Infla10® Pulse™Also Known As
Transobturator male sling, TOT sling, male suburethral sling, transobturator tape, male TOT, transobturator suburethral sling, male urethral sling (transobturator approach), AdVance sling, AdVance XP sling, Virtue male sling, I-STOP TOMS, Argus-T, ATOMS (Adjustable Transobturator Male System)
Definition
A transobturator male sling is a minimally invasive surgical device designed to treat male stress urinary incontinence (SUI), particularly following prostate surgery1. The device consists of a synthetic mesh or tape that is placed through the obturator foramen to provide support to the bulbar urethra2. The sling acts like a hammock beneath the urethra, exerting compression on the bulbous urethra and repositioning the proximal urethra3. This mechanism aids in urethral coaptation, effectively curbing urinary leakage by aligning the urethral sphincter complex and enhancing continence4.
The transobturator approach involves passing the sling arms through the obturator foramen, a triangular opening in the pelvic bone, rather than through the retropubic space5. This surgical technique requires making a perineal incision to access the bulbar urethra, followed by creating paths for the sling arms through the obturator foramen using specialized trocars6. The sling is then anchored to the ventral urethra and tensioned appropriately to elevate the urethra and restore continence7.
Modern transobturator male slings can be categorized into adjustable or non-adjustable types8. The non-adjustable slings provide fixed compression, while adjustable slings allow for post-operative tension modification to optimize continence outcomes9. These devices not only provide direct compression of the bulbar urethra but also allow for proximal urethral relocation by realigning the mobile sphincter complex to provide further urethral sphincter complex coaptation10.
Clinical studies have demonstrated that transobturator male slings can significantly improve urethral closure pressure and membranous urethral length, with cure rates (defined as no pad usage) of approximately 40% and improvement rates (reduced to 1-2 pads per day) of about 30%11. The procedure is generally well-tolerated by patients, with high satisfaction rates reported in clinical trials12.
Clinical Context
The transobturator male sling is primarily used in the clinical management of male stress urinary incontinence (SUI), particularly following radical prostatectomy1. Approximately 5% to 10% of men 65 years and older experience some form of urinary incontinence, and as many as 60% of men experience some degree of urinary incontinence following prostatectomy2-3. When conservative management approaches such as lifestyle modifications, pelvic floor physical therapy, bladder retraining, and medications prove ineffective, surgical options like the transobturator male sling are considered4.
Patient Selection Criteria
The ideal candidate for a transobturator male sling is a man with mild-to-moderate urine leakage, characterized as using 0 to 2 pads per day or having a total pad weight of less than 500 grams in 24 hours5. Some experts have suggested a 24-hour urine pad weight of 150 grams or less as a cutoff indication for urethral sling placement6. The procedure is most suitable for patients who have not responded adequately to conservative management but still exhibit some degree of residual voluntary sphincter function7-8.
Patient selection is critical for optimal outcomes. The transobturator male sling is generally not recommended for patients with severe incontinence (using more than 3 pads per day or having a pad weight exceeding 500g/24h), as these patients may benefit more from an artificial urinary sphincter9. Additionally, patients must be able to generate sufficient bladder pressure to surmount the urethral resistance produced by the sling10.
While a history of pelvic radiotherapy is not an absolute contraindication to male sling placement, it may affect outcomes and should be considered in the decision-making process11. Other relative contraindications include detrusor instability, active urinary tract infection, bladder outlet obstruction, small bladder capacity, recurrent urethral strictures, and high post-void residual urine volumes12.
Surgical Procedure
The transobturator male sling procedure is performed with the patient in the dorsal lithotomy position13. After administering prophylactic antibiotics, the surgical field is prepared and draped in a sterile fashion. A 16F indwelling catheter is typically placed to reduce the risk of intraoperative bladder perforation14.
The procedure involves creating a 5-cm vertical midline perineal incision centered over the mid-bulbar urethra15. The bulbospongiosus muscle is sharply dissected to expose the ventral urethra, and the perineal body or central perineal tendon is divided16. The trocar insertion sites are identified, and the trocars are passed through the obturator foramen with careful attention to avoid injury to surrounding structures17.
The sling is secured to the trocars and brought through the obturator foramen on both sides18. It is then anchored to the ventral urethra using absorbable sutures, with the proximal aspect positioned distal to the insertion of the central perineal tendon19. The sling arms are tensioned to elevate the urethra appropriately, and excess material is trimmed20. The bulbospongiosus muscle is reapproximated to cover the urethra and sling body, and all incisions are closed21.
Expected Outcomes
Following transobturator male sling placement, patients typically experience significant improvement in continence. Studies have reported cure rates (defined as no pad usage) of approximately 40% and improvement rates (reduced to 1-2 pads per day) of about 30%22. The procedure has been shown to improve urethral closure pressure from a mean of 13.2 cmH₂O to 86.4 cmH₂O and increase membranous urethral length from a mean of 3 mm to 17.2 mm23.
Recovery usually involves a short hospital stay, often with same-day discharge24. Patients may experience temporary urinary retention requiring catheterization for a few days due to post-operative swelling25. Most patients can return to normal daily activities within 2 to 6 weeks, with restrictions on heavy lifting, strenuous exercise, and sexual activity as advised by the surgeon26.
Potential complications include temporary difficulty urinating, development or worsening of urge incontinence, urinary tract infection, wound infection, pain (groin, pelvic, or during intercourse), and rarely, injury to the bladder, urethra, or blood vessels27. Long-term follow-up is essential to monitor continence outcomes and address any complications that may arise28.