Despite advances in prostatectomy technique, incontinence remains an impactful complication following prostate cancer treatment.¹ The incidence of urinary incontinence following radical prostatectomy varies widely from 1%–40% depending on the length of followup and definition of incontinence.² While the artificial urinary sphincter (AUS) remains the gold standard for treatment of post-prostatectomy incontinence (PPI) since its introduction by American Medical System Holdings, Inc. in 1973, there remain several drawbacks to this procedure including a continence rate of 75%–80% (inferring a 20%–25% incontinence rate), a revision rate of 15%–60% at 7–10 years, requirement of an intra-abdominal pressure regulating balloon, a mechanical pump requiring manual dexterity and a lack of adjustability (without a re-operation).³ Despite patient satisfaction rates consistently approaching 90%, these drawbacks combined with an overwhelming patient preference to avoid a mechanical pump have led to the development of male slings.⁴

Male sling devices are designed to passively coapt the urethra with either a synthetic material or fascia anchored to the anterior abdominal fascia, bone or secured via the transobturator approach. The majority of these are not adjustable once placed in situ. Though reported success rates vary widely, they are generally inferior to the AUS particularly in the setting of moderate-severe incontinence or in the setting of concurrent radiotherapy.^2,5

The adjustable transobturator male system (ATOMS), a self-anchoring male incontinence system with mesh arms and a silicone cushion, has been “building steam” in the male sling world with several series reporting on its effectiveness and safety.^6–9 The device has undergone a number of generational changes since it was first introduced in 2008. Insertion of the first generation ATOMS required 2 incisions (a perineal incision to position the hydraulic cushion with mesh arms and a second inguinal incision to place the titanium adjustment port). The device was modified in 2013 and the inguinal port was replaced with a simple scrotal port, thus converting the ATOMS insertion to a single-incision procedure. However, publications reporting early outcomes for the first and second generation ATOMS raised concerns regarding a higher than expected explantation rate, reportedly due to titanium intolerance of the injection port (10%–30%).¹⁰ To overcome this, the latest (third) generation of ATOMS has been modified to include a silicone covered scrotal port (see figure). Its main innovation may perhaps be its adjustable feature which, although not a novel concept, has proven beneficial especially when compared to other male slings, requiring only local anesthetic to inject into the scrotal port. This is particularly advantageous given the narrow margin of error between excessive urethral compression causing urinary retention or device erosion and insufficient compression resulting in persistent incontinence.

Figure. Anatomical placement and configuration of current (third generation) ATOMS device.

The procedure is typically performed as a short-stay procedure under general or spinal anesthetic with the patient positioned in the lithotomy position. Patients routinely have a 14Fr urethral catheter inserted for urinary drainage, which is removed 1–2 days postoperatively. A prophylactic antibiotic regime consisting of an intravenous aminoglycoside and a first generation cephalosporin or vancomycin is administered preoperatively. The procedure is performed through a midline perineal incision, and the device is positioned against the bulbospongiosus muscle and proximal bulbar urethra but underneath Colles’ fascia. The adjustment port is tunneled into a dependent portion of the left hemi-scrotum. The volume instilled at the time of surgery is determined by removing the air present in the system; the device is filled with 10 ml saline solution and then allowed to equilibrate until reaching ambient pressure. At this point of equilibrium typically a further 2 ml is added, but this may depend on the patient’s degree of incontinence and detrusor contractility. Adjustments are typically performed (if required) beginning 4 weeks after placement and up to 26 ml in total. ATOMS is not currently available in the United States but has been available in Canada since 2014.

There is currently no randomized study comparing ATOMS to other devices, but based on multi-center reports and meta-analysis the continence rates of ATOMS is typically 70%–75% even in patient populations typically deemed less than ideal candidates for slings, including concurrent radiotherapy and prior incontinence surgeries.^8,9 Likewise, improvement rates typically approach 90% after postoperative adjustments.^8,9 On balance, overall efficacy seems to fall just below the AUS but is typically superior to the majority of nonadjustable male slings. However, in common with all slings, prior radiotherapy and severe incontinence (>5–6 pads) are factors associated with failure to achieve continence, but may not diminish efficacy as dramatically as seen in nonadjustable slings.^8,9 Complications of any grade occur in approximately 15% of patients with a 3% rate of major complications.^8,9 The majority of complications include scrotal pain or paresthesia, wound infection, hematoma or transient urinary retention. Device explantation occurs in ∼6% of patients, which falls within the range of other male slings but lower than the explantation rate associated with an artificial urinary sphincter.^3,8,9

Overall, ATOMS has emerged as an acceptably safe and effective treatment for varying degrees of post-prostatectomy incontinence even in patient populations not typically deemed ideal candidates for a male sling procedure.