Male Sling Procedure: What You Should Know

Urinary incontinence in men affects their quality of life, and it is more common than people think.

The prevalence of this condition is around 30%, and it increases the risk of hospitalization. In most cases, incontinence is due to stroke, infections in the urinary tract, diabetes, or prostate problems (1).

These patients usually improve with tamsulosin, tolterodine, and other drugs. In some cases, prostatectomy and other surgical procedures are recommended.

Another option is the male bladder sling procedure, a hammock for the urethra that mainly works for stress incontinence. However, it can be useful in urge incontinence and other types, too.

What is a male bladder sling?

A male bladder sling or male urethral sling is a surgical treatment for incontinence in men. It is common in stress incontinence but can improve the symptoms of other types.

After placing a male bladder sling, no manual skill or training is required. It works mechanically as a hammock that brings up the urethra and applies gentle pressure. Since it works by itself and does not have complex mechanical parts, patients usually have rapid results (2).

There are two male bladder sling options available at the moment. One of them is Boston Scientific’s AdVance Male Sling System, and the other is Coloplast’s Virtue sling. The former uses two arms to do the job, and the latter uses four arms. In the past, there was also a three-arm sling available, the Argus sling.

What was the male sling developed for?

The bladder sling procedure in males was developed as a surgical treatment for certain types of urinary incontinence. This surgery works in males who suffer from bothersome but not severe symptoms.

These patients usually have mild or moderate incontinence problems. It mainly works successfully in cases of sphincter deficiency. In other words, when the ring-like muscle that keeps the urine in the bladder is no longer working as it should.

These patients typically have stress urinary incontinence and small leaks of urine. Instead of fixing the sphincter muscle, the male sling procedure is a type of extra source of grip. It is placed near the weak area, slightly lifting the urethra and providing support.

It does have a mechanical effect by pressing on the site against the bladder. Thus, it contributes to the urethra sphincter to keep the urine inside the bladder. As such, it is an appropriate measure for cases when the sphincter is the source of the incontinence problem (3).

It is not developed and not appropriate for:

  • Patients with severe symptoms of incontinence (less than 150 grams of urine leakage every day, according to certain authors) (4)

  • Patients with vesicoureteral reflux and other conditions that may compromise the kidney function

  • People with a compromise in the bladder neck or urethral tissue.

  • Patients with an ongoing urinary tract infection

It is also recommended to evaluate patients closely after radiation therapy and those who probably need a future transurethral procedure. In patients with metastatic prostate cancer, doctors should assess the patient’s prognosis and life expectancy.

What tests are done before the male sling procedure?

Tests are critical before a male sling procedure to prevent complications:

Urine culture and urinalysis

One of the contraindications listed above is a urinary tract infection. Thus, it is imperative to perform a urinalysis and urine culture. Patients should take the sample after cleaning their penis, especially the glans. They should take a sample after urinating a small amount and make sure that the cup is sterile. If they are not circumcised, they should retract the foreskin before taking the sample. If a urinary infection is detected, it should be treated before the male sling procedure.

Pad test

Another test usually performed before the intervention is a pad test. It is a 24-hour pad weight measure. In this case, it is a reliable way to measure urine leaks and its volume. Some authors recommend the procedure to patients with 150 grams of urine leak (4). However, some studies have shown significant improvements in patients with larger leaks. In one study, patients with 423 grams of urine leaks had 6 times more progress in their symptoms than patients with a larger leak (5).

PSA test

This is a screening test for prostate cancer in patients without a history of this disease. It is used to assess cancer status and rule out prostate cancer.

Serum creatinine

This is one of the most important tests to evaluate renal function. You may require other tests as well.

Cystoscopy

It assesses the lower urinary tract through a small endoscope introduced into the urethra. The endoscope has a potent light and is connected to video to evaluate the urethra, the bladder, and other structures. With this test, it is possible to assess the urethral sphincter’s function, which is fundamental to detect who will benefit from this procedure.

