Sling Procedures for Male Incontinence Technique

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

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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.

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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]

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