Sling Procedures for Male Incontinence
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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.
Sling procedures to treat male urinary incontinence are indicated for bothersome mild-to-moderate urinary incontinence due to irreversible intrinsic sphincter deficiency (ISD).
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.
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.
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.
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.
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]
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Wellman W Cheung, MD, FACS Clinical Professor, Department of Urology and Department of Obstetrics and Gynecology, State University of New York Downstate Medical School
Wellman W Cheung, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Chinese American Medical Society, Endourological Society, American Urogynecologic Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction
Disclosure: Received grant/research funds from Astallas for pi.
Sophia Kawa Chiu, MD, MA, MSc Resident Physician, Department of Urology, State University of New York Downstate Medical Center
Disclosure: Nothing to disclose.
Frank Anthony Myers, Jr, MD Resident Physician, Department of Urology, State University of New York Downstate Medical Center
Frank Anthony Myers, Jr, MD is a member of the following medical societies: Student National Medical Association
Disclosure: Nothing to disclose.
Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus.
Sling Procedures for Male Incontinence
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