Pressure flow urodynamics

Patients may need to go through a more specific test to evaluate their urine flow in some cases. In this test, doctors can determine the bladder structure and function and the type of incontinence.

What happens before the male sling procedure?

Before a male sling procedure, it is essential to perform a comparative evaluation of the patient. Doctors should take your medical history and perform a physical exam. As a part of your physical exam, the doctor needs to evaluate your genitalia and rectum. He might need to evaluate your rectal sphincter tone.

It is essential to perform a urine culture and a urinalysis, as noted above. It is also vital to evaluate surgical history and its association with incontinence symptoms.

Patients who had a radical prostatectomy should wait. In most cases, urinary incontinence improves by itself in a period of 1 year (4). But even after 6 months, some patients with bothersome symptoms can undergo cystoscopy. If they do have a significant sphincter defect, male urethral sling surgery may be recommended.

Your doctor may also recommend you to write a voiding diary. In this diary, you need to describe what you feel and the episodes of incontinence as accurately as possible. This data may help your doctor to know if you have the urge or stress incontinence.

Before the surgical treatment procedure, you will also be given prophylactic antibiotics. They are meant to prevent surgical-related infections. Similarly, you will discontinue temporarily aspirin and some NSAIDs that may affect your blood clotting function.

How is the male sling procedure done?

For this procedure, the first step is to give the patient anesthesia. It can be general anesthesia or spinal anesthesia, depending on the case. The ideal position in the surgery table is the dorsal lithotomy position.

It is simply lying on the back with the knees bent at 90 degrees and the legs flexed at 90 degrees. This position is adopted for surgery in the pelvic region, and it is similar to that adopted by pregnant women during childbirth.

The Three Techniques

Doctors can use one of three techniques:

  • The Bone-Anchored Bulbourethral Sling: This technique only requires one incision, and the sling fixes to the bony pelvis, holding and compressing the urethra. The fixation is done through titanium bone screws on either side of the bony pelvis. Then, a sling is cut in a trapezoid and secured to the bones with the right tension. It can be a fascial sling from the rectus fascia or another biological material (autologous fascial sling). It is possible to reposition the sling or use in-surgery tests to evaluate the tension (6).

  • The Transobturator Bulbourethral Sling: As the name implies, this technique uses a transobturator sling. It repositions the sphincter instead of creating extra pressure. In these patients, the urethra is lengthened and shifted to the back. It is made with a midline incision in the pelvic floor and uses a helical passing device with mesh instead of screws. Sutures are placed to each side to fix the surgical mesh sling in place. After that, the right tension of the mid-urethral sling is achieved by pulling on its arms (7).

  • The Quadratic Sling: This is a hybrid technique that includes the best of the above. It creates urethral compression while at the same time relocating the urethra. It requires a polypropylene synthetic mesh with 2 extensions for the transobturator and 2 extensions for the prepubic area (8).

What are the advantages of the male sling procedure?

If the patient was selected properly, the chance of a positive outcome is very high. According to studies, most patients say that the procedure is sufficient to treat urinary incontinence. Patients reduce the severity and frequency of urinary leaks and regain their quality of life (9).

Additionally, these patients do not require previous training or rehabilitation. They experience improvements shortly after recovering instead of going through an extra step.

What are the risks and complications of the male sling procedure?

Like any other surgical procedure, male bladder sling surgery can have a few complications and risks. The most common is pain after the procedure and wound infection.

However, other complications include problems with anchoring the sling and tingling in the skin (paresthesias).

Infection is probably one of the most notable complications, reported in 2-12% of patients (10). However, they are usually treated successfully with antibiotics and careful wound cleaning. In some cases, patients have experienced urine retention, but this is very uncommon, and most cases resolve by themselves. Other rare complications include bladder perforation and other forms of organ damage.

