Fig. 1
(a, b) Identification of the central tendon after corpus spongiosum mobilization
An incision is made approximately 1–2 cm below the adductor longus tendon and lateral to the ischiopubic ramus. The proper site is usually easily palpable, but a spinal needle may be used to identify the area of insertion. A small incision is made for the needle entry. The AdVance helical needle is held at 45° angle and placed straight through the incision (Fig. 2). A finger is placed in the incision below the ischiopubic ramus to protect the urethra and guide needle placement. Two “pops” are felt, and after the second “pop,” the needle is turned approximately a quarter turn. The needle is palpable on the physician’s finger. Prior to bringing the needle through the fascia, the surgeon’s hand is dropped, and the needle is brought out as high as possible in the triangle between the ischiopubic ramus and the urethra (Fig. 3). The mesh is secured to the needle and then brought back through the incision. This needle pass is repeated on the opposite side. The central portion of the mesh is fixed to the CS with the proximal aspect of the mesh being fixed at the level of our previous mark where the central tendon was taken down. If this area was lost accidentally, we can place a urethral catheter, and the site where it makes a turn into the proximal bulbar urethra is a safe location to place the proximal aspect of the mesh. Two sutures are placed proximally and two distally (Fig. 4).
Fig. 2
The AdVance helical needle is held at 45° angle to the patient and placed straight through the incision with the assistance of the contralateral thumb
Fig. 3
The AdVance needle is passed as high as possible in the triangle between the ischiopubic ramus and the corpus spongiosum
Fig. 4
The mesh is fixed to the corpus spongiosum with four sutures, two proximal and two distal. Note that the proximal aspect of the mesh is fixed at the level of our previous mark where the central tendon was taken down
Tensioning of the sling is done by pulling firmly on both arms of the sling (Fig. 5). Cystourethroscopy is performed to confirm coaptation of the external sphincter and to rule out any urethral injury. If no coaptation is identified, this is usually because the sling has been placed too proximal. The four sutures are removed, and the sling is repositioned approximately 0.5–1.0 cm distally. Once coaptation is confirmed, the muscle is closed as well as the subcutaneous tissues. A 14 Fr. Foley catheter is placed and left overnight. The outer covering of the mesh is removed, and although the sling is self-anchoring, the mesh is tunneled back to the midline incision with the aid of a tonsil clamp to reduce the risk of slippage of the mesh. Some have proposed to fix both ends of the sling by making a second incision beneath the first one, thereby anchoring the ends of the sling subcutaneously at a 90° angle [10]. Finally, the perineal incision is closed in the standard fashion taking care to re-approximate the BS muscle. Both trocar incisions can be closed with a simple interrupted stitch.
Fig. 5
Coaptation of the urethra after tensioning of the sling
Postoperative Care
The Foley catheter is removed the next morning. If the patient is unable to void, the catheter is replaced, and a voiding trial is attempted in approximately 1 week. If the retention lasts longer than 1 week, a voiding trial is attempted again in 5–7 days. Sometimes the catheter needs to be placed over a wire with the assistance of a cystoscope. The patient can also start clean intermittent catheterization. In the rare patient with retention >6 weeks, the sling can be removed with the patient returning to his previous status.
Most patients experience minimal postoperative pain and may want to return to normal activity as soon as possible. However, it is imperative that the patient follows the postoperative instructions, which include refraining from strenuous activity, lifting greater than 15 lbs, and squatting or climbing for at least 6 weeks. If not, patients will have a major risk of loosening the sling. Neurogenic bladder patients, especially those with impaired mobility, must be careful of physically exerting themselves during transfers.
In patients not continent after AdVance sling placement who might have done something in the first 6 weeks which loosened the sling, a repeat sling can be performed. In those patients, re-exploration through the previous incision is done. The BS muscle is opened and the CS is identified. Once the CS is identified, dissection is carried proximally until the top edge of the mesh is palpable. The arms are then identified laterally with a right angle clamp. These are transected (this allows the bulb of the CS to be pulled toward the surgeon). The broad portion of the mesh, which was attached to the CS, is then excised. Another sling is then placed as described above.
Outcomes
As the definition of success and improvement varies among different studies, a real comparison of outcomes is difficult. In spite of this, since the introduction of the AdVance sling, different centers have published promising and successful results. In their original study, Rehder and Gozzi reported a cure rate of 40% and an improved rate of 30% [3]; however as experience has accumulated, success rates have improved significantly. We recently published our results on a cohort of 102 patients with a minimum follow-up of 12 months [9]. Success at 12 months and 24 months of follow-up were 74% and 63% (43% cured and 20% improved). Even though cure rates declined over time, 40% of patients remained dry at final follow-up (36 months). Similarly, Rehder et al. [16] reported a cure rate of 53% and a failure rate of 27% at a 3-year follow-up on a study of 156 men. Likewise, Kowalik et al. [17] reported a cure rate of 60%, an improved rate of 13%, and a failure rate of 27% in a series of 30 patients. Interestingly, these authors also studied subjective outcomes comparing IIQ and UDI scores preoperatively and at a 3-year follow-up. No patients had worsening of IIQ or UDI scores, and 83% of men reported lower scores, indicating improvement. When asked to report a percentage improvement from baseline urinary symptoms, 77% of men reported a >85% overall improvement in their urinary symptoms.
Complications
The AdVance sling is a minimally invasive treatment with minimal intraoperative and postoperative complications, both in number and severity. The main potential intraoperative complication is a urethral injury during trocar passage. We have seen this in only two patients early in our experience. Urinary retention is the most common early postoperative complication with widely variable ranges reported from 0% to 30% [9, 17, 18]. Nonetheless, the risk of long-term urinary retention is minimal as showed by Bauer et al. [18] who reported that all their patients with acute urinary retention, except one, had a successful voiding trial within 12 weeks. Other early postoperative complications include minor wound infection, urinary tract infections, transient mild perineal discomfort, and dysuria. There has been only a single case report of urethral mesh erosion, and this was in a patient with prior radiation [19]. Most series do not report explantation of the sling.
What to Do After a Failed AdVance Sling
Following sling surgery, recurrence of incontinence ranges from 20% to 35% [13]. Fortunately, patients who suffer from persistent incontinence after sling placement have different options to consider. Before any additional treatment, it is important to evaluate whether recurrent or persistent incontinence represents sphincter dysfunction and no detrusor overactivity or another etiology. Reoperation is only indicated for those with recurrent or persistent SUI.
The AUS is the procedure of choice after a failed primary sling. Up to 13% of men will ultimately have implantation of an AUS after male sling surgery [20]. In general AUS placement in this situation has a success rate of 80–90% [21, 22]. Lentz et al. retrospectively reviewed their outcomes in a cohort of 29 patients and compared them with a control group after a virgin AUS procedure [22]. The AdVance sling was left in situ for all salvage AUS procedures. At the 3-month follow-up visit, 28 of 29 patients were using a pad or less per day. At an average 20.7-month follow-up in the salvage group, the revision rate was 6.9%, and no patient developed an infection. One erosion did occur at 11 months, but on explant, the device was deemed sterile. Outcomes after the salvage AUS compared favorably with the control group both in terms of success and required revisions.
Periurethral bulking agents can be injected at the area of coaptation in patients with minimal persistent incontinence. We have had good results injecting Macroplastique® (Uroplasty, Inc., Minnetonka, MN, USA) in this population.
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