By systematically combining data from existing literature, we aimed to qualitatively and quantitatively evaluate preoperative risk factors affecting outcomes of fixed male sling implantation (PROSPERO registration number: CRD42022307160).

A systematic search was conducted in PubMed/MEDLINE, Web of Science, Scopus and Cochrane databases, from inception up to September 2024, and in the reference lists of retrieved articles. Studies with at least 30 patients, six six-month follow-up and evaluating the association between at least one factor and continence outcomes (cure and/or overall success) were included. We performed separate meta-analyses for adjusted and unadjusted odds ratios using a random-effects model with Hartung-Knapp adjustment. Study quality was evaluated using the QUIPS tool, certainty in evidence was assessed using the GRADE framework, and the review was reported following PRISMA recommendations. The protocol has been previously published.

Sixty-two cohorts from 65 papers, involving 5696 patients, were included. Studies, mostly single-center (57%) and retrospective (74%), investigated 78 risk factors, generating 509 effect sizes and 70 meta-analyses. We found eight moderate-to-high certainty risk factors, with high certainty for pelvic irradiation, 24-hour pad use and 24-hour urine loss, and moderate certainty for urethral stricture, previous incontinence therapy, detrusor overactivity, higher male stress incontinence grading scale, and unfavorable repositioning test. Age and time from prostatectomy did not appear to affect sling outcomes (moderate certainty). Low/very low certainty was found for several other variables. Heterogeneity and suboptimal study quality are the main limitations.

Based on existing literature, there is sufficient evidence to consider some patient characteristics as useful predictors of fixed male slings outcome. These variables should be used to better inform treatment decision-making, patient counselling and guideline
recommendations. However, based on observed effect sizes, no factor should be considered in isolation as an absolute contraindication to sling, but the final choice of PPI treatment should be performed according to a more holistic evaluation including all concomitant risk factors, together with patient comorbidities and preferences.

Within the limits of existing literature, we found several preoperative risk factors for fixed slings failure. This information will assist healthcare professionals in patient selection and counselling.

Sacco E, Marino F, Gavi F, et al. Protocol for a systematic review and metaanalysis on preoperative risk factors for failure after fixed sling implantation for postprostatectomy stress urinary incontinence. F1000Research. 2023;12:19