Artificial Urinary Sphincter Beats Male Slings for Dryness, but Complication Profiles Differ, Systematic Review Finds

For the thousands of men who leak urine every time they cough, lift, or jog after prostate surgery, two very different implanted devices offer a route back to dryness: the artificial urinary sphincter, a mechanical cuff that has reigned as the gold standard since the 1970s, and the male sling, a simpler mesh support with no moving parts. A new systematic review published in Frontiers in Urology has now brought together the head-to-head evidence between these two implants, and its verdict is nuanced. Across nine comparative studies involving 5,921 men, the artificial urinary sphincter generally delivered higher continence rates, while slings caused fewer urethral erosions but more urinary retention. The review, led by Cyrille Guillot-Tantay of Hôpital Foch in France on behalf of the European Association of Urology Young Academic Urologists Functional Urology Working Group, also sounds a cautionary note: the evidence base is far weaker than the numbers suggest.

Stress urinary incontinence in men is defined by the International Continence Society as the involuntary loss of urine on effort, physical exertion, sneezing, or coughing. In men it most often follows radical prostatectomy, the surgical removal of the prostate gland for cancer, where the external urethral sphincter may be directly injured, the neurovascular bundles damaged, the membranous urethra shortened, or the sphincter displaced by loss of posterior support. Reported incidence after prostatectomy ranges widely, from 5 to 48 percent, a spread the authors attribute to differences in surgical technique, definitions, and timing of assessment. Despite pelvic floor muscle training, incontinence persists in 5 to 10 percent of men a full year after surgery, and for them surgical treatment becomes the realistic option.

The two devices work on fundamentally different principles. The artificial urinary sphincter, introduced by Scott in the 1970s, is a hydraulic prosthesis: a pressurized cuff around the urethra keeps it closed until the patient squeezes a pump implanted in the scrotum to relax the cuff and void. The male sling, first described by Kaufman in the same era and refined dramatically since, is a polypropylene mesh placed beneath the proximal urethral bulb. Its mechanism is thought to compensate for the post-prostatectomy laxity of posterior supporting structures by realigning the sphincter complex toward its pre-prostatectomy configuration. Slings carry practical advantages: no mechanical parts to fail, no manipulation needed to urinate, and lower cost. But their early history was marred by high rates of urinary retention and urethral erosion, problems that successive modifications in materials, fixation, and positioning have sought to tame.

What distinguishes the new review from its predecessors is its insistence on head-to-head comparisons. Earlier systematic reviews largely pooled single-arm results from separate case series, compared devices across different cohorts, or focused narrowly on post-prostatectomy incontinence or moderate leakage. The French-Italian-British-Portuguese-Polish team instead restricted inclusion to studies in which both devices were evaluated within the same cohort, using the same outcome criteria, in adult men with non-neurogenic stress urinary incontinence of any cause. The protocol was registered in PROSPERO and reported according to the PRISMA 2020 statement, with risk of bias assessed using the CASP checklist for cohort studies and the Cochrane ROB 2 tool for the randomized trial.

The search of Medline and the Cochrane Central database, spanning January 1998 to September 2025 and updated in August 2026, screened 133 references. After deduplication, 18 papers underwent full-text analysis, and nine studies totaling 5,921 patients made the final synthesis: one randomized controlled trial and eight cohort studies, six of them multicenter, six conducted in Europe. The primary outcome was strictly defined in advance as continence meaning no pad use or at most a single safety pad per day, and terms like cure, success, and improvement were deliberately not treated as interchangeable. Secondary outcomes focused on major device-related complications requiring reoperation: infection, urethral erosion, and urinary retention leading to explantation.

