Sling Procedures for Male Incontinence 

Updated: Oct 17, 2016
Author: Wellman W Cheung, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS 

Overview

Background

The male urethral sling is an important treatment for addressing male incontinence from multiple causes and unlike the artificial urinary sphincter, the sling requires no manual dexterity, no significant mechanical parts, and no patient training.[1] Currently, Coloplast’s Virtue sling (utilizes four arm approach versus two)[2] and Boston Scientific’s AdVance Male Sling System[3] are two available options for male urethral slings. The InVance bone anchored sling (a product of former company American Medical Systems) has fallen out of favor due to risk of osteomyelitis.[4] The Argus slings from the international company Promedon have also been used in the past.[5] Data presented reflects all three slings as described above.

Indications

Sling procedures to treat male urinary incontinence are indicated for bothersome mild-to-moderate urinary incontinence due to irreversible intrinsic sphincter deficiency (ISD).

Contraindications

Absolute contraindications to sling procedures for male incontinence include the following:

  • Severe incontinence that is not likely to be resolved with a sling procedure (A prospective study of 62 postprostatectomy patients with incontinence found that men with less than 423 g of daily leakage on a pad weight test prior to bone-anchored perineal sling placement were 6 times more likely to have a patient-defined successful outcome than those with higher pad weights.[6] Other authors advocate using a cutoff of 150 g on a 24-hour pad weight test.[7]

  • Bladder disorders that can jeopardize renal function, such as decreased bladder compliance and vesicoureteral reflux at low intravesicular pressures

  • Inadequate tissue integrity at the bladder neck or urethra (Patients may require bladder neck closure or urinary diversion.)

  • Active urinary tract infection

Relative contraindications to sling procedures for male incontinence include the following:

  • Prior history of radiation therapy or urethral erosion (Such patients are likely to have high-volume urine loss. Some authors have had disappointing results in this patient population.[7] Prior radiotherapy was associated with 85% failure in one study.[8]

  • Further need for transurethral procedures, such as in patients with bladder cancer or refractory vesicourethral strictures, since transurethral access might be impaired and repeated instrumentation can increase the risk of infection or erosion

  • Previous AUS placement (However, slings do not preclude future placement of an AUS.[9]

In patients with metastatic prostate cancer, the potential benefits in quality of life in the context of performance status, life expectancy, and surgical risk should be carefully considered.

Technical Considerations

The initial evaluation of a man with urinary incontinence requires a detailed history, physical examination, urinalysis, and urine culture. Candidates for sling procedures usually require more workup as part of surgical planning.

The medical history should include questions on the type, degree, and severity of urinary incontinence. The past surgical history should be elicited. The presence or absence of incontinence and/or associated voiding symptoms before surgery and the onset of leakage after surgery should be documented.

Since continence often improves after radical prostatectomy, some authors recommend a one-year observation period,[7, 10] but, if a patient has severe or gravitational urinary incontinence with no improvement after 6 months, it is unnecessary to delay intervention, especially if cystoscopy shows a significant external sphincter defect.[11]

A voiding diary and pad test can help differentiate between stress and urge incontinence and document the degree of incontinence. Self-reported daily pad usage is only moderately correlated with the volume of urinary incontinence[12] ; a 24-hour pad weight test is an objective measure that may be helpful in directing appropriate therapy.

The physical examination should include a detailed examination of the abdomen, back, genitalia, perineum, rectum, and nervous system. The skin should be inspected for signs of breakdown or infection that need to be treated prior to surgery. Rectal sphincter tone and contraction should be assessed.

Laboratory examinations include urinalysis and culture. Serum creatinine and prostate-specific antigen levels should be evaluated to assess renal function and cancer status after prostatectomy.

Procedure Planning

Cystoscopy is recommended in the evaluation of candidates for surgical correction of urinary incontinence since unrecognized urethral pathology can complicate all surgical approaches. During cystoscopy, the degree of residual external sphincter function can be estimated.

Assessment of bladder capacity, compliance, and contractility is required when considering a sling procedure. Although a careful history and voiding diary can confirm the adequacy of bladder function, pressure-flow urodynamics can accurately assess bladder function, the type of incontinence, and severity. Usually, ISD would be identified in most cases.

If detrusor overactivity is found, patients should be carefully counseled about realistic expectations for a successful outcome. Reduced bladder compliance is also a concern because prolonged storage at high pressures might contribute to upper tract deterioration. Detrusor hypocontractility might indicate the need for an AUS if the detrusor function is insufficient to allow voiding against the fixed resistance of a compressive sling.

Complication Prevention

Prophylactic antibiotics are given to prevent infection. Surgical approaches that avoid bone anchors would prevent bone-related complications such as osteitis and anchoring complications. Meticulous surgical technique, especially during sling tensioning, is important for the proper functioning of the sling.

