Aug 15, 2021
Here are my answers to the ten questions about the male urethral sling procedure.
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What is the diagnosis?
The diagnosis is urinary stress incontinence. A male urethral sling is placed for men with stress urinary incontinence, most often as a result of prostate removal for prostate cancer. Stress incontinence is leaking when a man coughs, sneezes, or lifts. Candidates for this type of surgery are generally men with mild to moderate leakage (1-4 pads daily).
Ideally men considering a sling should also have good bladder function with a bladder capacity > 250 cc and no detrusor instability or overactive bladder. Cystoscopy is also performed prior to surgery to determine there is no bladder neck contracture or urethral strictures.
Men must also be able to demonstrate urethral sphincter function either on urodynamics testing, starting and stopping midstream of micturition, or demonstration of urethral sphincter recruitment and closure on cystoscopy.
With a man in stirrups under spinal or general anesthesia, perineal incision is made below the scrotum and above the anus. The urethra is identified and mobilized to allow it to move when the sling is tensioned.
Separate bilateral incisions in the inner thigh are made and using a helical trocar the sling arms are brought from the perineal incision around the pelvic bones through the obturator fossa.
The central portion of the mesh is fixed to the urethra and tensioning of the sling is done by pulling firmly on both arms of the sling.
Cystoscopy is performed to confirm coaptation of the urethra. Once coaptation is confirmed, the wound is closed.
Men spend one night in the hospital when I do the procedure with a catheter in place. The catheter is removed the next day and men are monitored to make sure they can urinat adequately after the procedure. Men must be able to pee the next day before discharge. Some men will need to go home with a catheter.
What are the benefits of the procedure?
The goal of the procedure is full continence or control of the urine. The male sling does not guarantee complete control.
What are the drawbacks and risks of the procedure?
As with any surgery there is a risk of infection, bleeding, anesthesia risk and of course the discomfort associated with surgery. These risks are relatively small for the urethral sling.
I think the elephant in the room is that a man has a relatively high rate of leakage when compared with the artificial sphincter.
For men who do have continued leakage after a sling has been placed we can still place an artificial urinary sphincter at a later time. Obviously the goal is to get it right the first time, but it is important to know that it is not an either or proposition for men.
Inability to urinate or urinary retention is also a risk if the sling ends up being too tight or causes too much restriction. Most often urine retention improves over time after the procedure but some men depend on intermittent catheterization after the procedure.
If the urethra is injured while placing the cuff, we need to stop the procedure and let that heal before attempting that again. That is rare but can occur.
Also rare is a reaction to the mesh that would cause erosion or extrusion of the mesh.
Finally, over the long term, as our body tissues change some men will experience an increase in leaking years after the sling has been placed.
Alternatives to the sling are continuing the use of the diapers or pads, using an external compression device on the penis such as a Cunningham clamp, biofeedback, and external catheterization such as a condom catheter. Several models from different manufacturers of the urethral sling exist. The artificial urinary sphincter is the alternative surgical approach.
How common is this procedure?
The male urethral sling is a common enough procedure. Most men who have had prostate removal do not need any surgery to help with urinary control or choose not to do any further treatment. But the number of surgeries done every year means there are enough men who have problems who need to have the sling placed.
Why now or when should a man have the procedure?
The timing of placing a male urethral sling is usually at least one year from the time of the prostatectomy. It takes time for some men to regain urinary control. Most of you listening this far already know that you have continued problems with incontinence. You have tried Kegel exercises, biofeedback and possibly medication. You have also tried the external compression devices and the urinary pads, and you are looking for a definitive solution. As I have said before if you are a man considering this procedure take your time making this decision.
Preparing for the procedure:
Normal recommendations for prior to any surgery
Do not eat or drink anything after midnight the night before the procedure.
You should take your usual medications as you normally would the morning of your procedure with a small sip of water or clear liquid only (avoid juice, milk, coffee).
Starting 5 to 10 days prior to your procedure (ask your doctor for a specific time), it is important to stop taking medications that might increase your risk of bleeding. For a list of blood-thinning medications that should be avoided.
Preparing your skin by washing with antibacterial soap or Hibiclens for a week prior to surgery will help decrease ethe bacterial count on your skin to help with infection.
Have a driver and know the route the hospital, how you will get home, and bow will take care of you when you do get home.
After the procedure:
You will stay the night in the hospital. Pain is controlled, you will eat a normal diet and begin to walk around after surgery right away.
We leave a catheter in overnight and remove the next day. One of the critical steps when removing the catheter is making sure a man can void after the procedure. There is some risk of retention. If you need a catheter when you go home we will decide when to remove it at that time.
You will go home on antibiotics. Take the complete course of antibiotics prescribed unless you have a reaction to the medicine.
I usually will have an appt with you 2 weeks after the operation.
Here is the critical, critical thing. Plan to do only light duty and limited activity for at least six weeks after surgery. The sling can move in position with too much lifting, bending, straining. It heals into place and the body fixes it in position but it takes a while to do. One of the big advantages of this surgery is the small incision we make, but this means that we aren’t sewing the sling to bone or other structures to fix it in place. Your body must do that. That takes time.
Yes, there is usually good insurance coverage for this procedure. There is a prior authorization process, and our business office will help guide you. Know that you have coverage for this procedure before you get to the hospital on the day of surgery. You don’t want to have to sort through the billing issues after the procedure