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Male Urethral Slings & Implant Devices — Chooser

Male SUI implants divide into fixed slings, adjustable slings, periurethral balloons, and the AUS. Each device has its own canonical page; this article is the decision-and-comparison hub that ties them together.

Per-device deep-dives​

ClassDevicePage
Fixed slingAdVance / AdVance XPadvance-sling
Fixed slingVirtue (quadratic)virtue-sling
Adjustable slingATOMSatoms-sling
Adjustable slingArgus (Classic / T)argus-sling
Adjustable slingREMEEX (MRS)remeex-mrs
Periurethral balloonProACTproact-balloons
SphincterArtificial Urinary Sphincterartificial-urinary-sphincter

The historical bone-anchored InVance sling (silicone-coated mesh secured to the inferior pubic rami with titanium screws) is mentioned in many older guidelines; a review reported mesh infection in 2–12% of bone-anchored sling series.[36]

An earlier rectus-anchored bulbourethral sling preceded the bone-anchored InVance: three parallel bolsters, each an outer layer of PTFE vascular graft and an inner layer of woven polyester, were placed beneath the bulbous urethra over the bulbocavernosus muscle and anchored by paired polypropylene sutures passed retropubically and tied over buttons on the anterior rectus fascia, with each bolster 6 mm in diameter and 4 cm long.[28] The procedure was originally reported in a 64-man series (56% dry after a single procedure, rising to 75% dry or improved after selective retightening).[27]

Perioperative Basics​

Positioning (lithotomy) and intraoperative catheter use are device-specific. No sling or periurethral-balloon device carries a device-specific VTE recommendation. These are short perineal or transobturator implant procedures, so apply the general incontinence-procedure risk framework (age, obesity, prior VTE, malignancy, prolonged operation or immobility) on the VTE Prophylaxis page.

Mechanism comparison​

DeviceMechanismKey clinical implication
AdVance / XPRepositioning of the lax membranous urethra proximally — non-obstructiveRequires residual sphincter function; a positive repositioning test on cystoscopy is the usual selection step, although controlled studies have not shown that it predicts success[20]
Virtue (quadratic)Ventral elevation (transobturator arms) + compression (prepubic arms)Dual mechanism in theory; long-term durability disputed (one single-institution series with 68% failure at 55 months led its authors to abandon the device)[19]
ATOMSAdjustable ventral compression of the bulbar urethra against the urogenital diaphragmReported effective across severity strata in cohorts, though severity, radiation and diabetes predict failure; office-based percutaneous saline adjustment
ArgusCompression + mechanical washer adjustmentPain, erosion and explantation reported in some cohorts; rates depend on series and route
REMEEXCompression + suprapubic varitensor adjustmentPostoperative adjustment uses the suprapubic varitensor; later readjustment requires a minor procedure to reconnect the manipulator.[37] Retropubic passage carries bladder and bowel-injury risk
ProACTPeriurethral balloon compression at the bladder neck (focal, non-circumferential)Adjustable scrotal port; high explantation rate (all-cause 27%, range 7–55%, in the guideline review); offered only to non-irradiated men[20]
AUS (AMS-800)Hydraulic circumferential cuff at bulbar urethra; patient-activated pumpMost predictable and reliable option for mild through severe SUI (AUA/GURS/SUFU 2024)[20]; manual-dexterity prerequisite

A prospective dynamic-MRI study suggested that one possible transobturator-sling mechanism is lengthening the vesicourethral-anastomosis-to-bulbar-urethra distance: at rest, functional urethral length was 1.27 cm before sling placement (n = 17) and 1.53 cm afterward, versus 1.92 cm in continent post-prostatectomy controls (n = 14); the reported P = 0.09 compares the post-sling group with controls, not the pre/post change.[1]

