Skip to main content

Male Urethral Slings

Male urethral slings are minimally invasive devices used primarily for post-prostatectomy stress urinary incontinence (PPI), with overall success rates (cure + improvement) of 62–92% depending on sling design and incontinence severity.[1][2] Slings are a reasonable primary surgical option for mild-to-moderate male SUI; the artificial urinary sphincter (AUS) remains the gold standard for moderate-to-severe incontinence.[3]

Epidemiology and context​

Post-prostatectomy incontinence affects 5–20% of men long-term after radical prostatectomy and is the most common indication for male sling surgery. Other causes include SUI after TURP, HoLEP, or pelvic radiation. Conservative management — pelvic floor muscle training and behavioral therapy — should be attempted for 6–12 months before surgical intervention.[1][3]

Classification of male slings​

Male slings are broadly classified by mechanism of action and route of insertion.[2][4][5]

A. Fixed (non-adjustable) slings

  1. Retrourethral transobturator sling (AdVance / AdVance XP)
  2. Quadratic sling (Virtue)
  3. Bone-anchored sling (InVance) — largely historical
  4. Four-arm transobturator-prepubic slings (Surgimesh M-Sling)

B. Adjustable slings

  1. ATOMS (Adjustable Transobturator Male System)
  2. Argus / Argus T — adjustable retropubic / transobturator
  3. REMEEX — re-adjustable suburethral sling with suprapubic mechanical regulator

Mechanisms of action​

Understanding the mechanism is critical for patient selection and counseling.

SlingPrimary mechanismSecondary mechanism
AdVance / AdVance XPRepositioning of the lax membranous urethra proximallyLengthening of the functional urethral length
Virtue (quadratic)Ventral urethral elevation (transobturator arms)Urethral compression against the genitourinary diaphragm (prepubic arms)
Bone-anchored (InVance)Direct bulbar urethral compression—
ATOMSAdjustable bulbar urethral compression via inflatable cushion—
ArgusAdjustable urethral compression via silicone foam pad—

A dynamic-MRI study demonstrated that the transobturator sling works by lengthening the vesicourethral anastomosis-to-bulbar-urethra distance, restoring functional urethral length toward continent post-prostatectomy controls. At rest, functional urethral length increased from 1.27 cm pre-sling to 1.53 cm post-sling, approaching the 1.92 cm seen in continent controls (P = .09).[6]

AdVance / AdVance XP — retrourethral transobturator sling​

The most extensively studied male sling. The AdVance XP is the second-generation device with improved needle design and mesh anchoring.[9][10][11]

Technique​

  • Lithotomy position; perineal incision over the bulbar urethra
  • Polypropylene tape passed retrourethrally through the transobturator route (inside-out or outside-in)
  • The sling repositions the lax posterior urethra and membranous-sphincter complex proximally
  • Non-compressive — does not obstruct voiding
  • Operative time ~30–45 min; typically outpatient[9][12]

Patient selection — the "repositioning test"​

  • A positive repositioning test (improved coaptation of the membranous urethra with upward perineal pressure during cystoscopy) predicts success
  • Requires residual sphincter function — patients with intrinsic sphincter deficiency or absent coaptive zone are poor candidates[13][14]
  • Preoperative 24-hour pad weight <200–400 g and ≤2–3 pads/day favor success[13]

Outcomes​

StudyNFollow-upCureCure + improvedKey finding
Bauer 2009[9]12412 mo51.4%77.1%Prospective; QoL significantly improved
Cornu 2009[12]10213 mo (median)62.7%80.4%Prior radiation predicted higher failure (P = .039)
Rehder 2012[17]1563 yr—76.8%Stable efficacy at 3 yr; no worsening over time
Bauer 2017 (XP)[11]11536 mo66.0%89.4%Prospective multicenter; no erosions or explantations
Collado 2019[13]9449 mo (median)77%—Preoperative pad weight predicts outcome
Chua 2019[15]21556 mo (mean)44.7%69.8%Largest long-term series; severity and urgency predict failure
Papachristos 2018[18]7252 mo (median)51% (pad-free)76%Trend of declining continence beyond 4 yr

Key points

  • Cure rates decline over time — from ~65–77% at 1 yr to ~45–62% at 4–5 yr, though most patients remain improved[15][16][18]
  • Preoperative SUI severity is the strongest predictor of long-term success[15][16]
  • No erosions or explantations in most large series — a major advantage over compressive slings[11][13]

