].
3.2. Conservative therapy
Besides lifestyle interventions, conservative therapy for PPI
includes physiotherapy (pelvic floor muscle training
[PFMT]) as well as pharmacotherapy. Lifestyle interventions
include timed voiding, reduction of fluid intake, and the
reduction of bladder irritants (caffeine, hot spices). The
value of behavioral therapy was highlighted by Goode et al.
[10,28]. Recommendations for lifestyle interventions are
still mainly based on expert opinions [10].
3.2.1. Physiotherapy
Following current EAU guidelines, instruction for PFMT
should be offered to all men undergoing RP to speed up
postoperative continence recovery (GR: B) [10]. Fernández
et al. recently performed a meta-analysis of eight random-
ized controlled trials [29]. Four of the analyzed studies
compared PFMT with no physiotherapy [28,30–32]; the
remaining four studies compared PFMT sessions under
EUF-100; No. of Pages 15
4 EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX
professional supervision with PFMT at home [33–36]. The
authors found that PFMT improves continence rate in the
short, medium, and long-term follow-up after RP and
concluded that programs should include at least three sets
of at least 10 repetitions of muscle training daily [29]. How-
ever, it has to be stated that nearly all studies in this meta-
analysis focused on the perioperative period. Furthermore,
it does not include the recent controlled randomized clinical
trial by Geraerts et al, who analyzed 180 patients undergoing
RP and randomized them into a group that started PFMT 3 wk
before RP (altogether three preoperative sessions) and a
control group that started PFMT postoperatively. The authors
found no significant difference in duration of PPI between the
two groups; the median time to continence was 30 and 31 d,
respectively [37]. Regarding the effect of PFMT in the long-
term period after RP, Goode et al. found in a randomized
controlled trial that PFMT and behavioral therapy reduced
incontinence episodes even for patients experiencing PPI >1
yr, highlighting the beneficial effect of PFMT on PPI even a
long time after RP [28]. Thus there is currently level-1
evidence that, prior to offering invasive therapy, all patients
should undergo a course of PFMT.
Debate is still ongoing whether to combine PFMT with
additional biofeedback training. Goode et al. randomized
208 patients into three groups (8 wk of PFMT and behavioral
therapy, additional biofeedback and electrical stimulation
therapy, and control) and found no benefit after addition of
biofeedback and pelvic floor electrical stimulation
[28]. However, there are also randomized trials indicating
better continence results after additional biofeedback
therapy [32,38].
Evidence is also conflicting regarding the potential
benefit of electrical stimulation therapy. Although there
are studies indicating better continence improvement
through electrical stimulation therapy [39,40], there are
also studies showing no benefit after electrical stimulation
therapy [28,41,42]. Current EAU guidelines recommend not
using electrical stimulation therapy alone in the treatment
of male SUI (GR: A) [10].
3.2.2. Pharmacotherapy
According to current EAU guidelines, concomitant OAB
symptoms should be treated with antimuscarinics [10]. In
mixed urinary incontinence, the most bothersome symp-
tom should be treated first [10]. Regarding SUI after RP, no
approved pharmacotherapy yet exists. Duloxetine, a sero-
tonin-noradrenaline reuptake inhibitor, is an approved
treatment in some countries for female SUI, and evidence
indicates that it also reduces SUI-related symptoms in male
patient collectives [43–45]. In a recently published ran-
domized placebo-controlled double-blind trial, mean re-
duction in incontinence frequencies and impact on QoL
based on standardized questionnaires was analyzed
[44]. The authors randomized 31 patients with mild to
moderate SUI (16 subjects, 80 mg duloxetine for 8 wk vs
15 subjects on placebo) and found a significant reduction of
incontinence episodes as well as a significant improvement
of QoL for the duloxetine treatment group [44]. Treatment
was well tolerated; however, there were increased rates of
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
fatigue (50% vs 13% placebo), insomnia (25% vs 20%), loss of
libido (19% vs 7%), constipation (13% vs 7%), nausea (13% vs
7%), diarrhea (13% vs 7%), and dry mouth (6% vs 0%)
[44]. There is also current evidence that duloxetine seems to
have synergistic effects when combined with PFMT [43]. It
must be kept in mind that treatment of male SUI with
duloxetine is still off label [46]. Current EAU guidelines
conclude that duloxetine should not be offered to men who
are seeking a cure of their SUI but for a temporary symptom
relief (GR: B) [10].
3.3. Surgical therapy
Current EAU guidelines recommend surgical treatment if
initial conservative treatment strategies failed [5]. Offering
high continence rates as well as long-term follow-up
evidence, the AUS has been the therapeutic gold standard
for many years [47]. However, in recent years, male slings
have emerged as an important alternative treatment option
and are gaining worldwide popularity. The following
section summarizes current evidence regarding outcomes,
complications, and limitations of the respective devices.
Figure 2 shows a flowchart that provides recommendations
for different clinical situations based on expert opinions.
We point out that there might be a different ideal device for
each individual patient. Based on the respective clinical
situation, a retrourethral transobturator male sling, an
adjustable male sling, or an AUS might be the preferred
device.
3.3.1. Artificial urinary sphincter
The perineal AUS is the current established standard in the
treatment of moderate to severe PPI [5]. The AMS 800
(Boston Scientific, Marlborough, MA, USA, formerly AMS,
USA) is by far the most commonly used device; however,
alternatives are now available [48,49].
Table 1 summarizes selected contemporary studies
investigating the outcomes after AMS 800 implantation
with a minimum follow-up of 2 yr [25,50–57]. Most of them
were included in a 2013 meta-analysis by van der Aa et al.
[47]. Definition of success was based on pad usage in all
analyzed studies, and dry rates varied between 4.3% [51]
and 85.7% [58]. Notably, these case series were very small
(23 and 21 patients, respectively). Only one study reported
the outcome of >100 patients; it observed a dry rate of
57.3% [59]. Pooled analysis by van der Aa et al. revealed a
combined dry rate (based on pad usage) of 43.5%
[47]. Another pooled analysis of complications after
single-cuff AMS 800 placement showed urethral erosion/
infection in 8.5% of the patients, mechanical failure in 6.2%,
urethral atrophy in 7.9%, and a global reintervention rate for
any reason in 26.0% [47]. Regarding revision rates, patient
satisfaction correlates with the functional outcome after
AUS implantation and not with the number of reinterven-
tions [60].
Two studies reporting long-term outcome after AMS
800 implantation were published recently. Linder et al.
analyzed outcome after 1082 AUS implantations with a
median follow-up of 4.1 yr. The authors found a surgical
EUF-100; No. of Pages 15

EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX 5

Fig. 2 – Flowchart based on expert opinions indicating different therapeutic approaches for varying clinical conditions.

