Slings for Male Incontinence

Anatomy and Physiology

Maintaining male urinary continence is complex, relying on voluntary and involuntary interactions between various lower urinary tract muscular and connective tissue components.[8] This intricate anatomical unit is collectively called the urethral sphincter complex, comprising the internal (IUS) and external (EUS) urethral sphincters.[8][9]

The IUS is positioned at the level of the bladder neck and comprises smooth muscle fibers that are continuous with the inner longitudinal layer of the detrusor muscle and encircle the proximal urethra and bladder neck.[8][10][11][12] Tonic activation of the internal sphincter via sympathetic innervation during bladder filling ensures passive urethral closure, serving as the initial point of urinary control before the external sphincter.[13][14] Sympathetic innervation originates from the inferior hypogastric plexus with nerve roots T10-L2.[15]

The EUS comprises incomplete circular striated muscle fibers enveloping the membranous urethra as it traverses the pelvic floor within the deep perineal pouch; the bulbar urethra is anterior, and the anorectal ring is posterior.[8][9][10][11][12][16] The EUS is anchored within the bony pelvis to the bilateral pubic rami, suspended anteriorly to the pubic symphysis by the puboprostatic ligaments, and posteriorly to the perineal membrane.[9][12][17]

The EUS ensures continence during activities that cause sudden elevations in intraabdominal pressure via rapid contraction.[8] The pudendal nerve and pelvic nerve plexus dually innervate the EUS.[18][19] Contraction of the levator ani elevates and compresses the proximal urethra against the pubic bone, creating a muscular sling around the external urethral sphincter, further constricting the urethral lumen.[9][12][16][18]

These two urinary sphincters are integrated functional units extending from the bladder neck to the urogenital diaphragm.[11] The EUS compresses the membranous urethra to prevent urine flow, and the IUS contracts the bladder neck.[9] During micturition, parasympathetic stimulation induces relaxation of the IUS and detrusor contraction, facilitating urine passage coordinated with the simultaneous opening of the EUS.[9][19][20]

Pathophysiology of Male Stress Urinary Incontinence

Disruption of the sphincter complex is frequently observed after prostate surgery and can lead to urinary incontinence.[21] Post-prostatectomy SUI is often ascribed to external sphincter or pudendal nerve injury; damage to any part of the urethral sphincter complex can contribute to SUI.[1][21] Careful dissection during radical prostatectomy is critical for preserving the continence mechanism, particularly the striated portion of the EUS, as division of the bladder neck affects the passive continence mechanism produced by the IUS.[22]

Radical prostatectomy additionally weakens the structural support to the urethra due to damage to the endopelvic fascia and puboprostatic ligaments.[23] Studies have indicated that patients exhibit decreased urethral closure pressures and shortened functional urethral lengths after prostate surgery compared to continent controls due to compromises of the outlet resistance provided by the EUS and pelvic floor muscles.[21]

Male SUI may also occur secondary to urethral sphincter dysfunction due to neurologic disease, congenital abnormalities, direct traumatic injury, or postoperative bladder neck dysfunction.[1] In these patients, one or more of the following mechanisms contribute to SUI: disruption of the proximal bladder neck sphincter complex, denervation of the EUS impairing normal function, or inadequate urethral resistance and closure due to a dysfunctional urethral sphincter complex.[1][10]

Indications

Decisions regarding the optimum treatment of male SUI are guided by a comprehensive evaluation comprising a complete medical history, thorough physical examination, urinalysis, documentation of the postvoid residual, pad testing, urodynamics, and cystoscopy.[24] 

Male Urethral Slings

A male urethral sling is typically recommended for men with mild-to-moderate urine leakage, characterized as 0 to 2 pads per day or a total pad weight of less than 500 grams in 24 hours. Some experts have suggested a 24-hour urine pad weight of 150 grams or less as a cutoff indication for urethral sling placement.[25] A male urethral sling may also be appropriate for patients who have not responded adequately to conservative management.[5][26][27][28] Patients with severe incontinence are unlikely to achieve optimum results with male sling placement; an artificial sphincter may be a better option.

A male sling may also be indicated for men with post-prostatectomy SUI who exhibit some degree of residual voluntary sphincter function but have not responded sufficiently to conservative therapies; a history of pelvic radiotherapy is not an absolute contraindication to MS placement.[5][24][29] The residual sphincteric function can be evaluated endoscopically during awake cystoscopy or through urodynamic studies.[5] These patients must generate sufficient bladder pressure to surmount the urethral resistance the sling produces.[5]

Patients with isolated nocturnal urinary incontinence may benefit from a nighttime male external vacuum catheter. These catheters are appropriate for overnight use only and must be connected to a suction device.