Outcomes

In appropriately selected patients, the male urethral sling has been shown to be effective.[13, 14, 15] For example, some authors have demonstrated that preoperative severity of incontinence, low midurethral closure pressure, low abdominal leak point pressure, decreased urethral functional length, presence of detrusor overactivity, low Qmax on uroflow assessment, reduced bladder capacity and urethral disease may all be characteristics of patients who are poor sling candidates and those likely to fail.[16, 17, 18, 19, 20, 21] Grimbsy et al[22] retrospectively reviewed 31 patients at a single institution over a ten year period who underwent a transobturator sling procedure and concluded that obesity was directly associated with sling failure. Interestingly, whether or not a surgical learning curve impacts outcomes, particularly for the AdVance sling, is controversial.[23, 24] Nonetheless, sling procedures still appear to be relatively effective.

Contemporary data continues to demonstrate the effectiveness of the male sling.[4, 5, 17, 18, 20, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51] Welk et al performed a contemporary review of male sling procedures for post prostatectomy incontinence.[30] Multiple sling designs were incorporated and variable definitions of success and follow up periods were noted in each study. Success rates were from 40-91% depending on the study.[30] In a 2012 review by Trost et al, the authors found success rates to be from 9-100%.[33] In addition to objective measures of success, subjective metrics such as quality of life improvements have also been noted.[5, 28, 41]

Pain, infection, problems with anchoring, paresthesias, and a number of other complications have been noted to occur following male urethral sling placement.[5, 8, 11, 26, 30, 52, 53, 54] In the review by Welk et al, infection rates were from 2-12% and usually required sling explantation while erosion rates were 3-13%.[30] Urinary retention is uncommon and even when it occurs, patients tend to recover and go on to stay dry in the long term.[45] It has been noted in the literature that the dorsal nerve of the penis can potentially be injured (although rare) and should be taken into consideration with placement.[54]

 

Periprocedural Care

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]).

Patient Preparation

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

Bone-Anchored Bulbourethral Sling

The bone-anchored bulbourethral sling works by providing broad-based compression of the urethra, imparting outlet resistance through a sling that is stably fixed to the urethra. Advantages of this approach include a single perineal incision, stable fixation to the bony pelvis, and virtually no risk of injury to the bladder.[9] One popular model is the InVance implant (American Medical Systems [AMS], Minnetonka, MN).

The bone-anchored InVance sling. Courtesy of Ameri The bone-anchored InVance sling. Courtesy of American Medical Systems, Inc., ww.AmericanMedicalSystems.com.

After the patient is prepared and draped in the lithotomy position, a urethral catheter is placed to drain the bladder and facilitate identification and dissection of the urethra. While preserving the bulbospongiosus muscle, lateral dissection is carried out toward the medial aspect of the descending pubic ramus. A fine needle can be used to help localize the bone.

Two or three titanium bone screws preloaded with a pair of 1-0 polypropylene sutures are inserted into the bone on each side under direct visualization with a bone drill. The most proximal pair of screws is placed just beneath the junction of the pubic symphysis and the descending ramus. Subsequent screws are approximately 1 cm part, with the most distal screws approximately at the level of the bulbar urethra.

After placement of the bone screws, the sutures are cut, and a 4x7 cm sling graft composed of synthetic or biologic material, trimmed into a trapezoidal shape, is first secured to one side. Sutures are passed through the sling graft with the aid of an 18-gauge needle approximately 0.5 cm from the edge and equally spaced along its width. The sutures are then tied town firmly to the bone on one side.

Using a right-angle clamp, the sling is pulled across the bulbospongiosus muscle to approximate its final location.

The next step, appropriate tensioning of the sling, is the most critical part of the procedure. It can be done with a cough test if the patient is awake or with a retrograde leak point pressure (RLPP) test. The urinary catheter is pulled back into the distal penile urethra and the balloon is re-inflated. The catheter is connected to a bag of saline with saline tubing. The bag of saline is elevated until fluid flows through the bag, the drip chamber, and into the urethra. The RLPP is the height of the fluid column above the pubic symphysis at which fluid flow begins; 60 cm H2 0 was initially chosen based on AUS data, but subsequent studies have shown that patients achieving RLPP of 60 cm have better outcomes than those with lower compression pressures.[56]

The sling can be repositioned as necessary. The contralateral sutures are passed through the corresponding side of the sling and secured with a single throw of the suture over a silk safety tie.

The RLPP test is repeated to ensure proper tensioning, with adjustments to sling tension by moving the sutures more medially (tighter) or laterally (looser) until RLPP of 60 cm is achieved. The sutures are tied down completely, starting with the most anterior screw, and trimmed. Any excess sling graft is trimmed. The wound is irrigated copiously with antibiotic solution before closure in multiple layers.

The catheter may be removed in the recovery room or the following day after a trial of void.

