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ATOMS — Adjustable Transobturator Male System

The ATOMS (Adjustable Transobturator Male System) (A.M.I., Feldkirch, Austria; first introduced 2008) is an adjustable, non-circumferential compression device for post-prostatectomy stress urinary incontinence. Unlike the AdVance, which depends on urethral repositioning and residual sphincter function, the ATOMS provides adjustable ventral compression of the urethra against the urogenital diaphragm — making it suitable across a broader severity range and uniquely well-suited to salvage after a failed AdVance.[1][2][3][4]

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

Not currently FDA-approved in the US; widely used in Europe, Canada, Australia, and New Zealand.

Device design and mechanism​

  • Polypropylene mesh with a central silicone cushion placed beneath the bulbar urethra via a transobturator approach.
  • Mesh arms pass outside-in through the obturator foramina, self-anchoring to the inferior pubic ramus.[5][6]
  • The cushion is connected via a conduit to a subcutaneous port for percutaneous saline adjustment in the office.
  • Mechanism: adjustable ventral compression — distinct from AdVance repositioning.[7][8]

Device generations — port design matters​

The ATOMS has evolved through three port designs that materially affect outcome and complication profiles:[9][10]

GenerationYearsPortKey issue
IP — Inguinal Port2009–2013Titanium, inguinalHighest port-complication and explant rate; 41% of removals from local titanium intolerance
SP — Scrotal Port2013–2015Manually-connectable titanium, scrotalShorter OR vs IP; titanium intolerance persists
SSP — Silicone-covered Scrotal Port2014–presentPre-connected, fully silicone-covered, scrotalCurrent standard; significantly fewer port complications (IP vs SSP p = 0.019; SP vs SSP p = 0.045) and better ICIQ-SF scores; meta-confirmed device-generation effect on dryness rate

The current SSP is the only generation that should be implanted today.

Surgical technique​

  • Perineal incision; mesh + cushion placed beneath the bulbar urethra.
  • Proximal-bulbar positioning per Queissert 2023 optimization (focuses cushion immediately below the proximal bulbar urethra).[11]
  • Transobturator arms (outside-in) self-anchor to the inferior pubic ramus.
  • Subcutaneous silicone-covered scrotal port (SSP) for percutaneous saline adjustment.
  • Mean OR time ~ 47 min (range 29–112).[6]
  • Postoperative saline adjustments: mean 2.4–3.8 to optimize continence.[6][12]

Outcomes​

StudyNFollow-upContinenceDry rateNote
Seweryn 2012[6]3816.9 mo84.2%60.5%First prospective study
Hoda 2013[5]9917.8 mo92%63%European multicenter; 34.3% had prior failed surgery
Friedl 2017 (long-term EMC)[10]28731 mo (median)90% overall success64%Pad use 4 → 1; pad test 400 → 18 mL (both p < 0.001)
Angulo 2018 (Iberian)[13]21524.3 mo—80.5% dry after adjustment96.2% mild / 75.3% mod-severe; 85.1% satisfaction
Doiron 2019[12]1609 mo (median)80.0%—Canadian multicenter; radiation → 62.5% vs 87.9%
Esquinas 2019 SR/meta[14]1,393 (20 studies)20.9 mo (mean)—67% pooled dry / 90% improvedPad count −4.14/d; 24-h pad test −443 mL
Redmond 2021[15]28919.6 mo73.3%—Largest series of 3rd-gen SSP only; radiation HR 2.3, diabetes HR 2.2 predict failure
Angulo 2020 (Iberian long-term)[16]21560.6 mo—72.1% dry at last FU (46% no pads / 26% security pad)Among initially dry: 96/93.6/91.1/89.2/86.7% sustained at 1/2/3/5/8 yr; explant 11.6%
Giammò 2023 (Italian long-term)[17]9962.9 mo (median)74.7%—Device survival 97/93/91/90/87.9% at 12/24/36/48/60 mo
Bajaj 2024[1]14011 mo (median)82.9%76.4%Effective across all severity levels
Téllez 2024[18]4032.5 mo80% dry45% total continenceEffective after TURP / HoLEP, not just post-RP

Comparative evidence​

vs ProACT — Angulo 2019 PLoS meta​

ATOMS superior across all endpoints: dry 68% vs 55% (p = 0.01); satisfaction 87% vs 56% (p = 0.002); explant 5% vs 24% (p < 0.001); working device at 1 / 2 / 3 yr 92 / 85 / 81% vs 76 / 61 / 58%.[19]

vs REMEEX — Angulo 2021 SR/meta (n = 1,919)​

ATOMS superior across every endpoint:[20]

OutcomeATOMSREMEEXp
Dryness69.3%53.4%0.008
Improvement90.8%80.2%0.007
Complication18.9%35.8%0.096 (NS)
Explantation5.5%13.9%0.027

Differences persist when restricted to current-generation devices (ATOMS SSP vs Remeex System II).