revision rate of 31.3% with mechanical failure, erosion/
infection, and urethral atrophy the most frequent causes
[56]. Léon et al. analyzed the outcome of 57 consecutive
patients after a median follow-up of 15 yr. At the end of the
follow-up, 41% of the patients had their native AUS in situ,
47% had a revised active AUS in situ, and 12.3% had their
AUS explanted. The median time to erosion was >6 yr,
indicating that actual erosion rates might be higher than
expected based on current literature [57].
In 2003, the transscrotal (also known as penoscrotal)
approach was described by Wilson et al. [61]. However, a
recent multicenter study including 158 patients indicated
that dry rates might be lower with this approach (27.4%
compared with 44.1% with the classic perineal approach)
[62]. However, evidence indicates that outcomes might
improve after the introduction of the 3.5-cm cuff, and it has
been suggested that this cuff size should be used if possible
[63].
Debate is also ongoing about whether to use a primary
double-cuff device or not. Originally intended to improve
dry rates, there is currently evidence that the double-cuff
system might lead to increased complication rates without
improving continence rates [52].
Evidence addressing alternative AUS is still weak and
based on small case series. The ZSI 375 (Zephyr Surgical
Implants, Geneva, Switzerland) is a preconnected device
that does not need intraperitoneal implantation of a
reservoir balloon and therefore spares the abdominal
incision. Staerman et al. analyzed the outcome of 36 patients
[48]. After a mean follow-up of 15.4 mo, social continence
(0–1 pad per day) was achieved by 73% at 6 mo after device
activation [48].
The FlowSecure device (Barloworld Scientific, Stafford-
shire, UK) was introduced in 2006 by Knight et al. and
consists of a one-piece silicone device that comes prefilled
with 30 ml saline. It also includes a stress-release balloon to
cope with changes in intra-abdominal and intravesical
pressure changes. Preliminary results of 11 patients found a
reduction of mean daily leakage volume based on 7-d
voiding diaries from 771 ml to 55 ml at 12 mo postopera-
tively. Mean daily pad usage decreased from 3.3 to 1.6 pads
per day. No major complications were noted within the first
12 mo [64]. Both the FlowSecure and the ZSI 375 AUS have
been updated in the meantime. However, there is currently
no literature available evaluating those updated versions.
Complications after AUS placement, frequently urethral
erosion or device infection, usually lead to explantation of
the whole device. Implantation of a second device is
associated with a worse outcome [65]. Regarding different
revision techniques after primary AUS failure, Eswara et al.
recently analyzed the outcome of 90 patients who received
cuff downsizing, pressure-regulating balloon replacement,

Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
 6

EUF-100; No. of Pages 15

Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A

Table 1 – Selected studies analyzing safety and efficacy after artificial urinary sphincter implantation*

Study Device Patients Patients Study design Mean/median Success Definition of Improved, % Explantation, % Comments
included with PPI, % follow-up, yr rate, % success

Lai et al. [50] AMS 800 218 81 Retrospective single 2.2 NS 1 pad NS 27.1, including Previous radiotherapy
center revision in 34% of PPI patients

EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX

O’Connor et al. [51] AMS 800 29 100 Retrospective single 5 24.3 No pads; improved: 59 14 Mean patient age: 77.6 yr
center 1 pad
Trigo Rocha et al. [25] AMS 800 40 100 Retrospective single 4.4 50 No pads; improved: 40 12.5 –
center 1 pad
O’Connor et al. [52] AMS 800 47: 25 single cuff/ 100 Retrospective single 6.2, single-cuff/ 4.3, single cuff/ No pads; improved: 56.5, single cuff/ 16, single cuff/ –
22 double cuff center 4.8, double-cuff 11.1, double cuff 1 pad 61.1, double cuff 27.3, double cuff
Aaronson et al. [53] AMS 800 26: 18 perineal/ 78, perineal/100, Retrospective single 2.6, perineal/ 69, perineal/ Social continence NS 28, perineal/ –
8 transscrotal transscrotal center 2.3, transscrotal 81, transscrotal (NS) 13, transscrotal
Sathianathen AMS 800 77 NS Prospective, single 1.8 87 Social continence: NS NS; revision surgery: –
et al. [54] center 1 pad 10.3, nonirradiated/
12.5, irradiated
Hoy and Rourke [55] AMS 800 30 100 Retrospective single 2.8, perineal/ 77 Social continence: 20 7 Fragile urethra defined
center 3.2, transscrotal 1 pad as previous pelvic radiation,
previous failed AUS, previous
urethroplasty, and cystoscopic
and/or clinical findings
of urethral atrophy
Linder et al. [57] AMS 800 1082 78 Retrospective single 4.1 59 Social continence: NS NS; revision –
center 1 pad surgery: 31.2)
Léon et al. [53] AMS 800 57 NS Retrospective single 15 77.2 No pads NS 15.8 –
center
Staerman et al. [48] ZSI 375 36 NS Retrospective single 1.3 73, after Social continence: NS 11.1 –
center 6 mo 1 pad
Knight et al. [64] FlowSecure 9 89 Prospective single 1 NS NS NS (85% overall 22.2 –
center reduction of
urinary leakage)

AUS = artificial urinary sphincter; NS = not significant; PPI = postprostatectomy incontinence.

*
Published within last 10 yr; follow-up 12 mo.
EUF-100; No. of Pages 15

EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX 7

Table 2 – Contraindications, optional indications, and ideal indications for different surgical treatment options of male stress urinary
incontinence based on current expert opinions

Device system Ideal indication Optional indication Contraindication

AUS Complete intrinsic sphincter
insufficiency in the
urethroscopic repositioning
test
Complete incontinence
High level of suffering
Adjustable male sling Mild to moderate SUI
Patient able to interrupt urine
stream and capability to
store urine
Previous radiotherapy
Retrourethral transobturator Mild to moderate SUI
male sling
Coaptive zone >1 cm during
repositioning test
No previous radiotherapy
Compressive balloon Mild to moderate SUI
system
Bulking agents None
Mild to moderate SUI with high
level of suffering
Patients not able or not willing to
undergo AUS implantation
SUI after TURP or open enucleation
with positive repositioning test and
coaptive zone >1 cm
Previous radiotherapy and positive
repositioning test with coaptive
zone >1 cm
Urine loss >500 ml in 24-h pad test
History of previous urethral manipulation
Elderly patient; not fit for surgery
Patients mentally or manually unable to
use the AUS properly
Retropubic systems not suitable for patients
with SUI after orthotopic neobladder
Nocturnal incontinence
Negative repositioning test with coaptive
zone <1 cm
Previous radiotherapy
History of bulking agents
None

AUS = artificial urinary sphincter, SUI = stress urinary incontinence; TURP = transurethral resection of the prostate.

cuff repositioning, or placement of a second cuff. The
authors found that implantation of a second cuff led to more
favorable continence results, whereas cuff downsizing led
to an increased rate of mechanical failure [66].
Table 2 summarizes the ideal indications and contra-
indications for AUS implantation based on current expert
opinions.
3.3.2. Retrourethral transobturator slings
The AdVance sling (Boston Scientific) is the most frequently
used retrourethral transobturator sling worldwide and
consists of a polypropylene mesh that is placed under the
membranous urethra after transection of the centrum
tendineum via a transobturator approach. Regarding its use
for PPI, it is postulated that the AdVance sling acts
multifactorially via relocating the posterior urethra as well
as the sphincter region into its original position, increasing
the venous sealing effect and increasing the functional
urethral length [67]. Despite its frequent use, most evidence
is currently based on single-center studies (Table 3) with
only one multicenter study available to date [68–80]. Cure
rates vary between 9% and 63% with a follow-up of up to
40 mo. However, results are difficult to compare because
the definition of ‘‘cured’’ as well as ‘‘success’’ varies
significantly between the respective studies. Not all studies
focus on PPI, and there is a significant proportion of
evidence based on mixed patient populations. Regarding
the study by Cornel et al, reporting a cure rate of only 9%, the
authors used a very strict definition of success (no pad and
<2 g urine loss in a 24-h pad test) [73]. AdVance sling
placement seems to be a safe procedure, and severe
complications as well as sling explantations are rare
(Table 3). The most frequently observed complication
seems to be transient urinary retention and transient
perineal pain [75].
At the end of 2010, the AdVance XP, a second-generation
device, was introduced. It includes several innovative
features such as anchors at the sling arms to reduce early
postoperative sling loosening, an updated needle shape to
facilitate placement in larger and obese patients, increased
sling arm length, and protection sheaths on the sling arms
to cover the anchors during the implantation procedure.
Efficacy and safety of the AdVanceXP sling has been
evaluated in comparative nonrandomized studies
[79,80]. Cornu et al. analyzed 110 patients treated with
AdVanceXP and found a cure rate (no pad or one safety pad)
of 59% after a median follow-up of 16 mo and a transient
urinary retention rate of 2% [80]. Bauer et al. reported a
slightly higher cure rate of 65% (no pad or one safety pad)
after a median follow-up of 25 mo and a persistent residual
urine rate of up to 5%. However, the residual urine
disappeared in all affected patients after dissection of one
sling arm [68].
There is evidence that the efficacy of retrourethral
transobturator slings is reduced in patients with previous
pelvic irradiation therapy [75,81–83], and therefore its use
is not generally recommended in this patient collective.
Best results can be achieved in patients with good residual
sphincter function with long functional sphincter and a
mobile posterior urethra. Unlike the adjustable male slings,
no postoperative readjustment is possible. However,
regarding the principle of a tension-free repositioning sling,
a readjustment, in terms of increasing the tension of the
sling, is not expedient. In case of failure after AdVance sling
implantation, an explantation of the sling is usually not
necessary and goes along with considerable collateral

Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
EUF-100; No. of Pages 15

8 EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX

Table 3 – Selected studies analyzing safety and efficacy after retrourethral transobturator male sling implantation*

Study Device Patients Patients Study design Mean/median Cure Definition of Improved, %
included with PPI, % follow-up, mo rate, % cure

Cornu et al. [69] AdVance 102 95 Prospective 13 62.7 No pads 17.6

single center
Bauer et al. [70] AdVance 70 100 Prospective 12 51.4 No pad or one 25.7
single center dry safety pad
Rehder et al. [71] AdVance 118 NS Prospective 12 73.7 No pads 16.9
single center
Bauer et al. [72] AdVance 126 93 Prospective 27 51.6 No pad or one 23.8
single center dry safety pad
Cornel et al. [73] AdVance 35 100 Prospective 12 9 No pad and 45.5
two center <2 g urine loss
in 24-h pad test
Cornu et al. [74] AdVance 136 100 Prospective 21 62 No pads 16
single center
Rehder et al. [75] AdVance 156 93 Prospective 36 42.3 No pad or one 9
multicenter dry safety pad
Hoy and AdVance/ 124 patients: 100 Retrospective 24 AdVance/ 88.2/87.5 1 pad for patients 6.5, AdVance/
Rourke [76] AUS 76 AdVance, single center 42 AUS with >1 pad 8.3, AUS
48 AUS Preoperatively,
0 pads for patients
with 1 pads
preoperatively
Zuckerman AdVance 102 86.4 Retrospective 36 42 No pad or one 20
et al. [77] single center dry safety pad
Kowalik AdVance 30 100 Prospective 39 60 No pad or one 13
et al. [78] single center dry safety pad
Bauer AdVance/ 80: 39 AdVance, 100 Prospective 21, AdVance/ 63, AdVance/ No pad or one 16, AdVance/
et al. [11] AdVanceXP 41 AdVanceXP single center 16, AdVanceXP 59, AdVanceXP dry safety pad 17, AdVanceXP
Cornu AdVance/ 221: 121 AdVance, 100 Prospective 25, AdVance/ 46.2, AdVance/ No pad or one 23.1, AdVance/
et al. [27] AdVanceXP 110 AdVanceXP single center 12, AdVanceXP 65.9, AdVanceXP dry safety pad 24.4, AdVanceXP

AUS = artificial urinary sphincter.

*
Published within last 10 yr; follow-up 12 mo.

damage. Instead, implantation of a second AdVance sling is
possible. However, there is evidence that the functional
outcome after second implantation might be less favorable
compared with primary implantation [84].
Several additional retrourethral male slings were
recently introduced in the marketplace including the
TOMS male sling (CL Medical, Sainte Foy Les Lyon, France)
and the Virtue male sling (Coloplast, Humlebaek, Denmark)
that has four sling arms. Both devices seem to show
comparable results, but further evidence is needed
[85–87].
Table 2 summarizes the ideal indications and contra-
indications for retrourethral transobturator male sling
implantations based on current expert opinions.
3.3.3. Adjustable male sling systems
Adjustable male slings are generally inserted suburethrally
on top of the bulbospongiosus muscle and put pressure
primarily on the bulbar urethra and to a lesser extent on the
more vulnerable membranous urethra to improve basic
continence. Postoperatively, the tension can be adjusted.
However, current EAU guidelines state that there is no
evidence that adjustability of a sling offers a benefit for the
patient (level of evidence [LE]: 3) [5]. In contrast to
nonadjustable retrourethral transobturator slings, good
continence rates can also be achieved in patients with
more severe PPI and previously irradiated patients. The
following adjustable male slings are currently available
(alphabetical order): Argus classic (Promedon, Córdoba,
Argentina), ArgusT (Promedon), Phorbas (Promedon),
ATOMS (A.M.I., Feldkirch, Austria), and Remeex (Neomedic,
Barcelona, Spain). Current evidence indicates that efficacy
of the respective slings is comparable (Table 4). However,
there are differences in the complication rates and types of
complications that are addressed in this review article. Ideal
indications and contraindications for adjustable male sling
implantation based on current expert opinions are summa-
rized in Table 2.
3.3.3.1. Argus classic/ArgusT/Phorbas. The Argus classic and
ArgusT adjustable male sling systems consist of a radi-
opaque silicone foam pad attached to two silicone sling
arms (formed by multiple conical elements). Subcutane-
ously placed radiopaque washers fix the sling arms and
allow postoperative retensioning when indicated. Whereas
the Argus classic is implanted via a retropubic approach, the
ArgusT male sling system is implanted via a transobturator
approach.
Currently four studies are available that report outcome
after primary implantation of the Argus classic system with
a mean follow-up of up to 45 mo and include a total of >250
patients (Table 4) [88–91]. Definitions of success vary
between the respective studies, and therefore comparison is
nontrivial. Reported cure rates vary between 17% (defini-
tion of success: 0 pads or 1 safety pad per day) [89] and
79.2% (definition of success: 1 ml in 20-min pad test)

Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
EUF-100; No. of Pages 15

EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX 9

[90]. Readjustments had to be performed in about a third of

Explantation, %

11.9, including
failed patients
the patients. Regarding the safety of the Argus classic
system, the rate of intraoperative bladder perforation is
reported to be up to 10%. Consequently, an intraoperative
15.8

15.8

10.4

5.9
11

35
cystoscopy is recommended. The most frequently observed
4

postoperative complications include perineal pain (up to

100%/>1 readjustment: 33%

1–4 mo after implantation:
27%) and transient urinary retention (up to 35%). Based on

1 readjustment within
1.7: median per patient
38.6%: 9.9% loosening;
Readjustments

3.8: mean per patient

current evidence, explantation rates usually vary by

4: mean per patient

1: 24/2: 7/3: 1

approximately 10%, with one study observing an explan-

28.7% tightening tation rate of 35% [89]. Two comparative studies including
data about the Argus classic male sling were recently
published. Chung et al. compared patient choices as well as
19.4%
NS

functional outcome for the Argus classic male sling with the
nonadjustable AdVance male sling [92]. Patients were
Improved,

allowed to choose between the two male sling systems.

