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AdVance / AdVance XP — Retrourethral Transobturator Male Sling

The AdVance male sling (originally American Medical Systems, now Boston Scientific) is a retrourethral transobturator polypropylene mesh sling for mild-to-moderate post-prostatectomy stress urinary incontinence (PPI). First described by Rehder & Gozzi 2007, it is the most extensively studied male sling. The second-generation AdVance XP (2010) added revised mesh anchoring features and a redesigned needle to improve fixation and reduce migration.[1][2][3]

For positioning vs other male slings and the AUS, see Male Urethral Slings — chooser.

Mechanism​

Functional, non-obstructive. The AdVance repositions the lax and descended supporting structures of the external sphincter back to their pre-prostatectomy position, restoring functional urethral length and the coaptive zone.[4] A dynamic-MRI study showed the sling lengthens the vesicourethral-anastomosis-to-bulbar-urethra distance from 1.27 cm pre-sling to 1.53 cm post-sling at rest, approaching the 1.92 cm seen in continent post-prostatectomy controls (P = 0.09).[5]

The AdVance augments the residual sphincter — it does not replace it. Residual sphincter function must be present.

AdVance vs AdVance XP​

Hüsch 2018 (head-to-head): no significant difference in functional outcomes (ICIQ-SF, PGI, I-QoL, pad usage) between the two generations, but the XP had a significantly higher rate of postoperative urinary retention (p = 0.042) — likely reflecting the tighter anchoring profile.[6]

Patient selection — the "repositioning test"​

Performed during flexible cystoscopy preoperatively. Upward perineal pressure should improve coaptation of the membranous urethra and restore a visible coaptive zone of ≥ 1 cm. Patients without visible sphincter contractions or with a negative repositioning test are excluded — OR 29.0 for failure when the test is negative.[2][7]

Additional standard selection criteria:

  • Continent at night and at rest
  • No prior incontinence surgery (relative)
  • 24-hour pad weight < 400 g and ≤ 2–3 pads/day favor success[8]

Surgical technique — step by step​

  1. Lithotomy; Foley catheter in place
  2. Perineal incision 3–4 cm over the bulbar urethra, midway between scrotum and anus
  3. Dissect through bulbospongiosus to expose the bulbar urethra
  4. Mobilize urethra from the central tendon posteriorly
  5. Helical trocar needles passed inside-out from perineum through the obturator membrane to small groin incisions
  6. Polypropylene mesh tape attached to needles and drawn through the transobturator path
  7. Mesh positioned retrourethrally behind the bulbar urethra, creating a hammock
  8. Tension applied to reposition the membranous urethra proximally — the goal is relocation, not compression
  9. Mesh secured with non-absorbable sutures to bulbospongiosus — critical for long-term fixation; absorbable sutures with ≤ 4 stitches independently predict failure (OR 8.4)[7]
  10. Cystoscopy to confirm no urethral injury and adequate coaptation
  11. Close perineal and groin incisions; Foley out next day
  12. Operative time 30–45 min; typically same-day discharge or overnight stay[9][10]

Outcomes​

The evidence base consists of observational studies plus the MASTER RCT.

Short-to-medium term (1–3 yr)​

StudyNFollow-upCureCure + improvedNote
Bauer 2009[9]12412 mo51.4%77.1%Prospective single-center
Cornu 2009[10]10213 mo (median)62.7%80.4%Prior radiation predicted higher failure (p = 0.039)
Rehder 2012[11]1563 yr—76.8%Stable from 12 mo to 3 yr
Bauer 2017 (XP)[3]11536 mo66.0%89.4%Prospective multicenter; pad weight 272 → 21.8 g; no erosions or explantations
Ye 2018 (XP)[12]11324 mo22.6% (no leak / no pad)80.6% (≤ 1 PPD)Strict definition; reintervention 10%; Clavien IIIb 2.7%

Longer term (4+ yr)​

StudyNFollow-upCureCure + improvedNote
Grabbert 2019 (XP)[13]—48 mo71.7%86.7%13.3% failure
Collado 2019[8]9449 mo (median)77%—Preoperative pad weight predicts outcome
Chua 2019[14]21556 mo (mean)44.7%69.8%Largest long-term series; severity and urgency predict failure
Papachristos 2018[15]7252 mo (median)51% (pad-free)76%Australian cohort; objective dry only 38% by pad weight — declining continence beyond 4 yr

MASTER RCT (sling vs AUS)​

The MASTER trial is the only RCT comparing a male transobturator sling (predominantly AdVance) to AUS — 380 men across 27 UK centers.[16][17]

  • Primary outcome (continence at 12 mo): sling noninferior to AUS (87.0% vs 84.2% still incontinent by strict definition; risk difference 3.6%, 95% CI −11.6 to 4.6; non-inferiority p = 0.003)
  • ICIQ-UI SF: both improved; AUS slightly greater (mean difference 1.4, p = 0.02)
  • Serious adverse events: fewer with sling (6 vs 13)
  • All secondary outcomes that reached statistical significance favored AUS
  • Cost-effectiveness: sling more cost-effective (99% probability at £30,000 / QALY threshold), though slightly lower QALY gain