Decision matrix — which device for which patient​

The AUA/GURS/SUFU 2024 guideline recommends discussing male slings for mild-to-moderate SUI , not routinely implanting them for severe SUI , and says clinicians may offer adjustable balloons to non-radiated men with mild-to-severe SUI .[20] The EAU 2026 guideline recommends offering AUS or ProACT implantation only in expert centres .[40] Before implant selection, confirm stress urinary incontinence by history, examination, or ancillary testing , and perform cystourethroscopy to assess urethral and bladder pathology .[20] In men with severe radiation cystitis or advanced neurogenic dysfunction and suspected poor bladder compliance, urodynamics can assess storage pressure before sling or AUS surgery. Elevated pressures can be treated and rechecked before surgery; patients who proceed while at risk can be followed with periodic upper-tract imaging and/or urodynamics.[20] Treat symptomatic vesicourethral anastomotic stenosis or bladder-neck contracture before incontinence surgery ; after treating vesicourethral anastomotic stenosis, repeat cystoscopy at least four to six weeks later to document stability, and counsel that AUS is generally favored over a sling in this subgroup.[20] A sling is reasonable when the patient has not been irradiated and has minimal nocturnal leakage or isolated climacturia, or cannot operate an AUS because of hand function or cognition.[20]

Clinical scenarioFirst choiceAlternative(s)Avoid
Mild SUI, no radiation, positive repositioning testAdVance / XPATOMS, ProACT—
Moderate SUI, no radiationDiscuss AUS and a male sling . In the overall MASTER randomized cohort, sling was noninferior on the strict self-reported continence composite at 24 months, while symptoms and further surgery favored AUS.[20][21]ATOMS, AdVance XP. In Sacco's observational 35-pair comparison of AUS with the TiLOOP fixed sling, 33/35 (94.3%) versus 24/35 (68.6%) met the 12-month composite of at least “much improved” without further incontinence surgery or explantation.[3]Fixed sling alone if radiation history
Severe SUIAUSProACT in non-irradiated men [20]; ATOMS in selected cases (observational data)Fixed sling (AUA 2024: do not routinely implant in severe SUI)[20]
Mild–moderate, declines AUS pump but accepts an implantDiscuss a fixed male sling when residual sphincter function is adequate [20]Consider ProACT in selected non-irradiated men with repeat-adjustment and explant counseling [20]; urethral bulking only in limited circumstances—
SUI with prior pelvic radiationOffer AUS over a sling or adjustable balloon [20], with higher tissue-risk counselingSelected ATOMS series report lower success than non-irradiated cohortsProACT after radiation (AUA 2024 limits it to non-irradiated men; EAU advises against); counsel poorer fixed-sling outcomes
SUI after urethral reconstructionConsider AUS after individualized urethral assessment and counseling about higher complication risk [20]—Fixed male sling after most anterior or posterior urethral reconstructions
Recurrent SUI after failed AdVanceRe-evaluate the cause, then recommend AUS (AUA/GURS/SUFU 2024)[20]; selected ATOMS salvage is an alternativeQueissert's 88-man second-line ATOMS cohort reported 67/88 (76.1%) with no pad or one security pad and ≤20 mL on 24-h pad testing at mean 42.5 mo[34]; no randomized comparison to salvage AUS—
Recurrent SUI after failed ATOMSRe-evaluate the cause, then recommend AUS .[20]Repeat ATOMS may be considered in selected men. Angulo 2021 retrospectively compared 31 repeat ATOMS and 27 AUS implants after ATOMS revision for mixed indications; at mean 29.1-month follow-up, pad test, pad count, satisfaction and PGI-I favored repeat ATOMS, but treatment was selected by the surgeon.[35]—
Recurrent SUI after failed AUSEvaluate cause, then consider cause-specific AUS revisionComponent replacement, cuff revision or selected tandem-cuff approach—
Concomitant ED + SUIAUS + IPP, concomitant or staged (AUA 2024 conditional recommendation; counsel on longer operation and possible higher reoperation risk)[20]Sling + IPP—
Devastated outlet, all options exhaustedBladder-neck closure + MitrofanoffUrinary diversionContinued failed reconstruction

