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Editorial: A contemporary view on the use of slings and artificial urinary sphincters for the treatment of post‐prostatectomy incontinence in England

Post‐prostatectomy urinary incontinence (UI) is a well‐recognised consequence of radical prostatectomy carried out as treatment for organ‐confined prostate cancer. This interesting article [1] reviews the in-practice surgical management of post‐prostatectomy UI in England over an 8‐year period, using the Hospital Episodes Statistics (HES) database.

In total, 1414 patients had an artificial urinary sphincter (AUS) implanted, with a median follow‐up of 3.55 years. In contrast, 816 patients were treated with a male sling, with a median follow‐up of 3.23 years. Post‐prostatectomy AUS implantation was performed in 49 centres and male sling surgery in 48 centres. It is not clear whether the same centres were involved in implanting both devices; it is however of note that for AUS implantation, 34.7% of the centres performed fewer than six post‐prostatectomy AUS implantations over the 8‐year period and 18.4% performed >50 in the same period. Both re‐do and removal surgery of AUS had some association with low‐volume providers; 7.7% of patients received a second AUS and 0.8% had undergone the procedures three or more times. A total of 12.5% of patients had an AUS re‐do or removal; 0.6% of these were within 6 weeks of the index procedure. Prior sling surgery did not predict an increased likelihood of re‐do or removal. Similarly, 33.3% of centres performed less than six post‐prostatectomy sling surgeries over the 8‐year period and only 4.3% performed >50 procedures. There was no association of centre volume with the likelihood of sling revision.

With reference to the potential impact of radiotherapy (RT), in two centres there was a 19.3% incidence of patients with prior RT compared to 9.4% for the other provider groups. Prior RT was associated with a two‐fold increase risk of sling revision. The authors conclude that previous RT did not confer a higher risk of re‐do or removal of AUS.

As with any real‐life practice study, there are potential limitations to interpretation of the data.

  • The two surgical approaches have often been used for different levels of UI, where clearly the more severe forms of UI have tended to be considered as an indication for the AUS.
  • It is not possible to identify the severity of the preoperative UI.
  • There is no standard code for the removal of a male sling, which limits the ability to comment accurately on this. Nevertheless, as a proxy, a failed sling procedure would usually be an indication for using an AUS rather than another sling.

The most important take home message from this article is the importance of undergoing post‐prostatectomy UI surgery in a high‐volume centre. A prospective database should be established to document the indications for, as well as outcomes, following both AUS and sling surgery in real‐life clinical practice. Certainly, this is likely to become mandatory under European Commission law and it would be of importance for this to be likewise implemented in the UK in the future.

by Christopher Chapple


  1. Dosanjh ABaldwin SMytton J et al. A national study of artificial urinary sphincter and male sling implantation after radical prostatectomy in England. BJU Int 2020125467‐ 75.
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