Virtue Quadratic Male Sling for stress incontinence-surgical guide for placement and delayed revision

Abstract

The algorithm for surgical management of post prostatectomy incontinence classically includes male slings and artificial urinary sphincter (AUS) placement. The Virtue Quadratic Male Sling was designed to provide both urethral elevation and prepubic compression making it a viable option for a wider spectrum of incontinent men whose symptoms range from mild to severe. With a focus on two key steps of the surgery, (I) sling fixation (II) use of intraoperative retrograde leak point pressure (RLPP), this guide is intended to outline a safe and efficacious treatment for post-prostatectomy incontinence. Intriguingly, the sling can be revised in the event of refractory or worsening leakage, and does not preclude the placement of an AUS should it be needed. This paper describes a step by step approach to performing the procedure as well as expert tips to improve outcomes and avoid/manage complications that have been learned over the years.

Keywords: AdVance Male sling, transobturator male sling; Urinary incontinence; Virtue Male Quadratic Sling; artificial urinary sphincter (AUS); post-prostatectomy incontinence; sling revision.

Figure 1

The Virtue Quadratic Male Sling provides both urethral elevation and prepubic compression to treat male stress incontinence.

Figure 2

Prior to Alexis placement the bulbospongiosus muscle is dissected. The central tendon seen here is gently dissected in a semi-lunar fashion to create approximately 2 cm of mobilization.

Figure 3

The Alexis retractor is included in the mesh kit and is placed with the green ring in the incision (A), and the white ring is then folded inward to provide maximal visualization and retraction (B).

Figure 4

The sling should be draped over the patient as shown here. An easy mnemonic to remember is that “blue (like the sky) lies north.”

Figure 5

The J hook passer is designed to be used for both sides using the surgeon’s chosen dominant hand (A) while the T-slot is used primarily to hold the mesh suture in place and the L-slot is used for larger patients (B).

Figure 6

With the mesh suture attached in the T-hook, the TO arms are placed using an inside-out technique with the J hook passer. The passer hugs around the lower, descending potion of the pubic rami.

Figure 7

The set up for RLPP testing. This is a critical step to ensure effective sling tension. RLPP, retrograde leak point pressure.

Figure 8

The location of the fixation sutures can be seen here. It is necessary for the first throw to be securely within the periosteum.

Figure 9

We recommend #1 polypropylene suture (Covidien Surgipro #1 HGS-22 tapered needle for fixation sutures.

Figure 10

Sling revision: imbricating plication sutures are placed superficially through the mesh material. When tying the suture, confirm tension while watching the RLPP. RLPP, retrograde leak point pressure.