Dual-Balloon Adjustable Continence Device Therapy 

Dual-balloon adjustable continence device therapy (DBACT) employs percutaneously implanted bilateral periurethral silicon balloons to provide passive sphincter complex compression and control leakage.[30][31] The degree of compression can be adjusted by changing the balloon volume in the clinic or office via an accessible titanium scrotal port.[31] Placement, adjustment, and removal of the DBACT device can be accomplished in an office-based setting under local anesthesia. DBACT is indicated for men with moderate-to-severe SUI of at least 12 months duration due to intrinsic urethral deficiency after prostate surgery; severe SUI or a history of pelvic radiotherapy are relative contraindications to DBACT placement.[32][33]

Artificial Urinary Sphincter

An artificial urinary sphincter (AUS) is more appropriate for patients with significant, severe, and bothersome incontinence or a history of pelvic radiotherapy who have failed to respond sufficiently to less invasive treatments.[4][34][35][36][37] The main contraindication to AUS placement is an inability to operate the device due to limited manual dexterity or an inability to understand device operation.[26][38] AUS placement is the most invasive procedure for male SUI but may be the optimum intervention for complicated and severe incontinence. Detrusor instability, active urinary tract infection, bladder outlet obstruction, small bladder capacity, recurrent urethral strictures, and high post-void residual urine volumes are relative contraindications to AUS placement.[35][37]

Procedure Selection

Selecting the most appropriate male incontinence procedure requires consideration of the nature and severity of the incontinence, any history of radiotherapy, prior surgical procedures, comorbidities, reasonable patient expectations, and the functional status of the sphincter complex.[34][39] Patients with partial sphincteric function may be better candidates for a nonadjustable sling.[24][29] Patients without a history of pelvic radiotherapy with complete sphincteric loss who are not candidates for an AUS can be reasonably considered for DBACT or male sling placement.[40][41][42] Patients with a history of pelvic radiotherapy radiation history may benefit from an adjustable male sling.[43][44]

The overarching principle for device selection is multifactorial and must consider the experience of the surgeon, patient comorbidities, functional status, living situation, and the goal of the intervention. Patients may desire either the reduction of symptoms or the best chance of complete resolution.[4][5][34]

Contraindications

Absolute contraindications to sling procedures for male SUI include:

• The presence of bladder pathology with the possibility of renal compromise, such as a loss of compliance or vesicoureteral reflux at low intravesical pressures.
• Compromised bladder neck or urethral tissue integrity, particularly that requiring bladder neck closure or urinary diversion.
• Unresolved urinary outlet obstruction, such as an intractable, recurrent, or untreated urethral stricture.
• Untreated urinary tract infection.

Relative contraindications to sling procedures for male SUI include:

• History of prior pelvic radiation therapy or urethral erosions.[45]
• Patients with an increased likelihood of future transurethral procedures, including surveillance cystoscopy for urothelial carcinoma.
• Severe stress incontinence that an isolated sling procedure is unlikely to resolve completely.
• History of AUS placement: an AUS may be placed after a sling procedure.[46]
• Shortened life expectancy secondary to significant comorbidities such as metastatic malignancy.

Equipment

The equipment required to perform a male sling procedure for male SUI typically includes:

• Minor surgical tray
• Adson forceps
• Adson-Beckman and Richardson retractors
• Richardson retractors
• Metzenbaum, Mayo, and suture scissors
• Needle driver
• Surgical field antibiotic/antiseptic irrigation
• 3-0 and 4-0 braided and 4-0 monofilament absorbable sutures
• Skin tissue adhesive
• Electrocautery
• Perineal self-retractor
• 16F indwelling catheter
• Male urethral sling device

Personnel

The personnel required to perform an MS procedure for male SUI typically includes:

• Primary surgeon
• Surgical first assistant
• Anesthesia personnel
• Surgical technician or operating room nurse
• Circulating or operating room nurse
• Male urethral sling device company representative who can offer technical device guidance and troubleshooting

Preparation

Cystoscopy is a required component of the preoperative evaluation for all patients considering male sling placement. Additionally, a standing cough stress test or urodynamic evaluation is recommended.[39] The force of detrusor contraction must be high enough to overcome the intended partial outflow obstruction from the male sling and facilitate complete bladder emptying.[5] Preoperative urinalysis is essential to document the absence of urinary tract infection.[47] 

Technique or Treatment

Male urethral sling procedures are performed in the dorsal lithotomy position with appropriate cushioning for pressure points.[48] Prophylactic antibiotics should be administered intravenously before the incision. Hair should be removed from the thighs and perineum with clippers before chlorhexidine, and betadine skin antisepsis is performed.[49] The surgical field should be draped in a sterile fashion to exclude the perianal area.[50] Place a 16F indwelling catheter to reduce the risk of intraoperative bladder perforation.[48]

A male sling may be placed via a transobtuator or retropubic approach; some devices require a combined approach.[5]

