Surgical approaches to the removal of the prostate or prostatectomy are varied and depend on the type of disease to be treated, the characteristics of the patient, and the clinical experience of the surgeon. Surgery for symptomatic benign prostatic hyperplasia (BPH) consists of removing the glandular tissue (migratory zone) that is causing the obstruction; the prostatic envelope (peripheral zone) should remain intact. Removal of the prostate can usually be accomplished transurethrally (TURP) unless the prostate is very large. Large prostates require an incision in the abdomen for open prostatectomy. The prostate can be dealt with either through a bladder (suprapubic prostatectomy) approach or through a subpubic route in the retropubic space (retropubic prostatectomy). Regardless of the BPH procedure, patients remain at risk of developing prostate cancer after surgery, so it is important to continue annual PSA screening and rectal exams. Surgery for prostate cancer involves removing the entire prostate gland. This procedure is called a radical prostatectomy and requires an anastomosis of the bladder neck and urethra. Radical prostatectomy can be performed through either a retropubic approach or a transperineal approach, depending on the operator’s preference. Urinary incontinence is an uncommon but often devastating complication after all types of prostatectomy. An understanding of the associated anatomy and the physiology of controlled voiding in men is key to understanding its etiology and preventing and treating this complication. Normal controlled voiding function requires a stable bladder and an intact bladder neck/urethral sphincter mechanism. Urinary incontinence due to an overactive bladder is called urge incontinence; while incontinence due to a weakened bladder outlet is called stress incontinence; and urinary retention with intermittent leakage due to an overstretched bladder is called filling incontinence. Stress incontinence is very rare in men without neuropathy or surgical injury. The mechanism that controls urination in men was once arbitrarily divided into an internal and an external sphincter. The internal sphincter is not actually a sphincter, but is simply a general term for the smooth muscles of the bladder neck, prostate, and proximal urethra. These tissues are removed during all types of prostatectomy. The external sphincter is located in the distal prostate, in the membranous part of the urethra. It can be identified on endoscopy by its immediate distal aspect adjacent to the seminal caruncle. The external sphincter consists of a contractile urethral mucosal layer, urethral smooth muscle, transverse urethral muscle, and detrusor muscle. Injury to this structure during prostatectomy can lead to stress incontinence. Urinary incontinence after TURP or open prostatectomy is rare, with an incidence of 0.5%-3% reported in the literature. The seminal caruncle can be utilized as a marker during TURP to avoid resection of the distal part of the caruncle. Patients with anatomical abnormalities (because of locally advanced prostate cancer or previous radiation therapy) or neurological disorders (e.g., Parkinson’s disease, myasthenia gravis) are at a greatly increased risk for urinary incontinence. Patients with long-standing bladder neck obstruction are likely to have some degree of forced urethral instability, which may lead to urge incontinence after surgery. Incomplete resection or weak contraction of the forced urethra may lead to postoperative urinary retention and urge incontinence. Most patients requiring treatment for urinary incontinence that occurs after prostatectomy have had a radical prostatectomy. In fact, the vast majority of patients exhibit some degree of urinary incontinence during the initial period after surgery; incontinence symptoms usually resolve within a few months of surgery; therefore, invasive treatment for at least 6 months after surgery is unfounded. The incidence of persistent urinary incontinence has a large range of variability depending on the methodology of the study and the different definitions of incontinence. Modern series analyzing retrospective data generally report an incidence of incontinence of 5-10%, with severe incontinence occurring in <5% of patients. Analysis based on patient questionnaires suggests that more than 50% of patients have some degree of incontinence, with 25% of patients having severe incontinence. Surgical technique is crucial in avoiding urinary incontinence after radical prostatectomy. Preserving the length of the urethra as much as possible intraoperatively is the key to preserving the external urethral sphincter. Careful anastomosis of the vesicourethra is also important, as incontinence is often associated with anastomotic scars or strictures. Surgical approaches that preserve nerves have been shown to be associated with a lower incidence of urinary incontinence, but it is not clear whether this is because of the preservation of the neurovascular bundle or because more precise surgical maneuvers serve to promote urinary control. Urinary incontinence is often accompanied by impotence, either related to intraoperative nerve damage or because the patient's libido is diminished after surgery. Patient characteristics are important because younger patients have a lower incidence of urinary incontinence than older patients, probably because of the latter's lower tissue strength and tissue adaptability. Patients with shorter functional urethral lengths may also have a higher risk of urinary incontinence. Evaluation of all patients with post-prostatectomy incontinence should begin with a detailed history and physical examination. Important elements of the history include the etiology, extent, and duration of the leakage, the type of previous treatment received, and current voiding symptoms. If the patient has undergone radical prostatectomy, it is important to determine the current prostate cancer status (including recent PSA levels and adjuvant therapies). Abdominal examination should check for a distended bladder, and rectal palpation should note any signs of tumor recurrence. Examination of the external genitalia and perineum should be noted for signs of skin peeling due to prolonged wetness. Cystoscopy is often used to evaluate for anastomotic strictures, bladder stones, bladder tumors, or residual sutures that may be causing the patient's symptoms. If any of these findings are present, these complications should be treated and the patient should be reevaluated at a later date. Imaging urodynamics should be performed prior to undergoing any surgical treatment method. These tests should further demonstrate the degree of incontinence, rule out bladder neck obstruction, determine the presence of sphincter defects, and confirm manifestations of forced urethral instability. Rarely urinary incontinence is due to simple forced urethral muscle instability, a condition that can be treated with medications. Treatment of post-prostatectomy incontinence depends on the duration and severity of the incontinence. Initial treatment is appropriate to reassure the patient and Kegel training is appropriate. Persistent incontinence must be evaluated to exclude the presence of urge and overflow incontinence. Mild stress incontinence may (rarely) respond to treatment with а-adrenergic agonists. The majority of patients nevertheless require surgical treatment. Currently recognized surgical methods for the treatment of male stress incontinence include transurethral collagen injections and placement of an artificial urethral sphincter (AUS). Collagen injections may be effective in patients with less severe leakage, but in most patients the results are disappointing even with multiple injections. AUS placement is often recommended for patients with severe leakage or who have already undergone other treatments that have failed. Long-term control of voiding is excellent, but control of the device requires dexterity. In addition, multiple revisions are required because of mechanical failure, urethral atrophy, urethral erosion, and infection. Patients already undergoing radiation therapy to the prostate are particularly susceptible to complications. Urethral bulb suspension is another excellent treatment option. This method produces significant functional improvement and allows compression of the bulbous urethra to keep the external genitalia dry while allowing proper urination. The first reported success rate was 85% in non-radiated patients. Urinary pads, diapers, penile sleeve catheters, and penile clips can be used in patients with incontinence who do not wish to undergo surgery (Cunningham). The case reported in this article underwent radical prostatectomy 1 year ago, so it is unlikely to have improved by observation alone. The patient's PSA and rectal examination findings showed no evidence of tumor recurrence. Cystoscopy suggested no evidence of bladder neck contracture. Imaging urodynamics determined the presence of stress incontinence, with a reduced Valsalva leakage pressure of 50 cmH2O, normal bladder capacity, and no manifestation of detrusor instability. Despite the severity of the incontinence, the patient elected to undergo transurethral collagen injection therapy. After three injection treatments, there was only a temporary (1-2 weeks) improvement in the degree of leakage. The patient then underwent AUS placement and now has a level of leakage that only requires the use of 1-2 small pads per day The patient is interested in seeking treatment for the erectile dysfunction that exists in order to improve symptoms.