Stress urinary incontinence in men significantly affects the quality of life [1], and the artificial urinary sphincter (AUS) is the standard treatment for moderate to severe cases [2]. Surgical implantation of the AUS is most commonly performed using either the perineal or the penoscrotal (transscrotal) approach [3]. These two techniques differ in anatomical access and surgical exposure, leading to ongoing debate regarding their advantages and limitations. This study aimed to compare the clinical outcomes of perineal and penoscrotal approaches for artificial urinary sphincter implantation in men with stress urinary incontinence. We hypothesized that the two approaches differ in perioperative metrics and functional outcomes, which may influence surgical approach selection.

A systematic review and meta-analysis were conducted following a comprehensive literature search in PubMed, Scopus, Web of Science, and the Cochrane Library. Studies comparing the perineal and penoscrotal approaches for artificial urinary sphincter implantation and reporting outcomes such as cuff size, operative time, dry pad rates, social continence, complications, AUS removal, or revision rates were included.

Four observational studies with a total of 481 patients met the inclusion criteria. The perineal approach was associated with significantly larger cuff sizes (OR = 0.24 [0.1-0.54], P = 0.0006) and higher rates of dry pads (OR = 1.7 [1.08-2.65], P = 0.02) . In contrast, the penoscrotal approach was correlated with shorter operative times (MD = 28.73 [10.15-47.3], P = 0.02) and lower rates of AUS removal (OR = 2.98 [1.53-5.8], P = 0.001), while complications and social continence outcomes did not differ significantly between the two techniques.

The perineal approach may allow for more proximal cuff placement, resulting in larger cuff sizes and improved continence outcomes. Meanwhile, the penoscrotal technique provides advantages in operative efficiency and device retention, potentially due to its technical simplicity and reduced surgical dissection. The lack of significant differences in complication and social continence rates suggests that both techniques are generally safe and effective, with slight differences that may be clinically relevant.

Both perineal and penoscrotal approaches are effective options for AUS implantation. The perineal approach offers advantages in continence-related outcomes, while the penoscrotal approach benefits operative time and device preservation. The choice of surgical approach should be individualized based on patient anatomy, clinical priorities, and surgeon experience.

Lagro-Janssen TALM, Hilkens CJM, Klaasen RI, Teunissen D. Greater emotional and social effect of urinary incontinence in men than women. J Am Geriatr Soc. 2008 Sep;56(9):1779–81.
Tutolo, Manuela et al. (2018). Efficacy and safety of artificial urinary sphincter (AUS): Results of a large multi-institutional cohort of patients with mid-term follow-up. Neurourology and Urodynamics, 38(2), 710-718https://doi.org/10.1002/nau.23901
Henry, G. D., Graham, S. M., Cornell, R. J., Cleves, M. A., Simmons, C. J., Vakalopoulos, I., & Flynn, B. (2009). A multicenter study on the perineal versus penoscrotal approach for implantation of an artificial urinary sphincter: cuff size and control of male stress urinary incontinence. The Journal of urology, 182(5), 2404–2409. https://doi.org/10.1016/j.juro.2009.07.068