Surgery for postprostatectomy incontinence: which procedure for which patient?

Surgery remains the most effective treatment for postprostatectomy incontinence. Over the past two decades, this surgery has evolved with respect to both operative technique and sling design, and various devices are now available that have different mechanisms of action, such as the artificial urinary sphincter, retroluminal sling or quadratic sling. The choice of device, however, should be individualized according to the circumstances of each patient. The optimal surgical treatment depends on a variety of patient-related factors, including the degree of urine leakage as assessed by incontinence pad weight test results, bladder contractility, urethral compliance, history of radiation exposure or prior incontinence surgery, and patient preference--given the choice, most patients opt for a sling procedure over an artificial sphincter to avoid implantation of a mechanical device. Athorough urodynamic evaluation is, therefore, necessary for the majority of patients. An artificial urinary sphincter, retroluminal sling or quadratic sling might be the most appropriate choice for a particular patient, depending on their specific urodynamic findings. Progress in this field continues, and several new devices are in development.