Male stress urinary incontinence is a common complication after radical prostatectomy (4-74% at 12 months, depending on definition). Up to 5% of these patients will need surgery to regain continence. The artificial urinary sphincter (AUS) is the current gold-standard treatment, but it has considerable complication and failure rates. The slings are regarded as an option and their indications have been expanding. ATOMS (Adjustable transobturator male System ®) was created in 2008. It has an adjustable cushion that compresses the bulbar urethra achieving continence rates between 64-95% with major (Clavien III) complications in 2-4%. The market value is 40% less than the AUS. Since it has a compressing mechanism, one might expect it to cause urinary retention when used in patients with underactive detrusor.

We present a complex clinical case in which ATOMS was successfully implanted and we detail the surgical technique. This is a 70-year-old male, with right hemiparesis secondary to a stroke. Five years after radical prostatectomy with undetectable PSA, he complained of stress incontinence using 6 wet pads/day. Cystoscopy showed a patent anastomosis and a shortened hypotonic sphincter. Urodynamics confirmed a stable underactive detrusor, with minimal residual activity. Nonetheless, the patient was able to achieve adequate bladder emptying using Valsalva. Unfortunately, patient’s impaired manual dexterity prevents him from manipulating an AUS’s pump but, yet, he demonstrated he was capable of self-catheterization. In this scenario, ATOMS was chosen assuming the risk of catheterization. Daily pad count, uroflowmetry, post-void residual, along with IPSS were used during the follow-up.

As shown in the video, after general anesthesia the patient is placed in the lithotomy position. A standard midline perineal incision is carried out until bulbospongiosus muscle is exposed, but spared. Dissection on both sides of the muscle is done, until ischiopubic rami are exposed along with transverse perineal muscle, creating a safety triangular area. The tunneller needles are passed through the medial superior angle of the obturator foramina and the mesh arms are pulled out to place the cushion compressing atop of the bulbospongiosus muscle. The cushion is filled with saline and the port is placed under the dartos fascia in the scrotum. Estimated blood loss was 50 ml. Patient was discharged on postoperative day one, after Foley catheter is withdrawn and normal voiding is achieved. At 1-month follow-up, the patient is using no pads, with no need of self-catheterization and has a maximum flow 24 ml/sec with a few drops leaking only when the bladder is full. Two mL of extra saline are injected achieving complete dryness with no voiding symptoms at 6 months. Patient is fully satisfied.

ATOMS adjustable sling is effective for male stress incontinence, yet in severe cases. It can also have good results on complex cases, such as underactive detrusor or in patients who are not candidates for AUS. It should be considered as a part of the therapeutic armamentarium for male stress incontinence.

Esquinas C, Angulo J. 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
Doiron C, Saavedra A, Haines T, Nadeau G, Tu L, Morisset J, Steele S, Valiquette L, Elterman D, Maciejewski C, Rourke K. Canadian Experience with the Adjustable Transobturator Male System for Post-Prostatectomy Incontinence: A Multicenter Study. J Urol. 2019;202(5):1022-1028.