Virtue quadratic sling​

A unique four-arm design combining transobturator and prepubic fixation, providing both urethral relocation and compression.[7][19]

Technique​

  • Perineal incision; mesh placed beneath the bulbar urethra
  • Two transobturator arms through the obturator foramen → urethral elevation
  • Two prepubic arms anterior to the pubic bone → urethral compression
  • Intraoperative retrograde leak point pressure (RLPP) confirms adequate urethral resistance
  • The "fixation" technique (securing prepubic arms) significantly improved outcomes vs. the original unfixed design[7][19]

Outcomes​

StudyNFollow-upCureImprovementNote
Comiter 2014 (fixation)[19]—12 mo—70.9% subjective / 79.2% objectiveFixation technique critical; 88.3% pad-weight reduction
Ferro 2017[21]2936 mo—Significant improvement maintainedEffective for mild–moderate PPI
Roumeguère 2022[20]11736 mo19%51% objective / 34% subjectiveBMI, PVR, nocturia predict outcome

Combines two mechanisms (relocation + compression) — theoretically greater urethral resistance than pure transobturator slings. No explantations required in the European multicenter study. Cure rates are lower than AdVance under strict definitions, but improvement rates are substantial.[20]

Bone-anchored sling (InVance) — largely historical​

The first widely used male sling — silicone-coated polyester or polypropylene mesh secured to the inferior pubic rami with titanium bone screws.[2][22][23]

  • Success rates 40–88% (highly variable across series)[2]
  • Cure rates 39.5–87% depending on severity and sling material[22][23]
  • Mesh infection 2–12% — the major limitation, usually requiring explantation[2]
  • Silicone mesh outperformed porcine dermal collagen (87% vs. 56% cure)[22]
  • Severe incontinence, prior radiation, or prior AUS substantially worsened outcomes[23]
  • Largely abandoned due to high infection rates and superior alternatives[2]

ATOMS — Adjustable Transobturator Male System​

A self-anchoring transobturator device with an adjustable cushion filled via a subcutaneous titanium port, allowing postoperative titration of urethral compression.[8][24][25][26][27]

Technique​

  • Perineal incision; mesh with integrated silicone cushion placed beneath the bulbar urethra
  • Transobturator arms self-anchor to the inferior pubic ramus
  • Subcutaneous titanium injection port placed over the symphysis pubis
  • Postoperative saline injections through the port allow fine-tuning of urethral compression without reoperation
  • Mean number of adjustments: 2.4–3.97[8][24]

Outcomes​

StudyNFollow-upContinenceDry rateNote
Seweryn 2012[8]3816.9 mo84.2%60.5%First prospective study
Hoda 2013[27]9917.8 mo92%63%European multicenter; 34.3% had prior failed surgery
Doiron 2019[24]1609 mo (median)80.0%—Canadian multicenter; radiation → 62.5% vs 87.9%
Redmond 2021[26]28919.6 mo73.3%—Largest series; radiation HR 2.3, diabetes HR 2.2 predict failure
Bajaj 2024[25]14011 mo (median)82.9%76.4%Effective across all severity levels
Téllez 2024[28]4032.5 mo80% dry45% total continenceEffective after TURP / HoLEP, not just post-RP

Advantages

  • Postoperative adjustability — optimize continence without reoperation[8][24]
  • Effective even in severe incontinence (36% severe SUI in the Canadian series)[24]
  • Can be used after prior failed incontinence surgery (16–19% in large series)[24][26]
  • No urethral erosion reported in most series[8][27]

Complications

  • Explantation 4.4–7.9% (primarily port-related infection)[24][26]
  • Perineal / scrotal pain transient in ~69%, resolving within 3–4 weeks[27]
  • Port-related complications (infection, migration) 4–5%[24][26]

Adjustable retropubic slings — Argus, REMEEX​

Suburethral pad connected to retropubic traction threads with a suprapubic mechanical regulator, allowing postoperative tension adjustment.[2][29]

  • Success 61–79% at 26–45 mo follow-up[2][29]
  • Erosion 3–13%, infection 3–11% — significantly higher than transobturator slings[2]
  • Higher explantation rates than AdVance or ATOMS[2][5]
  • Bowel perforation has been reported during implantation (2/18 in one series)[29]
  • The re-adjustable feature is advantageous but comes with higher complication rates