The efficacy findings favor the sphincter, though with striking variability. Cure rates ranged from 14 to 94 percent for the artificial urinary sphincter against 11 to 69 percent for slings. Of the five studies reporting both devices, two achieved continence rates above 70 percent with the sphincter, and none did with a sling. The risk ratio for continence with the sphincter versus the sling exceeded one in all five comparative studies, reaching statistical significance in three retrospective cohorts, with risk ratios of 1.38, 2.09, 2.57, and 5.00, while the single randomized trial, the MASTER trial, showed a risk ratio of 1.24 that did not reach significance. Notably, the MASTER trial reported persisting incontinence in 87.0 percent of sling patients and 84.2 percent of sphincter patients at twelve months, far worse figures than the observational studies, a discrepancy the review attributes to its use of a patient-reported measure rather than a pad-based definition of dryness, and a vivid illustration of why crude cross-study comparisons are unreliable in this field.

The safety picture is more evenly divided. Eight of the nine studies reported complications. Device infection ranged from 0 to 3 percent for slings versus 1 to 7 percent for sphincters, but the direction of comparison was inconsistent across studies. Urethral erosion, however, told a clearer story: 0 to 1 percent after slings versus 1 to 25 percent after sphincters, with the risk ratio favoring slings in all six studies reporting the outcome and reaching dramatic significance in one, at a risk ratio of 63.87. Urinary retention ran the other way, at 1 to 15 percent for slings versus 0 to 13 percent for sphincters, with the risk ratio below one in four of six estimable studies, including the randomized trial at 0.29 and the largest cohort at 0.52. These patterns held across short, mid, and long-term follow-up categories, though the two studies suggesting lower infection risk with the sphincter were also the two with the shortest observation periods.

The review’s most important contribution may be its candor about the limits of these numbers. The central problem is confounding by indication: in routine practice the two devices are not offered to equivalent patients. Slings are preferentially proposed for mild to moderate, non-irradiated incontinence in the primary setting, whereas sphincters go to men with severe, irradiated, or previously operated incontinence. Indeed, in every study reporting baseline severity or prior radiotherapy, men receiving the sphincter had more severe incontinence or more frequent prior radiation. Only one of the nine studies was randomized and one was propensity-score matched; the rest were unadjusted. The authors therefore urge that the within-study differences be read as associations observed in clinically dissimilar groups, not as causal estimates of one device’s superiority over the other. Heterogeneity across studies also prevented any meta-analysis, and no multivariable adjustment was possible for confounders such as radiation, obesity, age, or redo surgery.

Where does this leave patients and surgeons? The review aligns directionally with prior syntheses by Chen, Choinière, Grigoryan, and Lin, but its head-to-head design lends the findings unusual internal consistency. The practical takeaway is that device choice remains a trade-off rather than a verdict: the sphincter offers the better odds of dryness, particularly for severe or irradiated incontinence, at the cost of a higher erosion risk, while slings suit milder leakage with a lower erosion burden but a greater chance of retention. The authors call urgently for standardized outcome reporting, noting that the FDA has endorsed the 24-hour pad weight test as a reliable endpoint even though its implementation is complex, and for a core outcome set of the kind proposed in the SATURN initiative, whose registry data showed continence improving from 49 to 76 percent at one year after sphincter implantation. With national healthcare databases increasingly available, the team argues, the field finally has the tools to move beyond heterogeneous cohorts and deliver the randomized evidence that men facing this deeply personal decision deserve.

Subject of Research: Comparative efficacy and safety of artificial urinary sphincters versus male slings for non-neurogenic male stress urinary incontinence

Article Title: ‘Efficacy and safety outcomes after slings or artificial urinary sphincter implantation for non-neurogenic male stress urinary incontinence: a systematic review’ for more clarity

Article References: Guillot-Tantay, C., de Cillis, S., Geretto, P., Vale, L., Tutolo, M., Cancrini, F., Phé, V., Osman, N. I., & Przydacz, M. (2026). ‘Efficacy and safety outcomes after slings or artificial urinary sphincter implantation for non-neurogenic male stress urinary incontinence: a systematic review’ for more clarity. Frontiers in Urology, 6, Article 1852334. https://doi.org/10.3389/fruro.2026.1852334

Image Credits: AI Generated

DOI: 10.3389/fruro.2026.1852334

Keywords: artificial urinary sphincter, male sling, stress urinary incontinence, radical prostatectomy, systematic review, urethral erosion, urinary retention, continence outcomes, prostate cancer, urology, medical devices, confounding by indication