Introduction
The male sub urethral sling is common surgical procedure for the management of stress urinary incontinence following the removal of the prostate for cancer. The procedure can however, be used for any form of stress urinary incontinence in a male regardless of whether their prostate has been removed or not.
There are two types of slings used in men – the non-adjustable Advance XP sling or the adjustable ATOMS sling. The ability to adjust the ATOMS sling allows the surgeon to make changes to how tight the sling is after the operation if the patient still leaks too much or if the sling is too tight and the patient has trouble urinating.
For incontinence that’s very severe, an artificial urinary sphincter (AUS) is often placed in order to obtain maximal control of the urine leakage. The artificial urinary sphincter has a cuff which sits around the urethra and squeezes it tight to prevent urine from leaking. A pump sits in the scrotum and once pressed it causes the cuff to stop squeezing the urethra and therefore allows the patient to empty the bladder. The decision to place a sub urethral or AUS is made after careful consideration of the risks and benefits of the procedure and is performed when non-surgical treatments do not work, or the incontinence is severe and disrupts a patient’s quality of life.
Indications
The sub urethral sling or AUS is used to treat stress urinary incontinence that has not responded to non-surgical treatments.
Preoperative Instructions
A urine test will be performed prior to the procedure to ensure there is no active urinary tract infection. An active infection will often require treatment prior to the placement of a sling or AUS. A cystoscopy will typically be performed prior to the procedure to assess the anatomy of the lower urinary tract and make sure there is no stricture (narrowing) of the urethra. Patient’s taking medications as warfarin, clopidogrel, apixaban and rivaroxaban will need to cease these a number of days prior to the procedure and this will be discussed with you by your surgeon.
Procedure
The details of the procedure will be discussed in depth by your surgeon. A single incision underneath the scrotum in performed for both the sling and the AUS. This is where both the sling and the AUS are placed. The AUS also requires an incision just above the groin to place another component called the pressure regulating balloon. These sites will be covered by a dressing at the end of the procedure and will be monitored for any signs of infection (redness, swelling, pain).
Post-operative Instructions
The length of hospital stay is usually 24-48 hours. A catheter is placed during the procedure and this is removed on the first or second post-operative day.
Those who have an AUS placed will leave hospital with the AUS not activated and the post-operative recovery depends upon the type of sling used – mesh or native tissue. The placement of a mesh mid urethral sling is usually performed as a day procedure or overnight stay. The patient is discharged home once they are passing urine well and is followed up in the clinic at 6 weeks’ time and then periodically thereafter.
The placement of a native tissue sling requires the patient to remain in hospital for up to three days as there is slightly more discomfort from the abdominal incision and there is often a tube called a drain left in the abdomen which is often removed after 48 hours. The native tissue sling has a greater risk of difficulty urinating after it has been placed, therefore these patients are seen earlier in the clinic in about 2 weeks.
All patients are advised to not do any heavy lifting or straining for 6 weeks after the procedure.
Risks
The risks following the placed of a sub urethral sling are:
- Bleeding.
- Infection.
- Retention of urine.
- Sling erosion.
- Need to explant sling.
- Mechanical failure (AUS).
- Recurrence of stress urinary incontinence.