%

Patients with previous radiotherapy were excluded from the

23.7

26.2

19.6
NS
NS
29

18

13

study, and both subgroups did not differ in severity of

preoperative incontinence based on daily pad use and 24-h
1 ml in 20-min pad test
Definition of success

0–5 ml in 24-h pad test

0–1 small safety pad/d
0–1 pad/d and <15 ml

pad test (2.5 of 345 g vs 2.3 of 325 g). Of 44 men who were
0 pads/d and <10 ml

included in the study, 57% chose the adjustable Argus sling

Dry or improved
in 24-h pad test

in 24-h pad test

instead of the nonadjustable AdVance sling. There was no

significant difference in achievement of social continence
1 pad/d
0 pads/d

(defined as no pads or one safety pad) between both slings

(92% [Argus] vs 84% [AdVance]) and patient satisfaction. The
most frequently observed complication was urinary reten-
72 (0 pads:

tion (4% vs 11%) [92]. Lim et al. compared the outcome of the
Success
rate, %

Argus classic male sling with the outcome after AUS

40%)

79.2

61.9

64.7
60.5

implantation in a patient cohort with moderate urinary

63

17

66

incontinence (defined as two to four pads per day) and found

Table 4 – Selected studies analyzing safety and efficacy after adjustable male sling implantation*

follow-up, mo
Mean/median

no significant difference in success rates (85% vs 73%; defined

as no pads or one safety pad) as well as complication rates
28.8
18

17

27

35
25

45

32

(15% vs 8%) between the two subgroups [93].

The ArgusT male sling system uses a transobturator
approach and therefore reduces the risk of intraoperative
Retrospective single center

Retrospective single center

Retrospective single center
Retrospective multicenter

Prospective single center

bladder perforations. However, evidence regarding the

Prospective multicenter

Prospective multicenter
Prospective two center

ArgusT male sling is still rare. Currently, only one prospective

Study design

two-center study is available addressing efficacy and safety

after 42 implantations (Table 4) [94]. After a mean follow-up
of 28.8 mo, success rate (defined by 0–5 g in 24-h pad test)
was 61.9% and therefore comparable with success rates
previously published for the Argus classic system [94]. In
contrast to the Argus classic system, no intraoperative
with PPI, %
Patients

complications were reported. However, persistent perineal

93

95

96

93
NS

74

84
100

pain >3 mo was more frequently observed (16.7%) than

reported for the Argus classic system.
Published within last 10 yr; follow-up 12 mo.

The newest innovation is the Phorbas sling. It is

included
Patients

implanted with a single incision via a transobturatoric

99

38

95

29
101

36
42

51

approach. Adjustment improved significantly and can be

performed by a scrotal port. To date no published data are
Argus classic

Argus classic
Argus classic

Argus classic

available.
Device

Remeex
ATOMS

ATOMS

All of the devices previously mentioned are silicone

ArgusT

cushioned that makes them more prone to device infections

but also easy to explant. After a failed Argus classic sling, an
Bochove-Overgaauw
et al. (2012) [95]

AUS can be placed, showing similar results compared with a

Romano et al. [91]
and Schrier [88]
Dalpiaz et al. [89]
Hübner et al. [90]

Bauer et al. [94]

Sousa-Escandon
Hoda et al. [96]

primary implantation [63].

et al. [97]
Seweryn

3.3.3.2. ATOMS. The ATOMS adjustable male sling system

Study

consists of a radiopaque silicone cushion attached to

bilateral monofilament polypropylene mesh arms. These
*

Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
 10

EUF-100; No. of Pages 15

Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A

Table 5 – Selected studies analyzing safety and efficacy after ProACT implantation*

Study Device Patients Patients Study design Mean/median Success Definition of success Improved, % Readjustments Explantation, %
included with PPI, % follow-up, mo rate, %

Hübner and Schlarp [98] ProACT 117 94 Prospective single center 13 67 No pad or one safety pad 25 Mean: 3 27.4
(range: 0–15)
Hübner and Schlarp [99] ProACT 50 100 Retrospective single center 20 60 No pad or one safety pad 22 Mean: 4 24
Kocjancic et al. [100] ProACT 65 92 Prospective single center 20 67 NS 15 Mean: 3 17, including unilateral
(range: 0–8) balloon explantation

EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX

Trigo Rocha et al. [103] ProACT 25 100 Prospective single center 22 65.2 0–1 pads 13 Mean: 4.6 17.3, including unilateral
(range: 1–7) balloon explantation
Lebret et al. [101] ProACT 62 100 Prospective multicenter 12 71 1 pad/d 89 for patients 4: 38.7% 30.6
without prior 3: 12.9%
radiotherapy 2: 24.2%
1: 12.9%
Gilling et al. [102] ProACT 37 81 Prospective single center 24 62 No pads 19 Mean: 3.3 11: bilateral explantation only
(range: 0–7)
Gregori et al. [104] ProACT 79 100 Prospective single center 25 66.1 No pad or one safety 25.8 NS 8, including unilateral balloon
pad, <8 g/24 h explantation
Rouprêt et al. [106] ProACT 128 94 Prospective single center 56 66, after No pad or one safety pad Overall 75% based NS 18
24 mo on subjective
evaluation
Kjaer et al. [107] ProACT 114 59 Prospective single center 58 50 0–1 pads/d and/or <8 g/24 h 30 Median 4 20.2
(range: 0–14)
Venturino et al. [105] ProACT 22 82 Prospective single center 57 4.5 0 pads 45 >1: 95.5% 55

NS = not significant; PPI = postprostatectomy incontinence.