vs AUS​

  • Geretto 2023 propensity-matched (n = 49 each, 43-mo mean) — AUS dryness 44.9% vs ATOMS 22.5% (p = 0.03), but equivalent self-reported improvement (81% vs 71%); AUS had more high-grade complications, reinterventions, and explantations; device survival at 60 mo favored ATOMS (82% vs 67%, p = 0.03).[21]
  • Esquinas 2021 prospective (102 ATOMS / 27 AUS) — equivalent total dryness (76.5% vs 66.7%) and social continence despite AUS patients having more severe baseline disease; surgical revision higher with AUS (22.2% vs 6.9%, p = 0.029); device durability favored ATOMS.[22]

Salvage roles​

ATOMS after failed AdVance / AdVance XP​

Queissert 2021 multicenter (n = 88, 42.5-mo mean): 76.1% social continence / 56.8% pad-free; mean leakage 422 → 38 g/d (p < 0.001) — the strongest evidence for any second-line device after a failed fixed sling.[23]

After failed initial ATOMS​

Angulo 2021 international multicenter (n = 902): 8.65% revision rate at mean 4.1 yr; of 58 reimplants (31 repeat ATOMS / 27 AUS), repeat ATOMS outperformed AUS on pad test (p = 0.016), pad count (p = 0.029), satisfaction (p = 0.04), and PGI-I (p = 0.025), with equivalent complications.[24]

Predictors of failure​

  • Prior radiation — most consistent negative predictor. Doiron 2019 — 62.5% irradiated vs 87.9% non (p = 0.002), satisfaction 69.8% vs 93.2% (p = 0.001), explant HR 2.7 (p = 0.02). Angulo 2023 dedicated multicenter of 223 irradiated patients — 42.6% dry / 11.7% explant / 84% satisfied. Kidess 2025 — radiation timing matters; lower complete continence (21% vs 51%, p = 0.02) but comparable long-term continence.[12][25][26]
  • Diabetes — independent predictor (HR 2.2, p = 0.007).[15]
  • Higher baseline severity — independently predictive (HR 1.1 per pad).[15][16]
  • Prior urethral / bladder-neck stricture — Ullate 2022 multicenter — dry rate 38% vs 83% (p < 0.05).[27]
  • Positive preop urine culture, poor Charlson comorbidity index, prior devices — Friedl 2016 multicenter risk-factor analysis.[28]
  • Age and obesity were NOT significant predictors in most studies.[15][28]

Complications​

  • Major complications (Clavien III+): ~ 3.0% pooled / 4.4% Canadian.[12][14]
  • Explantation: 3.25–11.6% depending on follow-up and generation.
  • Reasons for explantation in long-term Iberian: inefficacy 44%, port erosion 40%, pain + inefficacy 12%, infection 4%.[16]
  • Transient perineal / scrotal pain common early (68.7% in one series), resolves within 3–4 weeks; no chronic pain signal.[6][10]
  • Very low erosion (essentially unreported).[6][5][14]

Current positioning​

The ATOMS is a versatile, adjustable, minimally invasive device suitable for mild-to-severe post-prostatectomy SUI in both primary and salvage settings. Its key advantages:

  • Postoperative adjustability in clinic via SSP — no reoperation.[6][12]
  • Effective across all severity strata (96.2% mild → 75.3% mod-severe per Iberian).[13]
  • Very low erosion; superior device durability vs ProACT and comparable / superior vs AUS.[19][21]
  • Best-evidenced second-line option after failed fixed sling.[23]

Main limitations: absence of RCTs, reduced efficacy in irradiated patients and those with prior stricture, need for multiple office adjustments, and current US unavailability.

See Also​

References​

1. Bajaj M, Frampton C, Losco G, Westenberg A. Adjustable transobturator male system (ATOMS) for stress urinary incontinence: the evidence is mounting. BJU Int. 2024;133(Suppl 3):33–38. doi:10.1111/bju.16118

2. 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

3. 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

4. Sahai A, Abrams P, Dmochowski R, Anding R. The role of male slings in post-prostatectomy incontinence: ICI-RS 2015. Neurourol Urodyn. 2017;36(4):927–934. doi:10.1002/nau.23264

5. Hoda MR, Primus G, Fischereder K, et al. Early results of a European multicentre experience with a new self-anchoring adjustable transobturator system for treatment of stress urinary incontinence in men. BJU Int. 2013;111(2):296–303. doi:10.1111/j.1464-410X.2012.11482.x

6. Seweryn J, Bauer W, Ponholzer A, Schramek P. Initial experience and results with a new adjustable transobturator male system for the treatment of stress urinary incontinence. J Urol. 2012;187(3):956–961. doi:10.1016/j.juro.2011.10.138

7. Comiter C. Surgery for postprostatectomy incontinence: which procedure for which patient? Nat Rev Urol. 2015;12(2):91–99. doi:10.1038/nrurol.2014.346

8. 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

9. Mühlstädt S, Friedl A, Zachoval R, et al. An overview of the ATOMS generations: port types, functionality and risk factors. World J Urol. 2019;37(8):1679–1686. doi:10.1007/s00345-018-2548-4