Male sling vs. AUS — the MASTER trial​

The MASTER trial is the only RCT comparing male sling (transobturator) to AUS — 380 men across 27 UK centers.[1][30]

  • Primary outcome (continence at 12 mo): male 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 = .003)
  • ICIQ-UI SF: both groups improved; AUS slightly greater improvement (mean difference 1.4, P = .02)
  • Serious adverse events: fewer with sling (6 vs. 13)
  • All secondary outcomes that showed statistically significant differences favored AUS
  • Cost-effectiveness: sling more cost-effective (99% probability at £30,000 / QALY threshold), though slightly lower QALY gain[30]
  • Conclusion: both procedures improve symptoms and satisfaction, but overall secondary analyses favor AUS[1]

A propensity-score-matched study confirmed that for moderate SUI (3–5 pads/day), AUS significantly outperformed the fixed transobturator sling: 94.3% vs. 68.6% continence at 12 mo (P <.001).[31]

A single-surgeon series demonstrated that for mild SUI, sling success was 78%; for moderate SUI, AUS achieved 80% vs. only 63% for sling (P = .02).[32]

Current consensus (6th ICI; AUA / SUFU)[3]​

  • Mild SUI (≤2 pads/day): male sling is an acceptable first-line surgical option
  • Moderate SUI (3–5 pads/day): AUS preferred; sling may be offered with counseling about lower efficacy
  • Severe SUI (>5 pads/day): AUS recommended; slings have poor outcomes in this group

Predictors of failure​

Risk factorEffect on outcomeStrength of evidence
Prior pelvic radiationOR 0.67–0.68 for success/cure; ~3× higher explantation and infectionMeta-analysis (strongest predictor)[34]
Severe preoperative SUI (≥5 pads/day)Significantly lower cure and success ratesMultiple prospective studies[15][16]
Detrusor overactivityIndependent predictor of poor mid-term outcomeProspective / urodynamic[35]
Obesity (BMI >30)OR 7.9 for failure (AdVance); predictive in VirtueMultiple series[14][20]
Prior bladder neck stenosisOR 2.6 for failureProspective[14]
Weak residual sphincter / negative repositioning testOR 29.0 for failureProspective[14]
DiabetesHR 2.2 for failure (ATOMS)Multicenter[26]
Prior incontinence surgeryLower continence, improvement, satisfactionMultiple series[3][26]

Radiation is the single most important predictor of failure. A meta-analysis of irradiated vs. non-irradiated patients demonstrated significantly lower odds of success (OR 0.68, P <.001),[34] and single-institution experience with the AdVance sling specifically confirmed that radiation history materially worsens continence outcomes.[36]

Complications by sling type​

ComplicationAdVance / XPATOMSBone-anchoredArgus / REMEEXVirtue
Urinary retention (transient)12.9–15%2%5–12%VariableRare
Perineal / scrotal pain3% chronic69% transientCommon earlyVariable2.9%
Mesh infectionVery rare4–5% (port)2–12%3–11%None reported
Urethral erosionNone reportedNone reported1–3%3–13%None reported
ExplantationVery rare4.4–7.9%Common (infection)HigherNone reported
De novo urgency / OAB16%10.3%VariableVariable10.3%
Bowel injuryNot reportedNot reportedNot reported2/18 (Argus)Not reported

References for the table: AdVance / XP[9][11][13][33]; ATOMS[24][26][27]; bone-anchored[2][22][23]; adjustable retropubic[2][29]; Virtue[19][20].

Sling after failed sling, and sling before AUS​

A failed male sling does not preclude subsequent AUS implantation.[3] ATOMS can be used after prior failed incontinence surgery (16–19% of patients in large series).[24][26] Simultaneous male sling + penile prosthesis implantation is feasible and safe — social continence 72–100% and prosthesis satisfaction 84–100% in pooled series.[37]

Surgical technique — AdVance XP, step by step​

  1. Patient in lithotomy; Foley catheter in place
  2. Perineal incision 3–4 cm over the bulbar urethra, midway between scrotum and anus
  3. Dissection through bulbospongiosus to expose the bulbar urethra
  4. Mobilize urethra from the central tendon posteriorly
  5. Helical trocar needles passed from the perineal incision through the obturator membrane to small groin incisions (inside-out)
  6. Polypropylene mesh tape attached to the 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 — goal is relocation, not compression
  9. Mesh secured with non-absorbable sutures to bulbospongiosus — critical for long-term fixation; use of absorbable sutures with ≤4 stitches is an independent risk factor for failure (OR 8.4)[14]
  10. Cystoscopy to confirm no urethral injury and adequate coaptation
  11. Close perineal and groin incisions; Foley removed next day
  12. Operative time 30–45 min; typically same-day discharge[9][12]

