Management of male stress urinary incontinence (SUI) is a constantly developing field. Often secondary to radical prostatectomy, this condition has a significant impact on quality of life. Although the artificial urinary sphincter (AUS) remains the gold standard, there is a continuous search for a less complex solution. The adjustable male sling was born of the difficulty of achieving the perfect balance of tension in traditional slings: tight enough to create continence, but loose enough to avoid retention.

What Are the Options?

There are 3 main types of adjustable male slings, which offer variations in positioning, material and method of adjustability: Argus-T® (Promedon, Cordoba, Argentina), ATOMS® (Adjustable Transobturator Male System; A.M.I.®, Feldkirch, Austria) and Remeex Male, or MRS (Male Re-adjustable System; Neomedic, Barcelona, Spain).¹

Argus-T is a silicone-based sling consisting of a silicone pad that sits under the bulbar urethra and 2 silicone arms that are brought out to the subcutaneous level via a transobturator approach (fig. 1). There is no mesh component. The Argus-T is tightened by sliding 2 rings (reinforcement and adjustment rings) along each silicone arm. Adjustments require an incision to access the rings.

ATOMS features an inflatable silicone cushion that sits under the bulbar urethra, 2 polypropylene mesh arms and a titanium access port for device inflation (fig. 2). The mesh arms are passed through the obturator foramen and then secured back to the cushion, creating a 4-point fixation. The ATOMS is adjusted by increasing the volume of the cushion through percutaneous instillation of normal saline into a port located in the scrotum; adjustments are easily performed in the clinic.

Figure 1. Argus-T is completely silicone sling consisting of suburethral pad and transobturator notched arms with adjustment achieved by 2 sets of rings.

The Remeex Male consists of a short polypropylene mesh sling that sits under the bulbar urethra and is connected to a varitensor device by 2 sutures (fig. 3). The varitensor sits in the suprapubic area, above the rectus fascia. This location cleverly provides increased resistance across the urethra when the patient increases the abdominal pressure (eg during a cough). The device is adjusted by rotation of an external manipulator once the patient wakes from surgery. Adjustment is easily done with the patient in a standing position. Once adjusted, the external manipulator is removed, but it can be reconnected with a short procedure if further adjustments are required.

Do They Work?

The evidence base for adjustable male slings is growing. A recent systematic review and meta-analysis focusing on adjustable male slings found an overall cure rate (defined as 0–1 pad per day) of 69%.² A systematic review and meta-analysis of all sling types by Meisterhofer et al reported that adjustable slings may have slightly higher objective cure rates than fixed slings (pooled estimate 0.61 vs 0.50), albeit with substantial heterogeneity among the studies and significant 95% confidence interval overlap between the estimates.³

Figure 2. Adjustable Transobturator Male System (ATOMS) consists of volume-adjustable silicone cushion, polypropylene mesh arms that loop around inferior pubic rami and silicone-covered titanium scrotal port.

Historically, male slings have been recommended for men with mild to moderate incontinence. There is hope that the adjustable slings may also prove efficacious for men with severe SUI. A meta-analysis and systematic review by Guachetá Bomba et al compared adjustable male slings to AUS specifically for men with severe post-prostatectomy incontinence and found no significant difference in efficacy.⁴ However, although included studies had at least 1 year of followup, this may not be long enough to assess durability of effect. Casteleijn and Cornel addressed the long-term durability of the Argus-T with 5-year followup data at their center.⁵ The authors divided patients into baseline incontinence less than vs more than 250 gm/day. Initially there was no difference in cure rates between groups; however, after 2 years of followup, the rates diverged (71% vs 40%, p=0.045) and the difference persisted through to 5 years (54% vs 29%, p=0.02). Other patient factors, such as history of radiation therapy, are likely important but have been inadequately studied.

Are They Safe?

A main concern with any implantable foreign material is the rate of extrusion, erosion and need for explant. The meta-analysis by da Silva et al reported an extrusion rate of 9.8% and local infection between 4% and 12%.² They did not differentiate between types of adjustable sling; however, it is known that some sling materials are explanted more frequently than others. For example, a study by Friedl et al reported a 20% explant rate for the ATOMS device, with 41% of explants being due to local titanium intolerance.⁶

Figure 3. Remeex Male consists of polypropylene mesh sling connected by 2 polypropylene sutures to varitensor device placed in suprapubic area. Manipulator is removed with disconnector after adjustment is completed, before hospital discharge.

When Should You Consider an Adjustable Sling?

The American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) Guideline on Incontinence after Prostate Treatment does not differentiate adjustable from fixed male slings; male slings are suggested as a treatment option for those with mild or moderate incontinence and only in special circumstances for those with severe incontinence.⁷

With limited guidance, it is important to consider the individual patient’s circumstances. Comorbidities such as poor dexterity or cognition may preclude a patient from undergoing AUS even in the setting of severe incontinence, an excellent opportunity for adjustable sling use.

Given the efficacy and safety discussed above, patient preference is paramount. Many patients wish to avoid a complex mechanical device such as the AUS even if the alternative may be less efficacious.⁸ When given the choice between a fixed and an adjustable sling, Chung et al demonstrated that many patients will choose an adjustable sling for the perceived advantage of a simple revision surgery in the face of persistent or recurrent incontinence.⁹ In the instance that a patient does need a secondary incontinence procedure, an adjustable male sling is a safe option, but patients should be counseled on the likely lower efficacy.¹⁰

Conclusion

Adjustable slings are appealing both to physicians wishing to precisely tension the sling and to patients wishing to avoid a mechanical device or repeat major operation in the face of recurrent or persistent incontinence. The safety is similar to AUS, and some studies suggest the efficacy approaches that of AUS even in the case of severe incontinence.