Recovery and outlook

After the surgery, most patients need to maintain an indwelling catheter. This stays for 1-2 days, while oral antibiotics are recommended for one week. NSAIDs control pain symptoms as the patients recover.

In the recovery period, patients should not lift weight, bend, or do any strenuous work. They should also abstain from sexual intercourse for the following 6 weeks.

Constipation and abdominal pressure can increase the risk of complications. Thus, patients are usually recommended stool softeners or a high-fiber diet. You should avoid bicycling and any other activity that places body pressure on the pelvic organs.

As noted above, some patients may experience urine retention, but it is a transient symptom. Thus, these patients and their caregivers should place a catheter. They should know how to perform self-catheterization. When this problem shows up, it usually resolves by itself in no more than two or three weeks (11).

Conclusion

Urinary incontinence is more common in males than we usually think. The triggers are not only prostate cancer and BPH. Diabetes, obesity, and other chronic condition may also contribute to the problem. In some cases, there’s a dysfunction of the urinary sphincter. In other cases, an overactive bladder. 

These patients are often treated with medications, but surgery can be performed in some cases. Bladder sling surgery is one such procedure. It is primarily for patients with urinary sphincter problems. Unlike women who suffer from pelvic organ prolapse and require a pubovaginal sling, males’ procedure is quite different.

There are a variety of traditional suburethral sling procedures. They all have in common a preparation period where patients are screened for prostate cancer, urinary infections, and other conditions. Preparation for surgery also requires a series of tests to ensure that the patient will benefit from this type of procedure. Another feature in common is a post-operative period in which patients should not lift weight, practice horseback riding, or have sexual intercourse.

In this procedure, the surgeon creates a hammock to embrace and lift the urethra. This repositions the urethra or causes compression to help the urinary sphincter. Either way and depending on the technique, patients improve their urine control and reduce urinary leaks’ volume and frequency.

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Sources

  1. Shamliyan, T. A., Wyman, J. F., Ping, R., Wilt, T. J., & Kane, R. L. (2009). Male urinary incontinence: prevalence, risk factors, and preventive interventions. Reviews in urology, 11(3), 145.
  2. Available online at http://www.coloplast.us/surgical-urology/professional/male-urinary-incontinence/#section=Virtue%c2%ae-male-sling_83691. Accessed: November 29, 2020.
  3. Comiter, C. V. (2005). The male perineal sling: intermediate‐term results. Neurourology and Urodynamics: Official Journal of the International Continence Society, 24(7), 648-653.
  4. Flynn, B. J., & Webster, G. D. (2004). Evaluation and surgical management of intrinsic sphincter deficiency after radical prostatectomy. Reviews in Urology, 6(4), 180.
  5. Fischer, M. C., Huckabay, C., & Nitti, V. W. (2007). The male perineal sling: assessment and prediction of outcome. The Journal of urology, 177(4), 1414-1418.
  6. Ullrich, N. F., & Comiter, C. V. (2004). The male sling for stress urinary incontinence: urodynamic and subjective assessment. The Journal of urology, 172(1), 204-206.
  7. Rehder, P., & Gozzi, C. (2007). Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. European urology, 52(3), 860-867.
  8. Comiter, C. V., Nitti, V., Elliot, C., & Rhee, E. (2012). A new quadratic sling for male stress incontinence: retrograde leak point pressure as a measure of urethral resistance. The Journal of urology, 187(2), 563-568.
  9. Boone, T. B. (2016). How to Decide Whether an Artificial Urinary Sphincter or a Male Sling is Best for Male Stress Urinary Incontinence.
  10. Welk, B. K., & Herschorn, S. (2012). The male sling for post‐prostatectomy urinary incontinence: a review of contemporary sling designs and outcomes. BJU international, 109(3), 328-344.
  11. Wessells, H., Peterson, A. (2011). Surgical procedures for sphincteric incontinence in the male: the artificial genitourinary sphincter and perineal sling procedures. Campbell-Walsh Urology. 10th ed.

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