Climacturia​

Climacturia is involuntary urine loss during orgasm. In a mailed survey of 906 men treated for prostate cancer, 412 responded and 75.2% of respondents were sexually active or experiencing orgasms; within that subgroup, 28.3% after surgery alone and 5.2% after radiation alone reported climacturia.[24] Rates after prostatectomy appear to decline with time since surgery.[20] First-line management is behavioral: voiding immediately before sexual activity, condom use, or a penile constriction ring or loop during intercourse. Pelvic floor muscle training may also help; a randomized trial in men with persistent erectile dysfunction 12 months after nerve-sparing radical prostatectomy found better erectile function and climacturia improvement after three months of training, at 15 months after surgery.[25] When conservative measures fail, a standard incontinence procedure (fixed sling or AUS, per the decision matrix above) treats climacturia along with any concurrent stress incontinence.

A dedicated combined procedure also exists for the man having simultaneous penile prosthesis surgery: the mini-sling (Andrianne mini-jupette), a small mesh or allograft sutured across the bulbar urethra to the corporal bodies at the time of inflatable penile prosthesis placement, which compresses the urethra passively when the prosthesis is inflated. In 5-year follow-up of the original multicenter pilot cohort (23 of the original 38 patients evaluable, mean 59 months), 91% reported subjective improvement in SUI and 73% in climacturia; mean pad use fell from 1.4 to 0.4 per day; one patient required subsequent AUS placement.[26]

Comparative-meta snapshot​

ComparisonSourceVerdict
Sling vs AUS (overall)MASTER RCT, Abrams 2021 and Constable 2026 (380 randomized; 12- and 24-month outcomes)[2][21]Sling noninferior on the strict self-reported continence composite at both time points; symptom and satisfaction measures and further surgery favored AUS
Sling vs AUS (moderate SUI)Sacco 2021 propensity-matched, retrourethral TiLOOP sling vs AMS 800[3]AUS 94.3% vs sling 68.6% met the 12-mo composite of at least "much improved" without further incontinence surgery or explantation (p < 0.001)
Sling vs AUS (mild vs moderate)Khouri 2020[4]Single-surgeon AdVance series: mild — sling 78%; moderate — AUS 80% vs sling 63% (p = 0.02)
Adjustable sling vs AUS (subjective dry)Grabbert 2019 multicenter[5]Among men with postoperative subjective continence data, AUS 126/220 (57.3%) vs adjustable sling 18/82 (22.0%) reported complete dryness at maximum follow-up (p < 0.001); retrospective, and AUS patients had more severe baseline incontinence
ATOMS vs ProACTAngulo 2019 PLoS meta[6]Observational studies only; ATOMS higher no-pad or one safety-pad/day rate after initial adjustment (68% vs 55%), satisfaction and lower pooled explant rate (5% vs 24%); complication rate did not differ significantly (17% vs 26%, p = 0.07); in four durability studies (two per device), working device at 3 yr 81% vs 58%
ATOMS vs REMEEXAngulo 2021 SR/meta (n = 1,919)[7]Observational studies only; ATOMS higher no-pad or one safety-pad/day rate after adjustment (69.3% vs 53.4%, p = 0.008) and lower explantation (5.5% vs 13.9%, p = 0.027); complication rates 18.9% vs 35.8% (p = 0.096)
ATOMS vs AUS — durabilityGeretto 2023 propensity-matched[8]49 matched pairs: AUS higher dryness (44.9% vs 22.5%) but more high-grade complications, reinterventions and explantations; Kaplan–Meier freedom from explantation at 60 mo favors ATOMS (82% vs 67%, p = 0.03)

MASTER trial — the definitive sling-vs-AUS RCT​

The MASTER trial is the only RCT comparing male transobturator sling (predominantly AdVance) to AUS, with 380 men across 27 UK centers.[2][9]

