Male Urethral Sling

Background

Prostate surgery for benign or malignant disease carries a risk of inducing male stress urinary incontinence (SUI). Surgical correction was previously limited to the artificial urinary sphincter (AUS), which remains the gold standard. Introduction of a perineal sling (InVance) for mild to moderate SUI proved beneficial for some patients, but there were reported complications related to the bone anchors used to secure the device. Following the success seen in female patients, the transobturator sling procedure has been applied to men and become a reasonable option for well-selected individuals. The concept of a satisfactory level of continence without the need to cycle a device for each episode of urination is attractive for obvious reasons.

Patient Selection and Preoperative Preparation

Across the spectrum of prosthetic urology, patient selection and preoperative management of expectations are critical. For best results after sling surgery, patients should have mild to moderate SUI, typically requiring two pads or less per day. A thorough history and physical examination should include evaluation of all prior pelvic surgeries and any history of radiation. Although radiation is not an absolute contraindication to sling placement, such patients should be counseled properly about consideration of an AUS.

Further office assessment may include validated questionnaires, voiding diaries, and pad weight testing. There is no definite cutoff for pad weight criteria, but some have suggested better results if urine loss is less than or equal to 150 g/day. Urodynamics can be considered if there is any concern for bladder dysfunction. We require preoperative cystoscopy to rule out bladder neck contracture (BNC) and to observe for voluntary sphincter coaptation. If a BNC is present that will not allow passage of a standard flexible cystoscope, we do not offer sling placement until the BNC has been treated and stabilized and the subsequent degree of SUI assessed. After filling the bladder, we remove the cystoscope and observe the patient voiding and ability to voluntarily interrupt the urinary stream.

If the patient uses two pads or less each day and can both coapt his sphincter and interrupt his stream, we advise him that it is quite reasonable to expect at least 50% improvement in SUI from a sling procedure. We never guarantee a patient will be pad free, and we inform the patient that there may be some decline in his level of continence as the postoperative interval extends beyond 6 months. Additionally, we advise patients about the risk for postoperative retention requiring clean intermittent catheterization (CIC). In our practice, all such episodes have been temporary, but some patients have required CIC for up to 6 weeks. We have never had to revise (i.e., “loosen”) a male sling, nor have we ever seen a case of mesh erosion. Anecdotally, patients with temporary postoperative retention seem to have the best long-term continence. Admittedly, there have been a few patients in our series that have requested subsequent AUS for further improvement.

In advance of surgery, we require a negative urine culture. Anticoagulation must be held 10 days before surgery, and this includes aspirin, nonsteroidal antiinflammatory drugs, and fish oil. We ask that patients perform a Hibiclens (chlorhexidine) shower at home the night before and in the morning before coming to our center for the procedure.

Surgical Instruments

A basic minor instrument set should suffice for this operation. Adson forceps, an Adson-Beckman retractor, Richardson retractors, Metzenbaum scissors, a needle driver, Mayo scissors, and suture scissors are the main instruments. Retraction is provided by the self-retaining Lone Star Retractor System that comes in the box with the AdVance male sling. When a minimal depth of dissection is required to reach the location of interest, the Adson-Beckman retractor alone may be sufficient. For cases at the opposite end of the spectrum that feature an unusual amount of adipose and require a deeper dissection, an alternative is to use the ring component of a hand-assist port, as seen in laparoscopic surgery. Sutures required include 4-0 Vicryl, 3-0 Vicryl, and 4-0 Monocryl. We prefer to use the Colorado tip for electrocautery, but a standard tip is acceptable. Dermabond can be considered for closure of the trocar sites as an alternative to a simple suture. For prosthetic urology cases, we use surgical field irrigation inclusive of antibiotics (e.g., bacitracin and gentamicin).

Patient Positioning

The patient is positioned in dorsal lithotomy position using adjustable stirrups and padding for all pressure points. The edge of the buttocks should be at the end of the operating table. A rolled sheet is typically placed under the coccyx. After the perineum and medial thighs have been shaved, the operative field is prepared with a 10-minute scrub of chlorhexidine solution followed by ChloraPrep “paint.” The area is then sectioned off using sterile towels, with the upper aspect of the lower towel secured transversely with either staples or towel clips to exclude the anus. After surgical drape placement, a 14-Fr silicone Foley catheter is placed, inclusive of a catheter plug ( Fig. 103.1 ). In select cases of a redundant scrotum or when a surgical assistant is unavailable, the scrotum can be elevated using stay sutures or towel clips.

Surgical Steps

A 4- to 5-cm vertical midline perineal incision is made with a #15 scalpel centered over the midbulbar urethra. Dissection is carried down to the bulbospongiosus muscle using a combination of sharp and blunt dissection along with electrocautery. The hooks for the Lone Star retractor are readjusted as the dissection progresses deeper into the perineum. In doing so, we suggest fully removing and replacing the arms of the retraction hooks rather than just adjusting the end with the hook. Failure to do so may result in an unacceptable level of tension that shreds the bulbospongiosus muscle.

The bulbospongiosus muscle is opened sharply in the vertical midline to expose the pearly or faint blue tunica overlying the corpus spongiosum of the urethra. Cautery should be used only as necessary on the muscle, and bipolar current is preferred. At the inferior aspect of the muscle, locate the central perineal tendon (CPT). This structure can be palpated in the midline and feels like a taut “bowstring” when intact ( Fig. 103.2 ). There is debate as to what extent the CPT should be divided (e.g., two thirds vs. completely). We fully divide the CPT using either Metzenbaum scissors or monopolar electrocautery with a Colorado tip. A right angle clamp placed behind the tendon may be helpful in this part of the dissection ( Fig. 103.3 ). After dissection, a finger sweep is easily performed below the inferior aspect of the bulbar urethra ( Fig. 103.4 ). The location of the distal most aspect of the CPT is marked with a sterile marker, electrocautery, or a stay suture. The body of the sling will lie distal to this location. Placement that is too proximal can actually worsen a patient’s incontinence. With the tip of a finger, the site of planned trocar entry into the operative field is palpated. This is located at the angle formed by the crossing of the lateral edge of the urethra and the medial edge of the corpora cavernosa, which deviate laterally along the inferior pubic rami as they transition away from the penis into the perineum ( Fig. 103.5 ).