*
Published within last 10 yr; follow-up 12 mo.
EUF-100; No. of Pages 15
EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX
sling arms are subsequently placed around the Ramus
inferior ossis pubis. Readjustment is possible via an inguinal
or scrotal port.
To date, evidence is still rare, and currently only two
studies are available describing the outcome of the ATOMS
system after a follow-up of up to 18 mo and including a total
number of 137 patients (Table 4) [95,96]. Definitions of
success were comparable in both studies (<10 ml in 24-h
pad test vs <15 ml in 24-h pad test), and success rates
varied between 60.5% [95] and 63% [96]. However, explan-
tation rates varied between 4% [96] and 15.8% [95]. Re-
markably, the inguinal port was used in both studies. The
mean number of adjustments varied between 3.8 and
3.97 injections per patient [95,96].
Regarding the safety of the ATOMS system, the most
frequently reported complications were transient perineal
and scrotal pain (up to 68.7%) as well as postoperative port
infections and consequently device explantation (up to
10.5%). Current evidence indicates that the ATOMS device
shows comparable results in previously irradiated patients
[95,96]. Explantation of the ATOMS device with its mesh
arms is more challenging than explantation of a complete
silicone cushioned device. To date, there is no evidence
regarding the outcome after primary ATOMS failure.
3.3.3.3. Remeex. The Remeex system consists of a subureth-
rally placed mesh connected to a suprapubic mechanical
regulator via two bilateral monofilament fibers. The system
is implanted via a retropubic approach. The mechanical
regulator is called ‘‘varitensor’’ and is a suprapubically and
subcutaneously placed, cubically shaped permanent im-
plant. The readjustments are performed via an external
manipulator. Remarkably, the external manipulator is
connected to the varitensor during the device implantation
and left in situ until the first adjustment within the first 48 h
postoperatively. Subsequent adjustments have to be
performed with a single-use mechanical regulator, usually
under local anesthesia.
To date, only one multicenter study has systematically
analyzed the outcomes of 51 patients after a mean follow-
up of 32 mo (Table 4) [97]. Success rate (definition of
success: 1 pad per day) was 64.7% and therefore
comparable with other adjustable male sling devices
[97]. Postoperative complication rates were low; howev-
er, during the adjustment, rupture or infection of the
varitensor may occur. The reported explantation rate is
6% [97]. To date, there is no evidence regarding the use of
the Remeex system in previously irradiated patients. In
addition, there is no evidence of outcome salvage
therapies after primary Remeex failure. Comparable with
the ATOMS device, the explantation of the mesh part is
challenging.
3.3.4. Compressive balloon systems
The ProACT system (Uromedica, Plymouth, MN, USA)
represents a noncircumferential compressive device and
consists of two balloons that are placed bilaterally in the
bladder neck area and consequently achieve continence via
periurethral compression. The system can be readjusted via
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
11
two scrotal ports and allows repeating volume adjustments
of the device.
To date, 10 contemporary studies are available providing
data of >400 patients after a follow-up of up to 57 mo
(Table 5) [98–107]. Success rates vary between 60%
(definition of success: no pad or one safety pad) [99] and
67% (same definition of success) [98,100]. For instance,
Gregori et al. analyzed the outcome of 79 consecutive
patients with PPI and observed a dry rate (<8 g in 24-h pad
test and 0 pads or one safety pad per day) of 66%. Regarding
the safety of ProACT implantation, the authors found
intraoperative bladder perforation in 2.5%, transient urinary
retention in 1.2%, device migration in 3.8%, and urethral
erosion in 2.5% [104]. However, complication and consecu-
tive explantation rates were higher in other studies and
described within a range of 11% up to 58% [98,102]. In this
context, Gregori et al. concluded that complication rates
might be lower after transrectal ultrasound-guided implan-
tation of the ProACT device [104]. Most recently, Venturino
et al. published the long-term outcome of 22 consecutive
patients. Only 4.5% were immediately dry, and 95.5%
needed at least one adjustment. After balloon readjust-
ments, dry rate increased temporarily to 18%, but after a
median follow-up of 57 mo, dry rate decreased again to
4.5%. Overall, 45% of the patients were satisfied; the
remaining 55% were unchanged and dissatisfied. Strikingly,
the authors observed revision and explantation rates of 73%
and 55%, respectively, and they concluded that the ProACT
system does not seem to offer satisfactory results in the
long-term follow-up [105]. Based on current EAU guide-
lines, the ProACT device should not be implanted in patents
with prior pelvic radiotherapy and severe SUI (GR: C) [5].
Table 2 summarizes the ideal indications and contra-
indications for ProACT implantation based on current
expert opinions.
3.3.5. Bulking agents
Due to high initial failure rates and decreasing success rates
over time, bulking agents should not be offered to patients
with severe SUI and patients who are seeking for a cure of
SUI, but only to patients with mild to moderate SUI seeking
temporary relief of symptoms (GR: C) [5]. To date, no
evidence indicates that one bulking agent is superior to
others [5].
Table 2 summarizes the ideal indications and contra-
indications for bulking agents based on current expert
opinions.
4. Conclusions
The diagnosis of PPI is currently mostly based on expert
opinions. Recommended first-line therapy is conservative
treatment, and PFMT is the treatment of choice. Strong
evidence supports its use. Duloxetine remains an off-label
treatment that should only be offered to patients seeking
temporary symptom relief. Antimuscarinics should be
applied to patients experiencing additional urgency.
Regarding the invasive management of PPI, the AMS
800 AUS is still the treatment of choice for moderate to
EUF-100; No. of Pages 15
12 EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX
severe PPI, based on current EAU guidelines. However,
evidence is still based on mostly retrospective case series.
Alternative AUS are currently available that aim to address
known weaknesses of the AMS 800, but evidence is still too
scant to reach any final conclusions or offer recommenda-
tions. However, there is increasing evidence that male slings
are emerging as a worthy alternative, especially in patients
with mild to moderate PPI. Being confronted with an
increasing number of competing devices, adjustable or
nonadjustable, noncompressive as well as compressive, the
treating urologist must be aware that efficacy seems to be
comparable across most devices. Complication rates and
kinds of complications, however, may vary significantly
between the respective devices. With an increasing number
of competing devices, a sophisticated therapeutic approach
based on the clinical presentation of the individual patient is
crucial (Fig. 2).
Currently no randomized controlled trial has investigated
the outcome of one specific surgical treatment or compared
the outcome of different surgical treatment options, and
general LE is therefore very low. It is highly unlikely that we
will see the results of a comparative, prospective, and
randomized trial in the future, due to ethical concerns,
differences in indications, and logistic issues. Thus from a
short-term point of view, evidence must be improved by
large well-designed nonrandomized prospective studies
analyzing homogeneous patient cohorts in terms of severity
of incontinence, mode of prostatectomy, previous invasive
treatments, and concomitant symptoms.
