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Also known as
Male urethral sling, Retropubic urethral sling, Male suburethral sling, Retropubic suburethral sling, Pubovaginal male sling, Male incontinence sling, Retropubic male urethral support system
Definition
A retropubic male sling is a minimally invasive surgical device designed to treat male stress urinary incontinence (SUI) by providing support to the bulbar urethra.1 The sling is positioned beneath the anterior bulbous urethra via a retropubic approach, passing behind the pubic bone.2 This placement creates a hammock-like support structure that exerts compression on the bulbous urethra, effectively repositioning the proximal urethra and aligning it with the urethral sphincter complex.3 By bolstering urethral support, the sling prevents leakage during activities that increase intraabdominal pressure, such as coughing, sneezing, or lifting.4 The primary purpose of this procedure is to restore continence in men experiencing mild to moderate stress urinary incontinence, particularly following prostate surgery.5
Clinical Context
The retropubic male sling is primarily indicated for men with mild to moderate stress urinary incontinence (SUI), typically defined as using 0 to 2 pads per day or having a total pad weight of less than 500 grams in 24 hours.1 Some experts suggest a 24-hour urine pad weight of 150 grams or less as a cutoff indication for urethral sling placement.2 The most common cause of male SUI is radical prostatectomy, affecting approximately 5% to 10% of men 65 years and older, with as many as 60% of men experiencing some degree of urinary incontinence following prostatectomy.3
Patient selection is crucial for optimal outcomes. Ideal candidates should demonstrate some degree of residual voluntary sphincter function, which can be evaluated endoscopically during awake cystoscopy or through urodynamic studies.4 Patients must generate sufficient bladder pressure to surmount the urethral resistance the sling produces.5 A Valsalva leak point pressure (VLPP) greater than 60cmH₂O is associated with higher success rates, with some studies suggesting that a VLPP greater than 100cmH₂O correlates with even better outcomes.6
The retropubic approach for male sling insertion employs both perineal and abdominal incisions.7 The procedure involves placing the sling under the bulbar urethra and anchoring it to the rectus fascia or pubic bone, creating tension that compresses and elevates the urethra.8 This anatomical change lengthens the functional membranous urethra from a mean of 3mm to 17.2mm, which contributes to improved continence.9
Success rates for the retropubic male sling range from 70% to 90% in appropriately selected patients, with most studies reporting significant improvements in quality of life.10 However, a history of pelvic radiotherapy is associated with lower success rates and is considered a relative contraindication by many surgeons.11 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 volumes.12