Stress urinary incontinence (SUI) is a common complication following radical prostatectomy, significantly impairing quality of life. The artificial urinary sphincter (AUS) is considered the historical gold standard, while male slings offer a less invasive alternative. A direct comparison of their efficacy and safety, particularly regarding prior pelvic radiotherapy, is essential for clinical decision-making.
We aimed to compare the efficacy and complication profiles of AUS and male slings for post-prostatectomy SUI, with attention to the impact of prior pelvic radiotherapy.

A systematic search of PubMed, Medline, Web of Science, and Scopus was conducted in May 2025 for studies comparing AUS and male slings. Six studies (n = 1,639 patients), including randomized controlled trials and multicenter cohorts, were included. Data on continence outcomes, patient satisfaction, reoperation rates, and complications were extracted and analyzed.

Pooled analysis demonstrated superior outcomes with AUS: dryness rates (0–1 pad/day) were 57.3% versus 22.0% for slings (Grabbert, 2019). AUS showed higher patient satisfaction (90.6% vs 72.2%, p < 0.001) and lower 12-month reoperation rates (1.8% vs 7.2%, p = 0.01) in the MASTER trial. Overall complication rates were not significantly different (RR = 1.28, 95% CI 0.94–1.75, p = 0.12). However, AUS was associated with more severe complications requiring revision (erosion, mechanical failure), while slings were linked to transient issues (pain, urinary retention). Prior pelvic radiotherapy was identified as an independent risk factor for worse outcomes, particularly with AUS.

The findings of this systematic review indicate a clear efficacy advantage of the artificial urinary sphincter (AUS) over male slings in achieving continence after radical prostatectomy. The substantially higher dryness rates and patient satisfaction associated with AUS reinforce its role as the gold standard, particularly in patients with moderate to severe stress urinary incontinence. These results are consistent with the established understanding that AUS provides more reliable outlet resistance compared to slings, which rely on residual sphincter function.

Despite similar overall complication rates, the nature of complications differs meaningfully between the two approaches. AUS is associated with more severe, device-related complications such as erosion and mechanical failure, often necessitating revision surgery, whereas male slings tend to cause less severe, transient complications. This highlights an important trade-off between efficacy and invasiveness that should be carefully considered in clinical decision-making.

The negative impact of prior pelvic radiotherapy on outcomes further underscores the importance of patient selection. Radiotherapy likely compromises tissue quality and sphincter function, reducing the effectiveness of both interventions but particularly influencing outcomes with AUS. Nonetheless, AUS appears to maintain relative superiority even in this high-risk subgroup, suggesting it remains the preferred option in irradiated patients with significant incontinence.

Overall, these results support a tailored approach to treatment: AUS for patients with severe SUI or prior radiotherapy who prioritize maximal continence, and male slings for selected patients with mild to moderate symptoms who prefer a less invasive option with a lower risk of major complications.

AUS provides superior continence outcomes, especially in men with severe incontinence or prior radiotherapy, albeit with higher risk of major complications. Male slings are effective for mild to moderate SUI with fewer severe adverse events. Treatment selection should be individualized based on incontinence severity, radiotherapy history, and patient preference.