10. Friedl A, Mühlstädt S, Zachoval R, et al. Long-term outcome of the adjustable transobturator male system (ATOMS): results of a European multicentre study. BJU Int. 2017;119(5):785–792. doi:10.1111/bju.13684

11. Queissert F, Bruecher B, Schrader AJ. A new proximal adjustable sling ATOMS SSP implantation technique with focus on the urethral bulb: lessons learned from revision surgery. J Clin Med. 2023;12(13):4409. doi:10.3390/jcm12134409

12. Doiron RC, Saavedra A, Haines T, et al. Canadian experience with the adjustable transobturator male system for post-prostatectomy incontinence: a multicenter study. J Urol. 2019;202(5):1022–1028. doi:10.1097/JU.0000000000000420

13. Angulo JC, Cruz F, Esquinas C, et al. Treatment of male stress urinary incontinence with the adjustable transobturator male system: outcomes of a multi-center Iberian study. Neurourol Urodyn. 2018;37(4):1458–1466. doi:10.1002/nau.23474

14. Esquinas C, Angulo JC. Effectiveness of adjustable transobturator male system (ATOMS) to treat male stress incontinence: a systematic review and meta-analysis. Adv Ther. 2019;36(2):426–441. doi:10.1007/s12325-018-0852-4

15. Redmond EJ, Nadeau G, Tu LM, et al. Multicentered assessment of clinical outcomes and factors associated with failure of the adjustable transobturator male system (ATOMS). Urology. 2021;148:280–286. doi:10.1016/j.urology.2020.09.045

16. Angulo JC, Virseda-Chamorro M, Arance I, et al. Long-term outcome of adjustable transobturator male system for stress urinary incontinence in the Iberian multicentre study. Neurourol Urodyn. 2020;39(6):1737–1745. doi:10.1002/nau.24410

17. Giammò A, Ammirati E. Long-term survival rate of ATOMS implant for male stress urinary incontinence and management of late complications. J Clin Med. 2023;12(6):2296. doi:10.3390/jcm12062296

18. Téllez C, Diego R, Szczesniewski J, et al. Results of adjustable transobturator male system for stress urinary incontinence after transurethral resection or holmium laser enucleation of the prostate: international multicenter study. J Clin Med. 2024;13(16):4628. doi:10.3390/jcm13164628

19. Angulo JC, Schönburg S, Giammò A, et al. Systematic review and meta-analysis comparing adjustable transobturator male system (ATOMS) and adjustable continence therapy (ProACT) for male stress incontinence. PLoS One. 2019;14(12):e0225762. doi:10.1371/journal.pone.0225762

20. Angulo JC, Ruiz S, Lozano M, et al. Systematic review and meta-analysis comparing adjustable transobturator male system (ATOMS) and male readjustment mechanical external (REMEEX) system for post-prostatectomy incontinence. World J Urol. 2021;39(4):1083–1092. doi:10.1007/s00345-020-03300-1

21. Geretto P, Ammirati E, Falcone M, et al. Comparison study between artificial urinary sphincter and adjustable male sling: a propensity-score-matched analysis. J Clin Med. 2023;12(17):5489. doi:10.3390/jcm12175489

22. Esquinas C, Ruiz S, de Sancha E, et al. Outcomes of a series of patients with post-prostatectomy incontinence treated with an adjustable transobturator male system or artificial urinary sphincter. Adv Ther. 2021;38(1):678–690. doi:10.1007/s12325-020-01563-z

23. Queissert F, Rourke K, Schönburg S, et al. ATOMS (adjustable transobturator male system) is an effective and safe second-line treatment option for recurrent urinary incontinence after implantation of an AdVance/AdVance XP fixed male sling? A multicenter cohort analysis. J Clin Med. 2021;11(1):81. doi:10.3390/jcm11010081

24. Angulo JC, Schönburg S, Giammò A, et al. Artificial urinary sphincter or a second adjustable transobturator male system offer equivalent outcomes in patients whom required revision on the initial ATOMS device: an international multi-institutional experience. Neurourol Urodyn. 2021;40(3):897–909. doi:10.1002/nau.24646

25. Angulo JC, Téllez C, Giammò A, et al. Results of adjustable trans-obturator male system in patients with prostate cancer treated with prostatectomy and radiotherapy: a multicenter study. J Clin Med. 2023;12(14):4721. doi:10.3390/jcm12144721

26. Kidess M, Lederer E, Pyrgidis N, et al. Adjustable transobturator male system (ATOMS) after radiotherapy: is timing everything? A single-center experience. Neurourol Urodyn. 2025. doi:10.1002/nau.70158

27. Ullate A, Arance I, Virseda-Chamorro M, et al. ATOMS (adjustable trans-obturator male system) in patients with post-prostatectomy incontinence and previously treated urethral stricture or bladder neck contracture. J Clin Med. 2022;11(16):4882. doi:10.3390/jcm11164882

28. Friedl A, Mühlstädt S, Rom M, et al. Risk factors for treatment failure with the adjustable transobturator male system incontinence device: who will succeed, who will fail? Results of a multicenter study. Urology. 2016;90:189–194. doi:10.1016/j.urology.2015.12.044