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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Two surgical methods are similarly effective in reducing men’s leakage of urine (incontinence) after prostate surgery, research found. The findings will help men make an informed choice about surgery.

Incontinence after prostate surgery is often addressed by a further procedure to fit an inflatable cuff around the urethra (the tube that drains urine from the bladder). This is called an artificial urinary sphincter; men control the cuff with a pump. A newer, simpler procedure, called a sling, fits a length of tape to support the bladder.

Before this study, it was unclear how the two techniques compared. This study assessed the procedures in men who experienced incontinence for more than 12 months after prostate surgery. It found that both methods improved men’s quality of life, and serious complications were rare. However, few men in either group achieved zero leakage.

The results will allow surgeons to better explain the benefits, drawbacks, and likelihood of success of both procedures. This will help men make an informed choice. But the researchers caution that men need realistic expectations ahead of either procedure.

More information on incontinence is available on the NHS website.

The issue: artificial urinary sphincter versus male sling

Men who have had prostate surgery often experience incontinence when they play sport or sneeze. For many, this remains a problem a year after surgery.

Incontinence is difficult to resolve and some men need to wear absorbent pads in their underwear. Incontinence can affect their work, social life, self-esteem, and sex life.

There are two surgical fixes. The first, called an artificial urinary sphincter, fits an inflatable cuff around the urethra. When inflated, it compresses the urethra and stops urine passing. When men need to urinate, they deflate the cuff by squeezing a small pump placed in the scrotum. The second, newer procedure, is called a male sling. This fits a length of tape to support the bladder (like a regular sling supports an arm) to prevent urine leaking.

The sling is easier for men to use (no pump), easier and faster for surgeons to implant, and cheaper than the artificial sphincter. Sphincters are also more likely to fail in the long-term, meaning further surgery is needed. However, sphincters are still the recommended option in UK guidelines.

There is little research that directly compares the two techniques. This has meant that men are unable to make an informed choice. For example, one patient said: “I fancied the sling a bit more but then again, apparently from what I’ve read it’s not been too much tried and tested over the years.”  

In this study, researchers compared how well the sling and sphincter stopped urine leakage in men who experienced incontinence for more than 12 months after prostate surgery. They also assessed the value for money of each.

What’s new?

The study included 380 men at 28 UK hospitals: half received an artificial sphincter and the others received a sling. Their average age was 68. Before surgery, more than 9 in 10 men leaked urine at least once per day, with more than 1 in 3 reporting ‘a large amount’.

Researchers asked men how much urine they leaked before and 12 months after their sling or sphincter was inserted.

The results showed that, at 12 months, both surgeries:

  • improved continence in most men (69% sling group; 68% artificial sphincter group)
  • led to zero leakage for some (13% sling group; 16% artificial sphincter group)
  • gave high levels of satisfaction, improved quality of life, and had few serious complications.

The artificial sphincter performed better than the sling in some respects: it reduced the impact of incontinence on everyday life more than the sling, and led to higher levels of satisfaction. More men in the sphincter group said they would recommend the surgery to a friend.

A few men (2%) in the artificial sphincter group required further surgery to improve their continence. More men in the sling group (10%) had further surgery (to insert an artificial sphincter).

The sling surgery cost almost £2,500 less than the artificial sphincter surgery and was better value for money.

Before their surgery, men said they wanted their surgery to achieve zero leakage, but would consider reduced leakage and less pad use a successful outcome. They wanted ‘some level of normality’ and said that successful outcomes would be ‘life-changing’.

Why is this important?

Both procedures reduced urine leakage and improved quality of life, and left most men in both groups satisfied. The results give surgeons and patients more evidence to make an informed choice on the type of surgery they want.   

Not all men expected either procedure to fix their incontinence completely. They appreciated reasonable reductions in urine leakage.

This study used a stricter definition of incontinence, based on men’s personal experiences rather than standard pad tests. So the number of men reporting zero leakage was lower in this study than other trials, the researchers say.

What’s next?

Surgeons can use these results to explain the benefits, drawbacks, and likelihood of success of both procedures; this will enable men to make an informed choice. The researchers caution that men need to be clear in advance about how far either procedure will prevent leakage. Men need to know that only a minority will have zero leakage after surgery, although most will have a meaningful reduction in leakage and pad use.

Men are now being asked about any pain associated with their surgery. The men from this study are being followed up for 5 years to investigate long-term satisfaction with treatment and quality of life.

Slings are a relatively new option, which means there is a lack of long-term data on their safety and effectiveness. Men need to be aware of this before they make their decision.

You may be interested to read

This Alert is based on: Constable L, and others. Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT. Health and Technology Assessment 2022;26:1–152

Information from Prostate Cancer UK on urinary problems following prostate cancer treatment.  

Information from Cleveland Clinic on incontinence following prostate cancer surgery.

NICE Guidelines on managing male lower urinary tract symptoms.

European Association of Urology Guidelines on managing male lower urinary tract symptoms.

Funding: This study was funded by the NIHR Health and Technology Assessment Programme.

Conflicts of Interest: Several authors have received fees and funding from various pharmaceutical companies. View the original paper for all declared conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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