A urethral sling placed via a transobturator approach has recently emerged as a treatment option for men with mild-to-moderate postprostatectomy incontinence.
The primary difference between this device (AdVance Male Sling) and previous slings for male incontinence is the location of the sling at the level of the most proximal portion of the bulb of the corpus spongiosum.
Sling placement proceeds through a midline perineal incision. The bulbospongiosus muscle is opened in the midline, and the attachment of the central tendon to the bulb of the corpus spongiosum is taken down sharply to allow tension-free proximal relocation of the bulb.
The needles are passed through the upper medial aspect of the obturator foramen just below the adductor longus tendon and exit in the angle between the bulb and the ischiopubic ramus under index finger guidance.
The sling is then attached and pulled through on each side. The wide part of the sling is sutured securely to the corpus spongiosum at the most proximal part of the bulb, and the sling is maximally tensioned and then cut at skin level.
With the craniocaudal direction of force provided by transobturator placement, the sling relocates the bulb approximately 3 cm superiorly and thereby provides support to the posterior urethra and bladder neck.
This results in more effective closure of the bladder neck at rest, increased length of the membranous urethra, and increased mean urethral closure pressure. The outcome is improved continence in the majority of patients, without compromise of urinary flow rates, as there is minimal direct compression of the urethra.
These findings correlate with the clinical observation that for the procedure to be effective, it is important for the patient to have a visually intact urethral sphincter mechanism at the time of cystoscopy and the ability to contract the sphincter voluntarily.
Transobturator sling placement also allows for adequate posterior urethral support without the need for bone anchors or other types of fixation, which are necessary when using a compressive mid-bulbous urethral sling.
Thus, the procedure is very well tolerated, with minimal postoperative discomfort, and urinary retention is uncommon. It is important to emphasize to patients that they must limit strenuous activity for six weeks following surgery to avoid loosening of the sling and recurrent incontinence.
An initial study of 35 patients treated at our institute for wide ranging severity of urinary incontinence demonstrated a subjective cure rate of 51%, with an additional 30% of patients being favorably improved. No patient reported worsened incontinence following the procedure. These results may be even better when the procedure is limited to men with mild-to-moderate incontinence, and it is anticipated that this will continue to be the optimal treatment group.
Based on this information, the transobturator urethral sling has assumed an important role in our treatment algorithm for patients with postprostatectomy urinary incontinence and nicely complements the artificial urinary sphincter in this setting.