Although artificial urinary sphincter is the preferred surgical option for treating severe stress urinary incontinence, male slings have been introduced to treat mild-to-moderate incontinence. Non-adjustable re-positioning slings such as AdVance™ and AdVanceXP© have rates up to 49% of dryness and adjustable slings, including ATOMS® system, up to 67%. Both techniques have shown a good safety profile.

Most published series report a 24-hour hospital stay or do not refer to it at all. We evaluate the outcomes and complications of our experience with the implantation of male slings in an outpatient setting.

We have performed a retrospective review of implantation of AdVance, AdVanceXP and ATOMS system as a day surgery it a third-level referral center between 2019 and 2023.

Preoperatively, all patients underwent a urethrocystoscopy to assess the integrity of the urethra and to rule out urethral stricture or urethrovesical anastomosis stenosis. The protocol we followed was surgery with same day discharge. All patients were scheduled for a consultation 24 hours after the surgery for the first evaluation and removal of the urethral catheter. Antibiotic prophylaxis was established with aminopenicillins for 7 days (quinolones during 5 days for those allergic).

A descriptive analysis was performed with baselines patient characteristics, type of prior surgery, adjuvant treatment with radiotherapy, pre-operative 24 hours pad test, intra and post-operative complications and functional outcomes.

A total of 51 patients were reviewed: 4 AdVance (7,8%), 6 AdVanceXP (11,8%) and 41 ATOMS (80,4%). 

The mean age was 70 years (SD±5,2) and the body mass index 27,9 (SD± 3,2). 12 patients (23,5%) were diabetic, and one (2%) was under pharmacological immunosuppression due to liver transplantation. The mean 24-h pad count before surgery was 2,1 (range 0-4) and the mean of pad weight was 144g (SD±138,5).). 

Most of the cases of incontinence were after radical prostatectomy (76,5%). Other patients reported urinary incontinence after Holmium laser enucleation of the prostate (7,8%), transurethral resection of the prostate (7,8%), retropubic adenomectomy (3,9%) or urethral surgery (3,9%). 4 of those patients who underwent to an ATOMS implantation received pelvic radiotherapy.

Only one intraoperative complication was registered: bleeding from the obturator foramen during ATOMS needle insertion. It was resolved by manual compression.

Complications within the first 30-days after surgery occurred in 23 patients (45,09%). Of these, 19 were classified as grade I in the Clavien-Dindo classification while 2 patients required surgical revision: one with a device infection requiring urgent removal of the ATOMS and the other with wound dehiscence. Details are specified in table 1.

Delayed post-operative complications were registered in 7 patients (13,72%): 3 de novo overactive bladder symptoms and 3 scrotal port skin erosion, requiring its removal. The left one presented persistent perineal pain refractory analgesia necessitating ATOMS removal.

For those patients who underwent ATOMS implantation, a standard cushion filling of 9ml was performed. In 26 out of the 41 patients (63,4%), subsequent adjustment was required (mean 1,66, SD 1,86), resulting in a final volume of 12.29 ml (8-25ml).

In our cohort, 30 patients (58,8%) reported being cured (completely dry) and 17 patients (33,3%) revealed an improvement in pad use and self-perceived satisfaction. The remaining percentage did not report subjective changes. Outcomes to each device can be seen in figure 2.

Our series has not shown compromised safety of surgery or functional outcomes when transitioning surgery to an outpatient setting. The implementation of this surgical regimen has not been compared or randomized with inpatient surgery, which was previously performed, so we cannot compare both groups. Another potential improvement for the study would be the introduction of questionnaires to assess the impact of incontinence on the patient's quality of life both pre- and post-surgery, aiming to make the functional outcomes more objective. Additionally, we acknowledge limitations such as the sample size and the retrospective nature of the study, and we hope to improve the study in the near future.

In our experience, the implantation of male slings in an outpatient setting does not compromise the safety or outcomes of the procedure and the results are comparable with data reviewed in the literature. However, we need more cases and a longer follow-up to generalize our results.

1.	Cornu J. N., et al. EAU Guideline on Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS).  Edn. presented at the EAU Annual Congress Milan March 2023. ISBN 978-94-92671-19-6
3.	Collado A, et al. Functional follow-up after Advance® and Advance XP® male sling surgery: assessment of predictive factors. World J Urol. 2019 Jan;37(1):195-200. doi:10.1007/s00345-018-2357
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