  • Design (protocol): a pragmatic noninferiority trial. The primary outcome was any leakage reported on either ICIQ-UI SF frequency or amount question at 12 months, and the prespecified noninferiority margin was 15 percentage points. Eligible men had urodynamic stress incontinence after radical prostatectomy or TURP; men with a prior sling or AUS, unresolved bladder neck contracture or urethral stricture, or insufficient dexterity to operate an AUS were excluded. Allocation was minimized on prostate operation, prior radiotherapy and center. The protocol did not specify a sling brand, only a suburethral transobturator type. The planned sample was 180 men per group; 380 were randomized.[23]
  • Primary outcome (continence at 12 mo): male sling noninferior to AUS on the two-item self-reported leakage composite: 134/154 (87.0%) versus 133/158 (84.2%) still reported leakage at 12 months, among 190 randomized to each arm.[9] Both papers' risk-difference figures describe this same composite continence comparison and favor the AUS, whose recipients had the lower incontinence rate: intention-to-treat success risk difference −3.4%, 95% CI −11.7 to 4.8, non-inferiority p = 0.003 in the full report[9]; the 2021 article's results table gives −3.6%, 95% CI −11.6 to 4.6, although its abstract inconsistently prints +3.6%[2].
  • ICIQ-UI SF: both groups improved (16.1 and 16.4 at baseline to 8.7 and 7.5 at 12 months); AUS slightly greater (adjusted mean difference 1.30, 95% CI 0.11 to 2.49, p = 0.032 in the full report; 1.4, p = 0.02 in the 2021 article).[9][2]
  • 24-month follow-up: the sling remained noninferior on self-reported continence (intention-to-treat absolute risk difference −0.006, 95% CI −0.092 to 0.080; noninferiority p = 0.001), with lower success in the sling group.[21] ICIQ-UI SF fell from 16.1 (sling) and 16.4 (AUS) at baseline to 7.9 and 7.1 (mean difference 1.42, 95% CI 0.18 to 2.65; p = 0.024).[9] Secondary outcomes favored AUS, and further surgery was more frequent after sling (20 men, 11%) than after AUS (4 men, 2%).[9][21]
  • Serious adverse events: 8 of 180 sling recipients and 13 of 175 AUS recipients had such events (15 AUS events; one man had three). Sling events were recatheterization, mesh erosion (3 each), urosepsis and coffee-ground vomit; AUS events included recatheterization and infection (3 each) and device erosion (2). The 2021 article reported serious adverse events in six sling recipients and 13 events among 11 AUS recipients.[2] The 2022 report counted eight sling and 13 AUS recipients (15 AUS events).[9]
  • All secondary outcomes with statistically significant differences favored AUS.
  • Cost-effectiveness: sling more cost-effective (99% probability at £30,000 / QALY threshold), though slightly lower QALY gain.[9]

Predictors of failure — common across implants​

Risk factorEffectStrength of evidence
Prior pelvic radiationOR 0.68 for pooled sling success and OR 0.66 for the AdVance subgroup; OR 2.93 for sling explantation (meta-analysis)[10]; ATOMS explant HR 2.7 and failure to achieve continence HR 2.3[15]Meta-analysis; multicenter cohort
Severe baseline SUILower cure after male sling; slings are not routinely recommended in severe SUIObservational cohorts[11][12]
Detrusor overactivityAn 80-man AdVance cohort (10 with DO) reported poorer mid-term outcomes; a heterogeneous 11-study review did not find a statistically significant overall increase in failure with preoperative DORetrospective cohort[13]; systematic review[38]
Weak residual sphincter function / incomplete closure on the repositioning testOR 29.0 for retrourethral sling failure; resorbable sutures with ≤ 4 fixation stitches in the studied AdVance cohort OR 8.4; no sling tunnelling OR 22.6Prospective[14]
DiabetesHR 2.2 for failure to achieve continence after ATOMSMulticenter[15]
Prior urethral stricture surgery, 24-h pad test > 200 gHigher failure after AdVance (ATOMS: Redmond found no association, whereas Ullate found prior treated stricture associated with failure after adjustment (OR 4.66, 95% CI 1.2–18.87)[32])[15]Prospective[16]