Author contributions: Alexander Kretschmer had full access to all the
data in the study and takes responsibility for the integrity of the data and
the accuracy of the data analysis.
Study concept and design: Kretschmer, Hübner, Sandhu, Bauer.
Acquisition of data: Kretschmer, Hübner, Sandhu, Bauer.
Analysis and interpretation of data: Kretschmer, Hübner, Sandhu, Bauer.
Drafting of the manuscript: Kretschmer, Hübner, Sandhu, Bauer.
Critical revision of the manuscript for important intellectual content:
Kretschmer, Hübner, Sandhu, Bauer.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: Kretschmer, Hübner,
Sandhu, Bauer.
Supervision: Hübner, Sandhu, Bauer.
Other (specify): None.
Financial disclosures: Alexander Kretschmer certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultancies,
honoraria, stock ownership or options, expert testimony, royalties, or
patents filed, received, or pending), are the following: Alexander
Kretschmer has nothing to disclose. Ricarda M. Bauer declares consultancy
work, lectures, and participation in clinical trials for American Medical
Systems (Minnetonka, MN, USA) and Promedon (Cordoba, Argentina).
Jaspreet S. Sandhu declares consultancy work for American Medical
Systems (Minnetonka, MN, USA). Wilhelm Huebner declares consultancy
work, lectures, and participation in clinical trials for Promedon (Cordoba,
Argentina) and Uromedica (Plymouth, MN, USA).
Funding/Support and role of the sponsor: None.
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
References
[1] Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfac-
tion with outcome among prostate-cancer survivors. N Engl J Med
2008;358:1250–61.
[2] von Bodman C, Matsushita K, Savage C, et al. Recovery of urinary
function after radical prostatectomy: predictors of urinary func-
tion on preoperative prostate magnetic resonance imaging. J Urol
2012;187:945–50.
[3] Giannantoni A, Mearini E, Zucchi A, et al. Bladder and urethral
sphincter function after radical retropubic prostatectomy: a pro-
spective long-term study. Eur Urol 2008;54:657–64.
[4] Wei JT, Dunn RL, Marcovich R, Montie JE, Sanda MG. Prospective
assessment of patient reported urinary continence after radical
prostatectomy. J Urol 2000;164:744–8.
[5] Lucas MG, Bosch RJ, Burkhard FC, et al. EAU guidelines on surgical
treatment of urinary incontinence. Eur Urol 2012;62:1118–29.
[6] Wei JT, Montie JE. Comparison of patients’ and physicians’ rating of
urinary incontinence following radical prostatectomy. Semin Urol
Oncol 2000;18:76–80.
[7] Konety BR, Sadetsky N, Carroll PR. CaPSURE Investigators. Recov-
ery of urinary continence following radical prostatectomy: the
impact of prostate volume–analysis of data from the CaPSURE
database. J Urol 2007;177:1423–5, discussion 1425–6.
[8] Begg CB, Riedel ER, Bach PB, et al. Variations in morbidity after
radical prostatectomy. N Engl J Med 2002;346:1138–44.
[9] Loughlin KR, Prasad MM. Post-prostatectomy urinary inconti-
nence: a confluence of 3 factors. J Urol 2010;183:871–7.
[10] Lucas MG, Bosch RJ, Burkhard FC, et al. EAU guidelines on assess-
ment and nonsurgical management of urinary incontinence. Eur
Urol 2012;62:1130–42.
[11] Bauer RM, Hampel C, Haferkamp A, Hofner K, Hübner W. Diagnosis
and surgical treatment of postprostatectomy stress incontinence:
recommendation of the working group Urologische Funktions-
diagnostik und Urologie der Frau [in German]. Urologe A
2014;53:847–53.
[12] Petros PE, Woodman PJ. The integral theory of continence. Int
Urogynecol J Pelvic Floor Dysfunct 2008;19:35–40.
[13] Schwalenberg T, Neuhaus J, Liatsikos E, Winkler M, Loffler S,
Stolzenburg JU. Neuroanatomy of the male pelvis in respect to
radical prostatectomy including three-dimensional visualization.
BJU Int 2010;105:21–7.
[14] Hübner WA, Trigo-Rocha F, Plas EG, Tanagho EA. Urethral function
after cystectomy: a canine in vivo experiment. Urol Res 1993;21:
45–8.
[15] Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a
brief and robust measure for evaluating the symptoms and impact
of urinary incontinence. Neurourol Urodyn 2004;23:322–30.
[16] Yalcin I, Bump RC. Validation of two global impression question-
naires for incontinence. Am J Obstet Gynecol 2003;189:98–101.
[17] Litwin MS, Hays RD, Fink A, Ganz PA, Leake B, Brook RH. The UCLA
Prostate Cancer Index: development, reliability, and validity of a
health-related quality of life measure. Med Care 1998;36:1002–12.
[18] Nitti VW, Mourtzinos A, Brucker BM, SUFU Pad Test Study Group.
Correlation of patient perception of pad use with objective degree of
incontinence measured by pad test in men with post-prostatectomy
incontinence: the SUFU Pad Test Study. J Urol 2014;192:836–42.
[19] Abrams P, Cardozo L, Fall M, et al. The standardisation of termi-
nology in lower urinary tract function: report from the standar-
disation sub-committee of the International Continence Society.
Urology 2003;61:37–49.
[20] Mouritsen L, Berlid G, Hertz J. Comparison of different methods for
quantification of urinary leakage in incontinent women. Neu-
rourol Urodyn 1989;8:579–87.
EUF-100; No. of Pages 15
EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX
[21] Bauer RM, Gozzi C, Roosen A, et al. Impact of the ‘repositioning
test’ on postoperative outcome of retroluminar transobturator
male sling implantation. Urol Int 2013;90:334–8.
[22] Flood HD, Alevizatos C, Liu JL. Sex differences in the determination
of abdominal leak point pressure in patients with intrinsic sphinc-
ter deficiency. J Urol 1996;156:1737–40.
[23] Barnard J, van Rij S, Westenberg AM. A Valsalva leak-point pres-
sure of >100 cmH2O is associated with greater success in Ad-
Vance sling placement for the treatment of post-prostatectomy
urinary incontinence. BJU Int 2014;114(Suppl 1):34–7.
[24] Han JS, Brucker BM, Demirtas A, Fong E, Nitti VW. Treatment of
post-prostatectomy incontinence with male slings in patients
with impaired detrusor contractility on urodynamics and/or
who perform Valsalva voiding. J Urol 2011;186:1370–5.
[25] Trigo Rocha F, Gomes CM, Mitre AI, Arap S, Srougi M. A prospective
study evaluating the efficacy of the artificial sphincter AMS 800 for
the treatment of postradical prostatectomy urinary incontinence
and the correlation between preoperative urodynamic and surgi-
cal outcomes. Urology 2008;71:85–9.
[26] Kawasaki A, Wu JM, Amundsen CL, et al. Do urodynamic param-
eters predict persistent postoperative stress incontinence after
midurethral sling? A systematic review. Int Urogynecol J
2012;23:813–22.
[27] Cornu JN, Melot C, Haab F. A pragmatic approach to the charac-
terization and effective treatment of male patients with postpros-
tatectomy incontinence. Curr Opin Urol 2014;24:566–70.
[28] Goode PS, Burgio KL, Johnson I TM, et al. Behavioral therapy with
or without biofeedback and pelvic floor electrical stimulation for
persistent postprostatectomy incontinence: a randomized con-
trolled trial. JAMA 2011;305:151–9.
[29] Fernandez RA, Garcia-Hermoso A, Solera-Martinez M, et al. Im-
provement of continence rate with pelvic floor muscle training
post-prostatectomy: a meta-analysis of randomized controlled
trials. Urol Int 2015;94:125–32.
[30] Filocamo MT, Li Marzi V, Del Popolo G, et al. Effectiveness of early
pelvic floor rehabilitation treatment for post-prostatectomy in-
continence. Eur Urol 2005;48:734–8.
[31] Manassero F, Traversi C, Ales V, et al. Contribution of early inten-
sive prolonged pelvic floor exercises on urinary continence recov-
ery after bladder neck-sparing radical prostatectomy: results of a
prospective controlled randomized trial. Neurourol Urodyn
2007;26:985–9.
[32] Van Kampen M, De Weerdt W, Van Poppel H, De Ridder D, Feys H,
Baert L. Effect of pelvic-floor re-education on duration and degree
of incontinence after radical prostatectomy: a randomised con-
trolled trial. Lancet 2000;355:98–102.
[33] Glazener C, Boachie C, Buckley B, et al. Conservative treatment for
