AdVance male sling

Abstract

The AdVance sling (American Medical Systems, Minnetonka, MN, United States of America) is a synthetic transobturator sling, which is a safe and effective minimally invasive treatment for mild to moderate stress urinary incontinence (SUI) in male patients. This article provides a step-by-step description of our technique for placement of the AdVance male sling, including details and nuances gained from surgical experience, advice for avoidance of complications and discussion on management of complications and sling failures. Patient selection is very important, including exclusion and preoperative treatment of urethral stenosis and bladder dysfunction. Previous pelvic radiation is a poor prognostic factor. In brief, the steps of sling placement are: (I) mobilization of the corpus spongiosum (CS); (II) marking and mobilization of the central tendon; (III) passage of the helical trocar needles exiting at the apex of the angle between the CS and inferior pubic ramus; (IV) fixation of the broad part of the sling body to the CS at the previous mark; (V) cystoscopy during sling tensioning; (VI) placement of a Foley urethral catheter; (VII) Subcutaneous tunnelling of the sling arms back toward the midline; (VIII) wound closure. The most common early postoperative complication is urinary retention but long-term retention is extremely rare. Management of sling failures include placement of an artificial urinary sphincter, repeat AdVance sling, urethral bulking agent or ProACT device.

Keywords: Urinary incontinence; intraoperative complications; postoperative complications; suburethral slings; urinary retention.

Figure 1

(A,B) The corpus spongiosum at the level of the central tendon is marked with either an absorbable suture or marking pen before the central tendon is dissected off the corpus spongiosum.

Figure 2

The trocar handle is held at a 45-degree angle, the trocar needle point is oriented perpendicular to the patient’s skin, and surgeon’s contralateral hand is suitably positioned for safe trocar insertion.

Figure 3

After the two “pops” are felt, the trocar is turned and the ipsilateral hand of the surgeon is dropped so that the point of the trocar needle is brought out as high as possible in the angle formed by the ischiopubic ramus and corpus spongiosum.

Figure 4

Sutures are used to fix the central portion of the mesh to the corpus spongiosum with the proximal edge of the mesh being fixed at the level of our previous marking where the central tendon had been dissected off the corpus spongiosum.

Figure 5

Pulling firmly on the sling arms tensions the sling.

Figure 6

The previous AdVance sling is dissected off the corpus spongiosum after the sling arms have been transected lateral to the corpus spongiosum which allows the corpus spongiosum to move toward the surgeon.