Prior pelvic radiation is associated with lower male-sling success.[10] Ghaffar 2023 meta-analysis: irradiated patients OR 0.68, p < 0.001 for sling success.[10]

Salvage pathways​

A failed male sling does not preclude subsequent AUS.[17][20] In one retrospective 61-man cohort after primary sling failure, 13/29 repeat slings (45%) met the study's composite success definition (0–1 pad/day, negative stress test, and pad weight <8 g/day), whereas 16/29 repeat slings (55%) and 2/32 salvage AUS procedures (6%) failed at median follow-up of 4 and 4.5 months, respectively.[20][39]

  • After failed AdVance. Re-evaluate the cause, then recommend AUS (AUA/GURS/SUFU 2024).[20] In a California administrative cohort of 1,400 sling recipients (median follow-up 3.7 years), the estimated proportion receiving salvage AUS reached 20% at eight years; subsequent AUS failure did not differ significantly from primary AUS (HR 0.79, 95% CI 0.55–1.13).[22] Selected ATOMS salvage is an alternative; Queissert's observational ATOMS cohort reported 76.1% social continence without proving superiority to AUS.[34]
  • After failed ATOMS. Repeat ATOMS or AUS; in Angulo 2021 (902 initial implants; 58 second implants: 31 repeat ATOMS and 27 AUS), observational outcomes favored repeat ATOMS over AUS after a mean 29.1-month follow-up on pad test, pad count, satisfaction, and PGI-I.[35]
  • After failed Argus or REMEEX. AUS (Hübner: seven AUS recipients among 16 Argus explants[33]).

A 2026 review of 21 mostly retrospective, small studies of simultaneous penile prosthesis implantation with several anti-incontinence devices, including slings, reported study-level social continence of 72–100% and prosthesis satisfaction of 84–100%; the authors could not pool these heterogeneous outcomes.[18] When performed as a single combined operation, placing the sling before the penile prosthesis has been described as reducing the chance that the transobturator trocar injures a prosthesis cylinder; the patient can remain in lithotomy or have the legs lowered for the prosthesis portion, though some surgeons reposition and re-prep fully between the two steps.[29]

Managing urethral mesh extrusion​

Urethral extrusion of sling mesh differs from vaginal or wound-surface erosion and should prompt urethroscopy for diagnosis; cystoscopy is warranted in a man with persistent retention after sling placement.[30] For confirmed sling infection or urethral erosion, remove the sling as completely as feasible without damaging adjacent structures and delay reimplantation .[20] A urethra-preserving repair has been described: the mesh is circumscribed lateral to the urethra on both sides and dissected away from the urethral wall to preserve as much native tissue as possible, then the defect is closed primarily, avoiding urethral transection when possible.[31] When urethral involvement is extensive or accompanied by stricture, an augmented ventral buccal mucosa graft has been described as an option at the time of repair.[31]

See Also​

Videos​

Step-by-Step Placement of the AdVance XP Male Urethral Sling
AUA Core Curriculum (2021)
Virtue Quadratic Male Sling for Stress Incontinence
AUA Core Curriculum (2017)
Modified Mini-Jupette Sling for Climacturia at IPP Placement
Kemble J, et al. Urology Video Journal 2023 (CC BY-NC-ND 4.0)
Open source videoRead the article

References​

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2. 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

3. 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

4. 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

5. Grabbert M, Hüsch T, Kretschmer A, et al. Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status. World J Urol. 2019;37(7):1415–1420. doi:10.1007/s00345-018-2523-0

6. 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

7. 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

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39. Ajay D, Zhang H, Gupta S, et al. "The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure." J Urol. 2015;194(4):1038–1042. doi:10.1016/j.juro.2015.04.106

40. European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms (LUTS). EAU Guidelines Office; 2026. Full guideline