Transobturator Male Urethral Sling Technique

Create a 5-cm vertical midline perineal incision precisely centered over the mid-bulbar urethra. Sharply dissect the bulbospongiosus muscle to expose the ventral urethra. Divide the perineal body or central perineal tendon and mark its distal-most aspect; this is the most proximal location for sling placement.[48]

To determine the size of the internal trocar exit, use a finger to delineate the triangular area formed by the lateral aspect of the urethra, inferior pubic rami, and medial aspect of the corporeal bodies.[51] The site of external trocar insertion should be situated 1.5 to 2 cm inferior to the insertion point of the adductor longus tendon. Once this point is identified, make a vertical stab incision with the scalpel.[48]

Delineate the trocar tract through the obturator foramen by introducing a spinal needle into the groin incision angled toward the coccyx; manipulate the spinal needle through the obturator foramen. Insert the trocar with its handle parallel to the perineal incision directed toward the previously defined tract. Apply steady pressure until 2 distinct "pops" are heard or felt; this signifies the passage of the trocar through the endopelvic fascia.[48][51]

Laterally adjust the trocar handle position by 45° degrees while maintaining its trajectory to ensure the proper alignment.[48] Place a finger at the trocar exit site to facilitate trocar guidance and medially displace the urethra out of the trocar's path.[51] Rotate the trocar handle to direct the trocar through the exit site and bring its tip into view. Secure the lateral sling loop to the trocar and bring the sling through the tract by reversing the path of the trocar. Repeat these steps on the contralateral side.[48]

Anchor the body of the sling to the ventral urethra using a 4-0 braided absorbable suture, ensuring the proximal aspect of the sling is positioned distal to the insertion of the central perineal tendon.[48] Draw both sling arms through the groin incisions to elevate the urethra and determine the appropriate sling tension.[5][48][51] Divide the sling and its overlying plastic sheath and cut the sling flush with the skin at the groin incision.[48][51] Reapproximate the bulbospongiosus muscle to cover the urethra and the body of the sling using 4-0 braided absorbable sutures. See Image. Transobturator Male Sling Insertion.

Close the perineal incision with a running stitch using 3-0 braided absorbable sutures. Close all skin incisions with 4-0 monofilament sutures and apply skin tissue adhesive.[48]

Retropubic Male Urethral Sling Technique

The retropubic approach for male sling insertion employs a perineal and an abdominal incision.[5] The perineal incision resembles that used in the transobturator approach but preserves the bulbospongiosus muscle and the central perineal tendon, which remain intact.[5][50]

Create a transverse suprapubic abdominal incision to access the rectus fascia. Bilaterally, place trocars in a retropubic position to pierce the fascia and exit in the same fashion as the transobturator approach.[27] Thread the sling device via the tracts created by the trocars, providing tension to the body of the sling positioned overlying the ventral urethra.

Perform a cystoscopy before passing the sling to document the absence of any bladder or urethral perforations.[27] Anchor the sling according to the device-specific manufacturer instructions and close the incisions described above.

Variations in Technique

The techniques employed during male sling placement are frequently device-specific. Some transobturator sling devices allow for or require inside-to-outside sling insertion, and some require that the central perineal tendon remains intact. Other devices have 2 sling arms on each side, allowing for transobturator and retropubic, or sometimes prepubic, fixation.[27]

Postoperative Care

Patients undergoing male sling placement for male SUI may be discharged on the day of surgery or kept overnight for observation.[51] A voiding trial can be commenced on the first postoperative day. Patients who fail a voiding trial can be treated with indwelling catheter placement and undergo a repeat voiding trial in 7 days after further recovery and a reduction in postoperative edema.[48]

If patients fail the second voiding trial, trials may be performed weekly, or intermittent self-catheterization can be initiated by patients able to comply. Repeat voiding trials or self-catheterization should continue until spontaneous urethral voiding results in bladder emptying.[48] Urinary retention lasting more than 3 months should prompt consideration of sling lysis.[48]

Patients undergoing male sling placement require postoperative analgesia, stool softeners, and 5 days of antibiotic coverage.[48][51] To minimize the risk of sling loosening, patients must avoid lifting objects in excess of 10 pounds and strenuous activity for 6 weeks.[48] Strenuous activity includes but is not limited to squatting, bending, climbing, extreme leg spreads, biking, jogging, and sexual activity. Immersive bathing and swimming should be avoided for 2 weeks following the procedure.

