Rees, R

Male sling, Incontinence, Urodynamics

This video illustrates in a step-by-step way the insertion of a Virtueâ quadratic male sling for post-prostatectomy incontinence.

A 72-year-old man with a history of localised Gleason 4+4=8 prostate cancer treated by robotic radical prostatectomy 16 months previously presented with symptoms of stress incontinence. He was using 3-4 intermediate pads per day depending on level of activity, with an average pad-weights of 284ml. He was dry overnight. A trial of Duloxetine 20mg bd was unsuccessful, and he proceeded to a full work up for incontinence surgery, including flexible cystoscopy and urodynamic studies.

Cystoscopy revealed a normal urethra, a snug but patient vesico-urethral anastomosis, and weak apposition of the sphincter-active urethra on perineal pressure. Urodynamics demonstrated a stable fill to 450ml, with normal compliance and no detrusor over-activity. He voided to completion with a PdetQmax of 42 cmH20.

He was counselled regarding the options of a male sling versus artificial urinary sphincter, and based on the extend of incontinence and patient preference, a decision was made to proceed with a male sling procedure.

Following positioning, sterilisation and draping, the patient in catheterised with a 14Fr Foley catheter, and a perineal incision performed to expose the bulbo-spongiosus. Lateral dissection is then performed to expose the inferior pubic rami, and the bulbar urethra is mobilised by elevation and division of the anterior fibres of the perineal body. This is made easier by asking the assistant for counter-tension by elevating the bulbar urethra with a forceps, and palpating the tendon fibres before division.

Four small skin incisions are then made 2cm below and lateral to the insertion of the adductor longus, and 2cm lateral to the pubic symphysis, bilaterally. The trans-obturator arms are then then attached to the introducer and inserted from in-to-out, positioning and suturing the central portion of the sling in the midline over the bulbo-spongiosus muscle, using absorbable sutures.

The sling is then tensioned by pulling firmly on both trans-obturator arms simultaneously until the urethra elevates fully and the urethra compressed. The introducer is then passed form out-to-in and the pre-pubic arms pulled through retrogradely. Whilst under tension, they are then sutured to either the periosteum of the pubic rami or the overlying tunica albuginea, (depending on surgeon preference) using absorbable sutures. Cystoscopy confirms apposition of the sphincter-active urethra when the irrigation is

switched off. The author has not found that measuring urethral leak point pressures leads to any meaningful intervention or improvements in outcome.

A vacuum drain is inserted into the perineum, and perineal fat, Colle’s fascia and skin are then closed using absorbable sutures.

The drain contained 30ml of blood and was removed in the first post-operative morning along with the catheter. The patient was discharged within 24 hrs and was asked not to distract his legs for the first 3 weeks, to avoid displacement of the sling arms. The early continence result is apparent when the catheter is removed and the bladder starts filling, but outpatient review 6 weeks after the operation was performed to assess the full result once the patient had returned to normal day-to-day physical activities.

There were no post-operative complications. The patient reported a significant improvement in his continence, using one small security pad per 24 hrs, and only experiencing small leaks at high pressure eg coughing / sneezing when the bladder was full. He was very satisfied with the outcome.

Coloplast for the graphical images included in the video.

Rubin RS, Xavier KR, Rhee E. Virtue Quadratic Male Sling for stress incontinence-surgical guide for placement and delayed revision. Transl Androl Urol. 2017 Aug;6(4):666-673