Initial Experience with the AdVance Male Urethral Sling
Robert C. Eyre, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Background - The AdVance Male Urethral Sling (American Medical Systems) is a new addition to the urologist's options for treating mild to moderate urinary incontinence (defined as <5 pads per day). The sling repositions the bulbous urethra in a more physiologic retropubic location. Advantages over the artificial urinary sphincter (AUS) include the lack of mechanical components that can malfunction, lack of circumferential pressure on the urethra that can lead to erosion, and the absence of any need for manipulation of a pump by the patient to achieve voiding.
Methods - Between July 2007 and April 2009, a total of 15 patients were treated. Mean age was 73 years (range 54-86)and mean duration of incontinence was 5 years (range 1-20 years). The etiology of the incontinence was post-prostatectomy in 14 and post-cystectomy with neobladder in 1. Five patients had received adjuvant radiation therapy. Four patients had failed prior urethral bulking procedures, and one had undergone removal of an eroded AUS. Two patients who used >6 pads/day and two patients with total incontinence opted for slings despite a low chance of cure, and the patient whose AUS was explanted had a "salvage" sling.
Results - Of the 11 patients whose pad use was from 1-5 per day preoperatively, 9 are completely continent, one uses an occasional pad for severe exertion (few drops of leakage), and one was significantly improved but opted to have an AUS because of a very physical lifestyle. One patient who used >6 pads per day is completely continent. Two patients with total incontinence were much improved, but subsequently chose to have AUS placement and are now totally continent. The patient with a "salvage" sling went from 1 pad/hour to 4 pads/day.
Two patients developed postoperative urinary retention requiring discharge with a urethral catheter for 2-3 days, and one patient who voided well postoperatively developed transient urinary retention following a total knee replacement several months later. No postoperative complications were seen.
The first 10 sling procedures were done with overnight admission in order to minimize activity that could lessen the tension on the sling, but with a minor modification to the surgical technique, all patients are now discharged on the day of surgery and activity restriction have been reduced.
Conclusions - The AdVance male urethral sling is a well-tolerated procedure with immediate results and minimal risk. It should be considered as first-line therapy for men with mild to moderate stress urinary incontinence (5 or fewer pads/day). Patients with more severe incontinence may be offered a sling with an expectation of significant improvement, but complete continence is unlikely. Placement of an AdVance sling does not preclude the later placement of an AUS.
Without the new option of the AdVance sling, several men would have chosen to live with their incontinence rather than undergo an AUS. The encouraging results suggest that it may be appropriate to offer patients whose incontinence has shown no improvement for several months a sling procedure to hasten the full recovery of continence following exenterative pelvic surgery.