urinary incontinence in Men After Prostate Surgery (MAPS): two
parallel randomised controlled trials. Health Technol Assess
2011;15:1–290, iii–iv.
[34] Moore KN, Valiquette L, Chetner MP, Byrniak S, Herbison GP. Return
to continence after radical retropubic prostatectomy: a randomized
trial of verbal and written instructions versus therapist-directed
pelvic floor muscle therapy. Urology 2008;72:1280–6.
[35] Overgard M, Angelsen A, Lydersen S, Morkved S. Does physiother-
apist-guided pelvic floor muscle training reduce urinary inconti-
nence after radical prostatectomy? A randomised controlled trial.
Eur Urol 2008;54:438–48.
[36] Dubbelman Y, Groen J, Wildhagen M, Rikken B, Bosch R. The
recovery of urinary continence after radical retropubic prostatec-
tomy: a randomized trial comparing the effect of physiotherapist-
guided pelvic floor muscle exercises with guidance by an instruc-
tion folder only. BJU Int 2010;106:515–22.
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
13
[37] Geraerts I, Van Poppel H, Devoogdt N, et al. Influence of preoper-
ative and postoperative pelvic floor muscle training (PFMT) com-
pared with postoperative PFMT on urinary incontinence after
radical prostatectomy: a randomized controlled trial. Eur Urol
2013;64:766–72.
[38] Ribeiro LH, Prota C, Gomes CM, et al. Long-term effect of early
postoperative pelvic floor biofeedback on continence in men
undergoing radical prostatectomy: a prospective, randomized,
controlled trial. J Urol 2010;184:1034–9.
[39] Yamanishi T, Mizuno T, Watanabe M, Honda M, Yoshida K. Ran-
domized, placebo controlled study of electrical stimulation with
pelvic floor muscle training for severe urinary incontinence after
radical prostatectomy. J Urol 2010;184:2007–12.
[40] Mariotti G, Sciarra A, Gentilucci A, et al. Early recovery of urinary
continence after radical prostatectomy using early pelvic floor
electrical stimulation and biofeedback associated treatment. J Urol
2009;181:1788–93.
[41] Wille S, Sobottka A, Heidenreich A, Hofmann R. Pelvic floor exer-
cises, electrical stimulation and biofeedback after radical prosta-
tectomy: results of a prospective randomized trial. J Urol
2003;170:490–3.
[42] Moore KN, Griffiths D, Hughton A. Urinary incontinence after
radical prostatectomy: a randomized controlled trial comparing
pelvic muscle exercises with or without electrical stimulation. BJU
Int 1999;83:57–65.
[43] Filocamo MT, Li Marzi V, Del Popolo G, et al. Pharmacologic
treatment in postprostatectomy stress urinary incontinence. Eur
Urol 2007;51:1559–64.
[44] Cornu JN, Merlet B, Ciofu C, et al. Duloxetine for mild to moderate
postprostatectomy incontinence: preliminary results of a ran-
domised, placebo-controlled trial. Eur Urol 2011;59:148–54.
[45] Schlenker B, Gratzke C, Reich O, Schorsch I, Seitz M, Stief CG.
Preliminary results on the off-label use of duloxetine for the
treatment of stress incontinence after radical prostatectomy or
cystectomy. Eur Urol 2006;49:1075–8.
[46] Bauer RM, Gozzi C, Hübner W, et al. Contemporary management of
postprostatectomy incontinence. Eur Urol 2011;59:985–96.
[47] Van der Aa F, Drake MJ, Kasyan GR, Petrolekas A, Cornu JN. The
artificial urinary sphincter after a quarter of a century: a critical
systematic review of its use in male non-neurogenic incontinence.
Eur Urol 2013;63:681–9.
[48] Staerman F, G-Llorens C, Leon P, Leclerc Y. ZSI 375 artificial urinary
sphincter for male urinary incontinence: a preliminary study. BJU
Int 2013;111:E202–6.
[49] Alonso Rodriguez D, Fes Ascanio E, Fernandez Barranco L, Vicens
Vicens A, Montes FG. One hundred FlowSecure artificial urinary
sphincters. Eur Urol Suppl 2011;10:309.
[50] Lai HH, Hsu EI, Teh BS, Butler EB, Boone TB. 13 years of experience
with artificial urinary sphincter implantation at Baylor College of
Medicine. J Urol 2007;177:1021–5.
[51] O’Connor RC, Nanigian DK, Patel BN, Guralnick ML, Ellision LM,
Stone AR. Artificial urinary sphincter placement in elderly men.
Urology 2007;69:126–8.
[52] O’Connor RC, Lyon MB, Guralnick ML, Bales GT. Long-term follow-
up of single versus double cuff artificial urinary sphincter insertion
for the treatment of severe postprostatectomy stress urinary
incontinence. Urology 2008;71:90–3.
[53] Aaronson DS, Elliott SP, McAninch JW. Transcorporal artificial
urinary sphincter placement for incontinence in high-risk patients
after treatment of prostate cancer. Urology 2008;72:825–7.
[54] Sathianathen NJ, McGuigan SM, Moon DA. Outcomes of artificial
urinary sphincter implantation in the irradiated patient. BJU Int
2014;113:636–41.
EUF-100; No. of Pages 15
14 EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX
[55] Hoy NY, Rourke KF. Artificial urinary sphincter outcomes in the
‘‘fragile urethra’’. Urology 2015;86:618–24.
[56] Linder BJ, Rivera ME, Ziegelmann MJ, Elliott DS. Long-term out-
comes following artificial urinary sphincter placement: an analy-
sis of 1082 cases at Mayo Clinic. Urology 2015;86:602–7.
[57] Léon P, Chartier-Kastler E, Rouprêt M, Ambrogi V, Mozer P, Phe V.
Long-term functional outcomes after artificial urinary sphincter
implantation in men with stress urinary incontinence. BJU Int
2015;115:951–7.
[58] Singh G, Thomas DG. Artificial urinary sphincter for post-prosta-
tectomy incontinence. Br J Urol 1996;77:248–51.
[59] Mottet N, Boyer C, Chartier-Kastler E, Ben Naoum K, Richard F,
Costa P. Artificial urinary sphincter AMS 800 for urinary inconti-
nence after radical prostatectomy: the French experience. Urol Int
1998;60(Suppl 2):25–9, discussion 35.
[60] Gousse AE, Madjar S, Lambert MM, Fishman IJ. Artificial urinary
sphincter for post-radical prostatectomy urinary incontinence:
long-term subjective results. J Urol 2001;166:1755–8.
[61] Wilson S, Delk II J, Henry GD, Siegel AL. New surgical technique for
sphincter urinary control system using upper transverse scrotal
incision. J Urol 2003;169:261–4.
[62] Henry GD, Graham SM, Cornell RJ, et al. A multicenter study on the
perineal versus penoscrotal approach for implantation of an arti-
ficial urinary sphincter: cuff size and control of male stress urinary
incontinence. J Urol 2009;182:2404–9.
[63] Kretschmer A, Buchner A, Grabbert M, Stief CG, Pavlicek M, Bauer
RM. Risk factors for artificial urinary sphincter failure. World J
Urol. In press.
[64] Knight SL, Susser J, Greenwell T, Mundy AR, Craggs MD. A new
artificial urinary sphincter with conditional occlusion for stress
urinary incontinence: preliminary clinical results. Eur Urol
2006;50:574–80.
[65] Linder BJ, de Cogain M, Elliott DS. Long-term device outcomes of
artificial urinary sphincter reimplantation following prior explan-
tation for erosion or infection. J Urol 2014;191:734–8.
[66] Eswara JR, Chan R, Vetter JM, Lai HH, Boone TB, Brandes SB.
Revision techniques after artificial urinary sphincter failure in
men: results from a multicenter study. Urology 2015;86:176–80.
[67] Rehder P, Gozzi C. Transobturator sling suspension for male
urinary incontinence including post-radical prostatectomy. Eur
Urol 2007;52:860–6.
[68] Bauer RM, Homberg R, Gebhartl P, et al. The AdVanceXP male
sling: results of a prospective multicenter study. J Urol
2014;191:e342.
[69] Cornu JN, Sebe P, Ciofu C, et al. The AdVance transobturator male
sling for postprostatectomy incontinence: clinical results of a
prospective evaluation after a minimum follow-up of 6 months.
Eur Urol 2009;56:923–7.
[70] Bauer RM, Mayer ME, Gratzke C, et al. Prospective evaluation of
the functional sling suspension for male postprostatectomy stress
urinary incontinence: results after 1 year. Eur Urol 2009;56:
928–33.
[71] Rehder P, Mitterberger MJ, Pichler R, Kerschbaumer A, Glodny B.
The 1 year outcome of the transobturator retroluminal reposition-
ing sling in the treatment of male stress urinary incontinence. BJU
Int 2010;106:1668–72.
[72] Bauer RM, Soljanik I, Fullhase C, et al. Mid-term results for the
