Introduction

The Advance male sling is a device made of synthetic material, that is surgically placed under the urethra to give it support. It treats stress urinary incontinence (leaking from physical exertion) in men. Once in place, the sling works on its own and does not need manipulation or activation when a patient is passing urine.

Advance XP Male Sling

Indications

In patients who suffer from mild to moderate levels of male stress urinary incontinence (see post prostatectomy urinary incontinence), the male sling is a good surgical option. It helps to treat or reduce the leaking with activities such as heavy lifting, coughing, sneezing, and exercising.

In patients with more severe levels of incontinence or those who had radiotherapy or an underactive bladder, the success rate is not as good comparatively. Therefore, patient selection is important and a proper assessment and discussion with your urologist is advised.

Preoperative Instructions

Inform your doctor if you are taking any of the medications below as you may have to withhold them before the surgery:

  • Certain newer diabetic medications such as Forxiga (Dapaglifozin), Jardiance (Empaglifozin), Xigduo XR (Dapaglifozin / Metformin), Glyxambi (Empaglifozin / Linagliptin), Jardiamet (Empaglifozin / Metformin) or Qtern (Saxagliptin / Dapaglifozin) – must be stopped 2 to 3 days prior to surgery.
  • Aspirin, Plavix, Iscover, Asasantin – must be stopped 7 days prior to surgery.
  • Xarelto, Eliquis (Apixaban) – must stopped 2 to 3 days prior to surgery.
  • Pradaxa, Warfarin – must be stopped 5 days prior to surgery.
  • Brilinta (Ticagrelor) – must be stopped 10 days prior to surgery.
  • Anti-inflammatories such as Brufen, Voltaren, Celebrex – must be stopped 7 days prior to surgery.

You will be given fasting instructions by your doctor. In general, you need to fast about 6 hours before the surgery.

See preparing for surgery, for more instructions.

Procedure

The surgery is usually done under general anaesthesia. It takes about 90 minutes to do. Most patients stay one night in the hospital. There is an incision in the perineum (area between the scrotum and anus) where the sling body is placed, and two small stab incisions (one on each inner thigh) where the sling arms are placed.

A catheter is placed in the penis to drain the bladder overnight. This is removed the following morning.

Postoperative Instructions

After any anaesthesia (general, spinal or sedation), do not undertake any of the following activities for 24 hours:

  • Driving a car.
  • Operating machinery.
  • Handling hot cooking instruments.
  • Drinking alcohol.

No squatting movement or any other movement that involves stretching the legs wide apart, for 6 weeks after surgery, as this may stretch the sling and make it loose. Swing the legs closed together when getting in and out of the car.

It is common for the urinary flow to slow down a bit, but it should not be a struggle to void each time.

Uncommonly, if you are unable to pass urine when the catheter is removed, another catheter may have to be placed for about 1-2 weeks. Alternatively, you may be taught to perform intermittent self-catheterisation, until the post-op swelling reduces and you are able to pass urine.

You will notice an improvement in the incontinence straight away when the catheter is removed the following day. However, you may not be 100% completely continent, but the sling will still greatly improve your leakage. The success rate of the procedure is >80%.

Finish your course of oral antibiotics as prescribed. Report to your doctor if you get fevers or wound discharge at home.

There may be swelling and bruising around the wound and scrotum. This may take a few days to a couple of weeks to settle down. You will be given pain relief medications if needed. Wear supportive underwear (not boxers).

Remove the dressings in 5 to 7 days’ time. Do not worry if they fall off before then. Just keep the wound clean. The dressings are waterproof and you can shower with them. The sutures are dissolvable, and take a few weeks to do so.

No driving for 2 weeks. No heavy lifting or strenuous exercises for 4 to 6 weeks. You can do light duties at home, walk up 1 to 2 flight of stairs or go for gentle walks in the park.

Risks

General risks:

  • Anaesthetic risks such as heart or lung problems.
  • Wound infection – you will be covered with antibiotics during and after the surgery.
  • Bleeding – it is uncommon to need a blood transfusion for this surgery.
  • Clots in the legs (DVT) or pulmonary emboli.
  • Chest infection, urinary tract infection.
  • Allergic reactions (e.g., to dressings, drugs etc.) – inform us if you have any known allergies.
  • Risk of death is a very rare complication that may arise from any surgery or anaesthetic. Modern medicine and anaesthesia have made this extremely rare. The risk varies with each individual’s general health conditions and the complexity of the surgery. The male sling surgery is not considered to be a major surgery.

Specific risks:

  • Inner leg pain (about 3%) – most of these are transient and resolve within days to a few weeks. Very rarely it may be chronic.
  • Urethral erosion – very rarely the sling may slowly grow into the urethra and damage it. When this happens, the patient may have pain, blood in the urine, difficulty voiding, or fevers. The sling has to be removed if so.
  • Urinary retention – Uncommonly, the sling may be too tight and a patient may still be unable to pass urine a few months after the surgery. It may have to be divided to lessen the tension.
  • Persistent urinary incontinence – in uncommon cases when this happen, an artificial urinary sphincter may still be placed safely, as the surgical fields are not in the same area.

Treatment Alternatives

An artificial urinary sphincter device may also be considered, especially if a patient has moderate to severe levels of incontinence.

If the incontinence is mild, a patient may continue to work on pelvic floor exercises (although this may not improve it further after 12 months).

A penile clamp can be used but is generally only recommended as a short-term option. There is a risk of penile and urethral damage with longer-term use.

See post prostatectomy urinary incontinence, for more information on treatment alternatives.