Transobturator Bulbourethral Sling

Unlike the bone-anchored bulbourethral sling, the transobturator bulbourethral sling (AdVance, AMS) improves incontinence by repositioning a functional sphincter back into the pelvis. As Rehder and Gozzi demonstrated with their pilot study involving cadavers and patients, the membranous urethra is shifted posteriorly and cranially and lengthened.[57]

The transobturator AdVance sling. Courtesy of Amer The transobturator AdVance sling. Courtesy of American Medical Systems, Inc., ww.AmericanMedicalSystems.com.

After the patient is prepared and draped in the lithotomy position with legs approximately shoulder-width apart and flexed at 90°, a urethral catheter is placed to drain the bladder and facilitate identification of the urethra. A midline perineal incision is made and dissected to the bulbospongiosus muscle, which is split centrally to expose the corpus spongiosum. The corpus spongiosum is mobilized distally, laterally, and inferiorly to level of the perineal body (central tendon), which is marked to facilitate sling positioning later.

Using the inferior margin of the adductor longus muscle as a landmark, a small stab wound is made approximately one fingerbreadth below and lateral to the ischiopubic ramus. A helical passing device is held at a 45° angle to the perineal incision and passed through the stab wound while a finger is placed below the ischiopubic ramus to protect the urethra and guide needle placement through the obturator foramen. The needle tip of the passing device is brought out as superior as possible in the triangle between the ischiopubic ramus and the corpus spongiosum. The sling mesh is secured to the needle, which is then rotated back through the incision to bring the mesh out to the thigh without tension. This is repeated on the contralateral side.

The sling mesh is then loosely positioned in the perineum with the proximal aspect of the mesh fixed at the level of the previously marked area. Two sutures each are placed proximally and distally to secure the sling mesh to the corpus spongiosum.

The sling is then tensioned by pulling on both arms of the sling, which should move the perineal body and proximal bulbar urethra 3-4 cm proximally and cephalad. This is repeated under cystoscopic visualization of the external sphincter to confirm reposition of the urethra and coaptation of the sphincter. The tail ends of the sling are either trimmed at the skin or tunneled subcutaneously toward the midline to reduce the chance of sling migration. The perineal incision is closed in layers, including the bulbospongiosus muscle, Colles fascia, and skin.

A catheter is usually left in place for one day before a trial of void.

Quadratic Sling

Recently, a hybrid Virtue sling has been introduced (Coloplast, Minneapolis, MN). This quadratic sling, which is designed to provide a greater length of ventral urethral compression, as well as proximal urethral relocation, since both are posited to be important for restoring continence, consists of large-pore knitted monofilament polypropylene mesh with 2 preattached inferior (transobturator) extensions and 2 superior (prepubic) extensions.

The quadratic Virtue sling. Courtesy of Coloplast The quadratic Virtue sling. Courtesy of Coloplast Corp.

After the patient is prepared and draped, a 14F catheter is placed to drain the bladder and facilitate identification of the urethra. A ventral perineal incision is made, and the ventral bulbous urethra and pubic rami are exposed, while leaving the bulbospongiosus muscle intact. The urethra is dissected from the perineal body to proximal urethral repositioning upon sling tensioning.

The transobturator arms of the sling are placed through an inside to outside fashion. The transobturator arm is attached to a curved introducer and passed in a medial to lateral fashion from the perineal incision through the obturator foramen. The introducer exits the skin approximately 2 cm inferior to the adductus longus tendon; a stab wound can be made to facilitate the passage of the introducer. The transobturator arm of the sling is pulled through the tissue.

The prepubic arms of the sling are then implanted. A stab incision is made 2 cm above the pubic symphysis and 3 cm lateral to the midline on either side. The curved introducer is passed from the pubic incision, anterior to the pubic bone, and out through the perineal incision lateral to the urethra on each side. The superior sling arm is then attached to the introducer and pulled up through the incision on each side.

RPPL can be measured during sling tensioning, with a goal of 60-70 cm. The transobturator arms are tensioned by simultaneously pulling both arms laterally so that the bulbar urethra moves approximately 3 cm proximally, and the prepubic arms are tensioned by providing upward tension to compress the urethra against the genitourinary diaphragm. Cystoscopy should be performed during tensioning to confirm coaptation of the external sphincter.

Next, the sling is fixed in place. Through the perineal incision, a long clamp is passed to the ipsilateral groin incision, and the mesh is grasped and pulled toward the midline and secured. The prepubic arms can be sutured in place with 1-0 polypropylene suture to the periosteum 1 cm lateral to the urethra at the inferior aspect of the symphysis pubis. Alternatively, a clamp can be inserted into one prepubic incision and tunneled toward the contralateral incision to grasp the mesh and pull it on the other side before being trimmed at the skin. The incisions are closed in layers, and a urinary catheter is left in place until the next day.[58, 59]