Complications

The most common postoperative complications of male sling placement for male SUI include transient perineal pain, urinary retention, de novo urgency, and infection.[4][52] Up to 45% of patients report some degree of postoperative pelvic pain, although this is typically mild and self-limited.[53] Urinary retention rates range from 3% to 46%, depending on the type of sling used.[4][29] The risk of infection is low and estimated at 1% to 3%.[4]

Compared to the artificial urinary sphincter, male slings have a much lower reoperation rate of approximately 1%.[4][54] Device erosion occurs in less than 1% of cases and is primarily observed when slings are placed after pelvic radiotherapy.[4][52] Patients with a history of pelvic radiotherapy are at increased risk for postoperative infections, incomplete resolution of symptoms, and an ultimate need for device explant.[55]

Device slippage occurs in less than 1% of patients and is usually secondary to sling disruption due to activities resulting in increased intraabdominal pressure.[48] Device slippage or failure may be treated with readjustment of adjustable slings or may require salvage AUS, DBACT, or repeated sling placement.[48]

Intraoperative complications during MS placement are very rare and are typically characterized by bleeding from an obturator vessel, urethral injury, or bladder perforation from the trocar insertion. Bleeding from trocar sites during male sling placement is reported to be minimal and self-limited in most cases. One study of 115 patients undergoing MS placement of the same device reported intraoperative bleeding requiring transfusion in 0.9% of patients.[56]

The rate of urethral injury from trocar passage is very low; reported rates are between 0% and 1.8%.[29][56][57] This risk is minimized by employing best intraoperative practices, including bladder emptying before trocar passage. Bladder perforation or injury during trocar passage is similarly uncommon; studies of transobturator and retropubic approaches report rates between 0% and 1.6%.[29][57][58]

Clinical Significance

The overall success rates for male slings range from 36% to 90%; success is typically defined as requiring 0 to 1 pad per day or a reduction of more than 50% in leakage, although definitions can vary across studies.[52] Success is also contingent on the preoperative severity of the SUI, with success rates of 80% to 90% observed for mild incontinence, 32% to 83% for moderate incontinence, and rates up to 70% for severe incontinence.[40][52][54][59][60] Overall, male sling procedures result in either a cure or substantial improvement in SUI in approximately 75% of properly selected patients. 

Patient satisfaction often exceeds objective success rates, with patients reporting improved quality of life despite residual leakage.[54] However, the durability of male slings diminishes over time, with efficacy declining after five years, which may necessitate revision, replacement, the insertion of a DBACT device, or the placement of an AUS.

Factors such as the severity of stress urinary incontinence, prior radiation therapy, and previous surgeries are associated with sling failure.[52] No substantial data currently suggests the superiority of adjustable slings over nonadjustable slings.[5] Patients must be counseled preoperatively regarding the outcomes of male sling placement, including decreasing efficacy and the possibility of not achieving complete continence.[5]

AUS is considered the gold standard for managing male SUI due to its superior efficacy and adaptability through an active, adjustable mechanism that allows cuff closure pressure to be tailored; AUS placement is associated with higher complication rates and increased complexity.[1] Long-term studies have indicated that up to 50% of patients achieve complete continence for up to 5 years following AUS placement, and an AUS is the recommended choice for patients with severe incontinence.[26][61][62] Placement of an AUS appears to offer a superior outcome compared to male sling placement in patients with a history of radiotherapy, although outcomes may depend on the specific male sling device.[63][64] However, operating an AUS requires manual dexterity from patients, and they carry a higher risk of erosions and infection. Additionally, patients with an AUS have a 20% to 30% rate of device revision or explantation.[1][61][65]

Shared decision-making should involve a comprehensive discussion regarding the benefits, risks, and outcomes of each device available to treat SUI, and the selection of a device should be tailored to the specific clinical situation and patient preferences.[1][5][65] However, current guidelines generally recommend slings as the first-line surgical treatment for mild-to-moderate male SUI, with treatment decisions guided by patient-specific factors.[26][34]

Enhancing Healthcare Team Outcomes

Providing effective counseling and education for patients considering male sling surgery necessitates an interprofessional team approach. Urologists and advanced practice providers must accurately convey the benefits, risks, limitations, and alternatives of the procedure during informed consent discussions with the patient and his family. This process facilitates shared decision-making and helps set appropriate expectations regarding postoperative urinary control.

Nurses play a pivotal role in preoperative education, guiding patients through the details of the procedure, recovery expectations, and postdischarge care. Their regular interactions with patients also allow for the reinforcement of critical information. Pharmacists ensure the proper management of perioperative medications and are responsible for the prudent use of antibiotics for surgical prophylaxis.

Effective communication and coordination among team members are vital for ensuring consistent patient education and seamless care transitions. Urologists, nurses, and other healthcare staff must collaborate to address patient queries and concerns. Following the placement of the sling, the team continues to engage with patients regarding recovery milestones, activity restrictions, follow-up care, and any potential complications that may require prompt treatment.

The interprofessional team enhances patient comprehension, safety, and overall satisfaction by working together. A collaborative approach to patient counseling ultimately fosters optimal outcomes and positive experiences for male sling surgery patients.