A propensity-score-matched study confirmed that for moderate SUI, AUS significantly outperformed the fixed sling: 94.3% vs 68.6% continence at 12 mo (p < 0.001).[18] A single-surgeon series found AUS 80% vs sling 63% in moderate SUI (p = 0.02), but sling 78% in mild SUI.[19]

Key points on durability​

  • Cure rates decline over time — from ~ 65–77% at 1 yr to ~ 45–62% at 4–5 yr, though most patients remain improved.[14][15]
  • Preoperative SUI severity is the strongest predictor of long-term success — Collado Serra 2013 quantified a 0.4% decrease in cure rate per 1 g increase in preoperative 24-h pad weight.[8][14]
  • No erosions or explantations in most large series — a major advantage over compressive slings.[3][8]

Complications​

Bauer 2010 (n = 156) overall complication rate 23.9%:[20]

  • Transient acute urinary retention 12.9–21.3% — self-limiting, resolves within 6 wk without intervention; the dominant complication
  • Sling explantation just 0.9%

MacAskill 2021 chronic-pain analysis: ~ 23% of men experience early postoperative pain, but the majority resolve within 4 weeks and only 2.3% remain with chronic pain (> 3 mo) — all of those resolved within 1 year.[21]

Erectile function (IIEF-5) and voiding parameters (IPSS, Qmax, PVR) are not significantly affected.[3][9] Reintervention rate ~ 10–12%.[11][12] Mesh erosion is essentially unreported across multiple series.[3][8]

Predictors of failure​

Risk factorEffectStrength of evidence
Prior pelvic radiationOR 0.66–0.68 for success; ~ 3× higher explantation and infectionMeta-analysis (strongest predictor)[22][23]
Severe preoperative SUI (≥ 5 PPD)Significantly lower cure / successMultiple prospective[14][15]
Detrusor overactivityIndependent predictor of mid-term failureProspective[24]
Obesity (BMI > 30)OR 7.9 for failureMultiple series[7]
Prior bladder-neck stenosisOR 2.6 for failureProspective[7]
Prior urethral stricture surgeryHigher failure (p = 0.013)Prospective[25]
Weak residual sphincter / negative repositioning testOR 29.0 for failureProspective[7]
Prior incontinence surgeryLower continence, improvement, satisfactionMultiple series[26]

Radiation is the single most important predictor. Ghaffar 2023 meta — irradiated patients OR 0.68, p < 0.001 for success; Torrey 2013 confirmed radiation history materially worsens AdVance outcomes.[22][23]

Salvage​

A failed AdVance sling does not preclude subsequent AUS implantation.[26] ATOMS is the best-evidenced second-line option after failed AdVance — Queissert 2021 multicenter (n = 88, 42.5-mo mean): 76.1% social continence / 56.8% pad-free.

Current positioning​

The AdVance XP is best suited for non-irradiated men with mild-to-moderate PPI (≤ 3 PPD or 24-h pad weight < 400 g) with a positive repositioning test.[3][11][19] Its advantages are minimally invasive technique, non-obstructive mechanism, preservation of the option for future AUS, and very low erosion / explantation rates. Main limitations: inferior efficacy vs AUS in moderate-to-severe SUI, poor outcomes in irradiated patients, and a trend toward declining continence beyond 4 years.

See Also​

References​

1. Welk BK, Herschorn S. The male sling for post-prostatectomy urinary incontinence: a review of contemporary sling designs and outcomes. BJU Int. 2012;109(3):328–344. doi:10.1111/j.1464-410X.2010.10502.x

2. Bauer RM, Kretschmer A, Stief CG, Füllhase C. AdVance and AdVance XP slings for the treatment of post-prostatectomy incontinence. World J Urol. 2015;33(1):145–150. doi:10.1007/s00345-014-1297-2

3. Bauer RM, Grabbert MT, Klehr B, et al. 36-month data for the AdVance XP male sling: results of a prospective multicentre study. BJU Int. 2017;119(4):626–630. doi:10.1111/bju.13704

4. Silva LA, Andriolo RB, Atallah ÁN, da Silva EM. Surgery for stress urinary incontinence due to presumed sphincter deficiency after prostate surgery. Cochrane Database Syst Rev. 2014;(9):CD008306. doi:10.1002/14651858.CD008306.pub3

5. Kahokehr AA, Selph JP, Belsante MJ, et al. Mechanism of action of the transobturator sling for post-radical prostatectomy incontinence: a multi-institutional prospective study using dynamic magnetic resonance imaging. Urology. 2018;116:185–192. doi:10.1016/j.urology.2018.01.053

6. Hüsch T, Kretschmer A, Thomsen F, et al. The AdVance and AdVanceXP male sling in urinary incontinence: is there a difference? World J Urol. 2018;36(10):1657–1662. doi:10.1007/s00345-018-2316-5

7. Soljanik I, Gozzi C, Becker AJ, Stief CG, Bauer RM. Risk factors of treatment failure after retrourethral transobturator male sling. World J Urol. 2012;30(2):201–206. doi:10.1007/s00345-011-0671-6