retroluminar transobturator sling suspension for stress urinary
incontinence after prostatectomy. BJU Int 2010;108:94–8.
[73] Cornel EB, Elzevier HW, Putter H. Can advance transobturator sling
suspension cure male urinary postoperative stress incontinence? J
Urol 2010;183:1459–63.
[74] Cornu JN, Sebe P, Ciofu C, Peyrat L, Cussenot O, Haab F. Mid-term
evaluation of the transobturator male sling for post-prostatectomy
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
incontinence: focus on prognostic factors. BJU Int 2010;108:236–
40.
[75] Rehder P, Haab F, Cornu JN, Gozzi C, Bauer RM. Treatment of
postprostatectomy male urinary incontinence with the transob-
turator retroluminal repositioning sling suspension: 3-year fol-
low-up. Eur Urol 2012;62:140–5.
[76] Hoy NY, Rourke KF. Stemming the tide of mild to moderate post-
prostatectomy incontinence: a retrospective comparison of trans-
obturator male slings and the artificial urinary sphincter. Can Urol
Assoc J 2014;8:273–7.
[77] Zuckerman JM, Edwards B, Henderson K, Beydoun HA, McCam-
mon KA. Extended outcomes in the treatment of male stress urinary
incontinence with a transobturator sling. Urology 2014;83:
939–45.
[78] Kowalik CG, DeLong JM, Mourtzinos AP. The advance transobtura-
tor male sling for post-prostatectomy incontinence: subjective
and objective outcomes with 3 years follow up. Neurourol Urodyn
2015;34:251–4.
[79] Bauer RM, Kretschmer A, Stief CG, Fullhase C. AdVance and Ad-
Vance XP slings for the treatment of post-prostatectomy inconti-
nence. World J Urol. In press.
[80] Cornu JN, Batista Da Costa J, et al. Comparative study of AdVance
and AdVanceXP male slings in a tertiary reference center. Eur Urol
2014;65:502–4.
[81] Bauer RM, Soljanik I, Fullhase C, et al. Results of the AdVance
transobturator male sling after radical prostatectomy and adju-
vant radiotherapy. Urology 2011;77:474–9.
[82] Torrey R, Rajeshuni N, Ruel N, Muldrew S, Chan K. Radiation
history affects continence outcomes after advance transobturator
sling placement in patients with post-prostatectomy inconti-
nence. Urology 2013;82:713–7.
[83] Zuckerman JM, Tisdale B, McCammon K. AdVance male sling in
irradiated patients with stress urinary incontinence. Can J Urol
2011;18:6013–7.
[84] Soljanik I, Becker AJ, Stief CG, Gozzi C, Bauer RM. Repeat retro-
urethral transobturator sling in the management of recurrent
postprostatectomy stress urinary incontinence after failed first
male sling. Eur Urol 2010;58:767–72.
[85] Grise P, Vautherin R, Njinou-Ngninkeu B, et al., Group HOIS. I-STOP
TOMS transobturator male sling, a minimally invasive treatment
for post-prostatectomy incontinence: continence improvement
and tolerability. Urology 2012;79:458–63.
[86] Yiou R, Loche CM, Lingombet O, et al. Evaluation of urinary
symptoms in patients with post-prostatectomy urinary inconti-
nence treated with the male sling TOMS. Neurourol Urodyn
2015;34:12–7.
[87] Comiter CV, Nitti V, Elliot C, Rhee E. A new quadratic sling for male
stress incontinence: retrograde leak point pressure as a measure
of urethral resistance. J Urol 2012;187:563–8.
[88] Bochove-Overgaauw DM, Schrier BP. An adjustable sling for the
treatment of all degrees of male stress urinary incontinence:
retrospective evaluation of efficacy and complications after a
minimal followup of 14 months. J Urol 2011;185:1363–8.
[89] Dalpiaz O, Knopf HJ, Orth S, Griese K, Aboulsorour S, Truss M. Mid-
term complications after placement of the male adjustable sub-
urethral sling: a single center experience. J Urol 2011;186:604–9.
[90] Hübner WA, Gallistl H, Rutkowski M, Huber ER. Adjustable bul-
bourethral male sling: experience after 101 cases of moderate-
to-severe male stress urinary incontinence. BJU Int 2011;107:
777–82.
[91] Romano SV, Huebner W, Rocha FT, Vaz FP, Muller V, Nakamura F. A
transobturator adjustable system for male incontinence: 30-
month follow-up of a multicenter study. Int Braz J Urol
2014;40:781–9.
EUF-100; No. of Pages 15
EUROPEAN UROLOGY FOCUS XXX (2016) XXX–XXX
[92] Chung E, Smith P, Malone G, Cartmill R. Adjustable versus non-
adjustable male sling for post-prostatectomy urinary inconti-
nence: a prospective clinical trial comparing patient choice, clini-
cal outcomes and satisfaction rate with a minimum follow up of
24 months. Neurourol Urodyn. In press.
[93] Lim B, Kim A, Song M, Chun JY, Park J, Choo MS. Comparing Argus
sling and artificial urinary sphincter in patients with moderate
post-prostatectomy incontinence. J Exerc Rehabil 2014;10:
337–42.
[94] Bauer RM, Rutkowski M, Kretschmer A, Casuscelli J, Stief CG,
Huebner W. Efficacy and complications of the adjustable sling
system ArgusT for male incontinence: results of a prospective 2-
center study. Urology 2015;85:316–20.
[95] Seweryn J, Bauer W, Ponholzer A, Schramek P. Initial experience
and results with a new adjustable transobturator male system for
the treatment of stress urinary incontinence. J Urol 2012;187:
956–61.
[96] Hoda MR, Primus G, Fischereder K, et al. Early results of a European
multicentre experience with a new self-anchoring adjustable
transobturator system for treatment of stress urinary inconti-
nence in men. BJU Int 2013;111:296–303.
[97] Sousa-Escandon A, Cabrera J, Mantovani F, et al. Adjustable sub-
urethral sling (male remeex system) in the treatment of male
stress urinary incontinence: a multicentric European study. Eur
Urol 2007;52:1473–9.
[98] Hübner WA, Schlarp OM. Treatment of incontinence after prosta-
tectomy using a new minimally invasive device: adjustable con-
tinence therapy. BJU Int 2005;96:587–94.
[99] Hübner WA, Schlarp OM. Adjustable continence therapy (ProACT):
evolution of the surgical technique and comparison of the original
50 patients with the most recent 50 patients at a single centre. Eur
Urol 2007;52:680–6.
Please cite this article in press as: Kretschmer A, et al. Evaluation and Management of Postprostatectomy Incontinence: A
Systematic Review of Current Literature. Eur Urol Focus (2016), http://dx.doi.org/10.1016/j.euf.2016.01.002
15
[100] Kocjancic E, Crivellaro S, Ranzoni S, Bonvini D, Gontero P, Frea B.
Adjustable Continence Therapy for the treatment of male stress
urinary incontinence: a single-centre study. Scand J Urol Nephrol
2007;41:324–8.
[101] Lebret T, Cour F, Benchetrit J, et al. Treatment of postprostatect-
omy stress urinary incontinence using a minimally invasive
adjustable continence balloon device, ProACT: results of a prelim-
inary, multicenter, pilot study. Urology 2008;71:256–60.
[102] Gilling PJ, Bell DF, Wilson LC, Westenberg AM, Reuther R, Fraun-
dorfer MR. An adjustable continence therapy device for treating
incontinence after prostatectomy: a minimum 2-year follow-up.
BJU Int 2008;102:1426–30, discussion 1430–1.
[103] Trigo-Rocha F, Gomes CM, Pompeo AC, Lucon AM, Arap S. Pro-
spective study evaluating efficacy and safety of Adjustable Conti-
nence Therapy (ProACT) for post radical prostatectomy urinary
incontinence. Urology 2006;67:965–9.
[104] Gregori A, Romano AL, Scieri F, et al. Transrectal ultrasound-
guided implantation of Adjustable Continence Therapy (ProACT):
surgical technique and clinical results after a mean follow-up of
2 years. Eur Urol 2010;57:430–6.
[105] Venturino L, Dalpiaz O, Pummer K, Primus G. Adjustable conti-
nence balloons in men: adjustments do not translate into long-
term continence. Urology 2015;85:1448–52.
[106] Rouprêt M, Misrai V, Gosseine PN, Bart S, Cour F, Chartier-Kastler
E. Management of stress urinary incontinence following prostate
surgery with minimally invasive adjustable continence balloon
implants: functional results from a single center prospective
study. J Urol 2011;186:198–203.
[107] Kjaer L, Fode M, Norgaard N, Sonksen J, Nordling J. Adjustable
continence balloons: clinical results of a new minimally invasive
treatment for male urinary incontinence. Scand J Urol Nephrol
2012;46:196–200.