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
| Class | Device | Page |
|---|---|---|
| Fixed sling | AdVance / AdVance XP | advance-sling |
| Fixed sling | Virtue (quadratic) | virtue-sling |
| Adjustable sling | ATOMS | atoms-sling |
| Adjustable sling | Argus (Classic / T) | argus-sling |
| Adjustable sling | REMEEX (MRS) | remeex-mrs |
| Periurethral balloon | ProACT | proact-balloons |
| Sphincter | Artificial Urinary Sphincter | artificial-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 but has been largely abandoned due to mesh-infection rates of 2–12%; it is not covered as a standalone device here.
Mechanism comparison
| Device | Mechanism | Key clinical implication |
|---|---|---|
| AdVance / XP | Repositioning of the lax membranous urethra proximally — non-obstructive | Requires residual sphincter function; positive repositioning test on cystoscopy is prerequisite |
| Virtue (quadratic) | Ventral elevation (transobturator arms) + compression (prepubic arms) | Dual mechanism in theory; long-term durability disputed (McCall 2016 Mayo abandonment) |
| ATOMS | Adjustable ventral compression of the bulbar urethra against the urogenital diaphragm | Effective across all severity strata; office-based percutaneous saline adjustment |
| Argus | Compression + mechanical washer adjustment | Highest complication burden of any modern male sling; unique urethral-erosion signal |
| REMEEX | Compression + suprapubic varitensor adjustment | Only truly non-invasive percutaneous re-tensioning, but retropubic-passage carries bladder + bowel-injury risk |
| ProACT | Periurethral balloon compression at the bladder neck (focal, non-circumferential) | Adjustable scrotal port; poor durability; avoid in irradiated patients |
| AUS (AMS-800) | Hydraulic circumferential cuff at bulbar urethra; patient-activated pump | Gold standard for moderate-severe SUI; manual-dexterity prerequisite |
A dynamic-MRI study demonstrated that the transobturator sling works by lengthening the vesicourethral-anastomosis-to-bulbar-urethra distance — 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 post-prostatectomy controls (P = 0.09).[1]
Decision matrix — which device for which patient
| Clinical scenario | First choice | Alternative(s) | Avoid |
|---|---|---|---|
| Mild SUI, no radiation, positive repositioning test | AdVance / XP | ATOMS, ProACT | — |
| Moderate SUI, no radiation | AUS (Sacco 2021: 94% vs sling 69%) | ATOMS, AdVance XP | Fixed sling alone if radiation history |
| Severe SUI | AUS | ATOMS (across all severity strata) | Fixed sling, ProACT |
| Mild–moderate, poor surgical candidate or declines implant | ProACT (60% dry / 82% improved) | Urethral bulking (niche) | — |
| SUI with prior pelvic radiation | AUS | ATOMS (62.5% irradiated vs 87.9% non) | All other slings |
| Recurrent SUI after failed AdVance | ATOMS (Queissert 2021: 76.1% social continence at 42.5 mo) | AUS | Repeat fixed sling |
| Recurrent SUI after failed ATOMS | Repeat ATOMS (Angulo 2021 favors over AUS) or AUS | — | — |
| Recurrent SUI after failed AUS | AUS revision; tandem cuff for atrophy (56.5% of revisions; Bentellis 2021) | Larger-cuff revision | — |
| Concomitant ED + SUI | Simultaneous AUS + IPP (synchronous or staged) | Sling + IPP | — |
| Devastated outlet, all options exhausted | Bladder-neck closure + Mitrofanoff | Urinary diversion | Continued failed reconstruction |
Comparative-meta snapshot
| Comparison | Source | Verdict |
|---|---|---|
| Sling vs AUS (overall) | MASTER RCT, Abrams 2021 (n = 380, 12 mo)[2] | Sling noninferior at 12 mo; all secondary outcomes favored AUS |
| Sling vs AUS (moderate SUI) | Sacco 2021 propensity-matched[3] | AUS 94.3% vs sling 68.6% (p < 0.001) |
| Sling vs AUS (mild vs moderate) | Khouri 2020[4] | Mild — sling 78%; moderate — AUS 80% vs sling 63% (p = 0.02) |
| Adjustable sling vs AUS (subjective dry) | Grabbert 2019 multicenter[5] | AUS 57.3% vs adjustable sling 22.0% (p < 0.05) |
| ATOMS vs ProACT | Angulo 2019 PLoS meta[6] | ATOMS superior on every endpoint; working device 3 yr 81% vs 58% |
| ATOMS vs REMEEX | Angulo 2021 SR/meta (n = 1,919)[7] | ATOMS superior on every endpoint (dryness 69.3% vs 53.4%, p = 0.008; explantation 5.5% vs 13.9%, p = 0.027) |
| ATOMS vs AUS — durability | Geretto 2023 propensity-matched[8] | AUS higher dryness (44.9% vs 22.5%) but device survival 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 — 380 men across 27 UK centers.[2][9]
- 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 = 0.003).
- ICIQ-UI SF: both groups improved; AUS slightly greater (mean difference 1.4, p = 0.02).
- Serious adverse events: fewer with sling (6 vs 13).
- 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 factor | Effect | Strength of evidence |
|---|---|---|
| Prior pelvic radiation | OR 0.66–0.68 for sling success; ~ 3× higher explantation; ProACT erosion p = 0.005; ATOMS HR 2.7 explant; REMEEX OR 8.4 failure | Meta-analysis[10] |
| Severe baseline SUI | Lower cure across all device classes | Multiple prospective[11][12] |
| Detrusor overactivity | Independent mid-term failure predictor | Prospective[13] |
| Obesity (BMI > 30) | OR 7.9 for AdVance failure | Multiple series[14] |
| Negative repositioning test | OR 29.0 for AdVance failure (functional only) | Prospective[14] |
| Diabetes | HR 2.2 ATOMS failure | Multicenter[15] |
| Prior bladder-neck stricture / urethral stricture surgery | Higher failure across implants | Prospective[14][16] |
Radiation is the single most important predictor of failure. Ghaffar 2023 meta — irradiated patients OR 0.68, p < 0.001 for sling success.[10]
Salvage pathways
A failed male sling does not preclude subsequent AUS.[17]
- After failed AdVance → ATOMS is the best-evidenced second-line (Queissert 2021 multicenter: 76.1% social continence).
- After failed ATOMS → repeat ATOMS or AUS; Angulo 2021 (n = 902) — repeat ATOMS outperforms AUS for repeat implant on pad test, pad count, satisfaction, and PGI-I.
- After failed Argus or REMEEX → AUS (Hübner: 7/13, Kim: 12/18).
Simultaneous male sling + penile prosthesis implantation is feasible and safe — pooled social continence 72–100% and prosthesis satisfaction 84–100%.[18]
See Also
- AUS (AMS-800) — gold standard
- Pelvic Floor Physical Therapy — universal first-line
- Male SUI database — full treatment ladder
- Penile Clamp and Condom Catheter — containment
References
1. 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
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
8. 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
9. 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
10. 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
11. 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
12. 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
13. 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
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. 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. Cornu JN, Sèbe P, Ciofu C, et al. Mid-term evaluation of the transobturator male sling for post-prostatectomy incontinence: focus on prognostic factors. BJU Int. 2011;108(2):236–240. doi:10.1111/j.1464-410X.2010.09765.x
17. 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
18. 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