8. Collado A, Domínguez-Escrig J, Ortiz Rodríguez IM, et al. Functional follow-up after AdVance and AdVance XP male sling surgery: assessment of predictive factors. World J Urol. 2019;37(1):195–200. doi:10.1007/s00345-018-2357-9

9. Bauer RM, Mayer ME, Gratzke C, et al. Prospective evaluation of the functional sling suspension for male postprostatectomy stress urinary incontinence: results after 1 year. Eur Urol. 2009;56(6):928–933. doi:10.1016/j.eururo.2009.07.028

10. Cornu JN, Sèbe P, Ciofu C, et al. The AdVance transobturator male sling for postprostatectomy incontinence: clinical results of a prospective evaluation after a minimum follow-up of 6 months. Eur Urol. 2009;56(6):923–927. doi:10.1016/j.eururo.2009.09.015

11. Rehder P, Haab F, Cornu JN, Gozzi C, Bauer RM. Treatment of postprostatectomy male urinary incontinence with the transobturator retroluminal repositioning sling suspension: 3-year follow-up. Eur Urol. 2012;62(1):140–145. doi:10.1016/j.eururo.2012.02.038

12. Ye H, Haab F, de Ridder D, et al. Effectiveness and complications of the AMS AdVance male sling system for the treatment of stress urinary incontinence: a prospective multicenter study. Urology. 2018;120:197–204. doi:10.1016/j.urology.2018.06.035

13. Grabbert M, Mumm JN, Klehr B, et al. Extended follow-up of the AdVance XP male sling in the treatment of male urinary stress incontinence after 48 months: results of a prospective and multicenter study. Neurourol Urodyn. 2019;38(7):1973–1978. doi:10.1002/nau.24101

14. Chua ME, Zuckerman J, Mason JB, et al. Long-term success durability of transobturator male sling. Urology. 2019;133:222–228. doi:10.1016/j.urology.2019.07.032

15. Papachristos A, Mann S, Talbot K, Moon D. AdVance male urethral sling: medium-term results in an Australian cohort. ANZ J Surg. 2018;88(3):E178–E182. doi:10.1111/ans.13890

16. Abrams P, Constable LD, Cooper D, et al. Outcomes of a noninferiority randomised controlled trial of surgery for men with urodynamic stress incontinence after prostate surgery (MASTER). Eur Urol. 2021;79(6):812–823. doi:10.1016/j.eururo.2021.01.024

17. Constable L, Abrams P, Cooper D, et al. Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT. Health Technol Assess. 2022;26(36):1–152. doi:10.3310/TBFZ0277

18. Sacco E, Gandi C, Marino F, et al. Artificial urinary sphincter significantly better than fixed sling for moderate post-prostatectomy stress urinary incontinence: a propensity score-matched study. BJU Int. 2021;127(2):229–237. doi:10.1111/bju.15197

19. Khouri RK, Ortiz NM, Baumgarten AS, et al. Artificial urinary sphincter outperforms sling for moderate male stress urinary incontinence. Urology. 2020;141:168–172. doi:10.1016/j.urology.2020.03.028

20. Bauer RM, Mayer ME, May F, et al. Complications of the AdVance transobturator male sling in the treatment of male stress urinary incontinence. Urology. 2010;75(6):1494–1498. doi:10.1016/j.urology.2009.12.012

21. MacAskill F, Sheimar K, Toia B, et al. Prevalence of chronic pain following suburethral mesh sling implantation for post-prostatectomy incontinence. Neurourol Urodyn. 2021;40(4):1048–1055. doi:10.1002/nau.24666

22. Ghaffar U, Abbasi B, Fuentes JLG, et al. Urethral slings for irradiated patients with male stress urinary incontinence: a meta-analysis. Urology. 2023;180:262–269. doi:10.1016/j.urology.2023.07.022

23. Torrey R, Rajeshuni N, Ruel N, Muldrew S, Chan K. Radiation history affects continence outcomes after AdVance transobturator sling placement in patients with post-prostatectomy incontinence. Urology. 2013;82(3):713–717. doi:10.1016/j.urology.2013.03.075

24. Habashy D, Losco G, Tse V, Collins R, Chan L. Mid-term outcomes of a male retro-urethral, transobturator synthetic sling for treatment of post-prostatectomy incontinence: impact of radiotherapy and storage dysfunction. Neurourol Urodyn. 2017;36(4):1147–1150. doi:10.1002/nau.23078

25. Cornu JN, Sèbe P, Ciofu C, et al. Mid-term evaluation of the transobturator male sling for post-prostatectomy incontinence: focus on prognostic factors. BJU Int. 2011;108(2):236–240. doi:10.1111/j.1464-410X.2010.09765.x

26. Averbeck MA, Woodhouse C, Comiter C, et al. Surgical treatment of post-prostatectomy stress urinary incontinence in adult men: report from the 6th International Consultation on Incontinence. Neurourol Urodyn. 2019;38(1):398–406. doi:10.1002/nau.23845