Key takeaways​

  1. Male slings are best suited for mild-to-moderate SUI (≤2–3 pads/day); for moderate-to-severe SUI, the AUS provides superior outcomes.[1][3][31][32]
  2. The AdVance XP is the most studied fixed sling with the best safety profile (no erosions, no explantations in most series), but cure rates decline over time (~45–62% at 5 yr).[11][15][18]
  3. ATOMS offers postoperative adjustability and can be effective even in severe SUI and after prior failed surgery, though port-related complications occur in ~5%.[24][25][26]
  4. Radiation history is the strongest predictor of sling failure across all types — irradiated patients have ~33% lower odds of success and ~3× higher odds of explantation.[34]
  5. The MASTER trial showed noninferiority of sling vs. AUS at 12 mo, but all secondary outcomes favored AUS. The sling is more cost-effective but provides slightly less QALY gain.[1][30]
  6. Residual sphincter function is essential for transobturator sling success — a positive repositioning test and adequate coaptive zone on cystoscopy are prerequisites.[13][14]
  7. Male slings do not preclude subsequent AUS placement, making them a reasonable first-line option in appropriate candidates.[3]

References​

1. 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

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. 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. 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

6. 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

7. Comiter CV, Nitti V, Elliot C, Rhee E. A new quadratic sling for male stress incontinence: retrograde leak point pressure as a measure of urethral resistance. J Urol. 2012;187(2):563–568. doi:10.1016/j.juro.2011.09.152

8. 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

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. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Zuckerman JM, Edwards B, Henderson K, Beydoun HA, McCammon KA. Extended outcomes in the treatment of male stress urinary incontinence with a transobturator sling. Urology. 2014;83(4):939–945. doi:10.1016/j.urology.2013.10.065

17. 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

18. 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

19. Comiter CV, Rhee EY, Tu LM, Herschorn S, Nitti VW. The Virtue sling — a new quadratic sling for postprostatectomy incontinence — results of a multinational clinical trial. Urology. 2014;84(2):433–438. doi:10.1016/j.urology.2014.02.062

20. Roumeguère T, Elzevier H, Wagner L, et al. The Virtue quadratic male sling for postradical prostatectomy urinary incontinence: 3-year outcome measurements and a predictive model of surgical outcome from a European prospective observational study. Neurourol Urodyn. 2022;41(1):456–467. doi:10.1002/nau.24851

21. Ferro M, Bottero D, D'Elia C, et al. Virtue male sling for post-prostatectomy stress incontinence: a prospective evaluation and mid-term outcomes. BJU Int. 2017;119(3):482–488. doi:10.1111/bju.13672

22. Dikranian AH, Chang JH, Rhee EY, Aboseif SR. The male perineal sling: comparison of sling materials. J Urol. 2004;172(2):608–610. doi:10.1097/01.ju.0000132835.48647.23

23. Castle EP, Andrews PE, Itano N, et al. The male sling for post-prostatectomy incontinence: mean follow-up of 18 months. J Urol. 2005;173(5):1657–1660. doi:10.1097/01.ju.0000154782.86431.41

24. 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

25. 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

26. 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

27. 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

28. 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

29. Chiu LW, Chen WC, Hsieh PF, Chen YH, Huang CP. Efficacy and complications of the re-adjustable male sling system for stress urinary incontinence after radical prostatectomy. J Clin Med. 2022;11(22):6764. doi:10.3390/jcm11226764

30. 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

31. 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

32. 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

33. Leruth J, Waltregny D, de Leval J. The inside-out transobturator male sling for the surgical treatment of stress urinary incontinence after radical prostatectomy: midterm results of a single-center prospective study. Eur Urol. 2012;61(3):608–615. doi:10.1016/j.eururo.2011.10.036

34. 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

35. 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

36. 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

37. Ammirati E, Polisini G, Giammò A. Surgical treatment options and outcomes for concomitant treatment of post-prostatectomy erectile dysfunction and male stress urinary incontinence: a systematic review of the literature. Int J Impot Res. 2026;38(3):193–205. doi:10.1038/s41443-025-01202-7