Patient Education & Consent

Patient Instructions

If necessary in the immediate postoperative period, patients or their caregivers should be advised on how to care for indwelling catheters or to perform intermittent self-catheterization in case of postoperative urinary retention. Such retention usually resolves within weeks.^[11]Certain medications or supplements (eg, aspirin, NSAIDs) may need to be discontinued temporarily prior to surgery.

Elements of Informed Consent

Patients should be realistically counseled on the possible outcomes of the surgery, including the degree of improvement in incontinence expected given their specific situation. Future surgery (revision, AUS placement) may be necessary. In addition to complications such as bleeding, infection, pain, postoperative urinary retention, and risks associated with anesthesia, patients should be advised about possible persistent pain and osteitis for a bone-anchored procedure. AUS, the established device with more long-term data, may be discussed as an alternative.

Equipment

Slings come in commercially available kits; the operating room staff should be familiar with the components. A tall IV pole, saline, and sterile tubing are necessary if retrograde leak point pressures are to be tested. Equipment for cystoscopy should be on hand for transobturator and quadratic sling placement.

Various implant systems are available on the market, including a bone-anchored bulbourethral sling (InVance Male Sling System [AMS]), transobturator bulbourethral sling (AdVance Male Sling System [AMS]), and quadratic sling (Virtue Male Sling [Coloplast]).

Anesthesia

Sling procedures can be performed under spinal or general anesthesia.

Positioning

The patient is placed in the dorsal lithotomy position. Intravenous antibiotics are administered within 60 minutes of skin incision, as suggested by the 2008 American Urological Association Guidelines on antimicrobial prophylaxis.^[55]

Monitoring & Follow-up

Patients might have an indwelling catheter for one or more days postoperatively or may require intermittent self-catheterization. Oral antibiotics are usually administered for 5-7 days postoperatively, and NSAIDs are administered for pain control as needed.

Patients are instructed to refrain from strenuous activity (eg, lifting and bending) and sexual activity for approximately 6 weeks. Constipation should be avoided, possibly with the addition of a stool softener. Patients should avoid direct pressure on the perineal incision by sitting with body weight shifted toward the buttocks and avoiding activities that involve straddling (eg, bicycle or horseback riding).

Patients should be instructed to seek medical attention upon severe pain, fever, signs of wound or urinary tract infection, or urinary retention.

Technique

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Media Gallery

The bone-anchored InVance sling. Courtesy of American Medical Systems, Inc., ww.AmericanMedicalSystems.com.
The transobturator AdVance sling. Courtesy of American Medical Systems, Inc., ww.AmericanMedicalSystems.com.
The quadratic Virtue sling. Courtesy of Coloplast Corp.