The ’Debates On Male INcOntinence’ (DOMINO) working group is an independent central European collaboration of centers with expertise in male incontinence surgery. Within this project we conducted a study to compare the indications, results, complication rates, quality of life, and satisfaction rates of the two versions of the ATOMS™ adjustable male continence system with an inguinal (older version) and scrotal (newer version) port.

A total of 92 patients with the adjustable male continence system were enrolled, the follow-up ranged from 6 to 48 months. 66 patients (71.1%) received an inguinal port, 26 (28.3%) a scrotal port. Preoperative characteristics, outcome, and perioperative complications were retrospectively analyzed. Quality of life and patient satisfaction rates were evaluated by standardized, validated questionnaires. A chi2-test for categorical and independent t-test for continuous variables was performed to identify heterogeneity between the groups and to correlate preoperative characteristics with the outcome.

Patient characteristics showed no difference between the inguinal and scrotal port group. 17/92 patients (18.5%) had a history of radiation therapy. All patients received perioperative antibiotics, mostly a combination of penicillin and gentamycin (79.3%). Mean operation time was significantly longer in the inguinal port group (45.7 vs. 31.5 min). Mean pad use per day decreased from 4.9 to 1.5 and mean urine loss in the 24h pad rest from 767 gr to 42.7 gr, without statistical significance between groups. No implant specific complications occurred in both groups. 6 patients experienced urinary retention usually managed with deflation of the cushion. Postoperative infections occurred in 4 patients with implant removal in 3/4 cases. No significant differences were identified in the quality of life instruments I-QoL, ICIQ-SF, PGI-I, and VRS with a high satisfaction rate in both groups. Patients in both groups would recommend the procedure to a friend or would repeat it, respectively (97% vs. 100%).

With respect to the outcome there are no significant differences between the inguinal and scrotal port system of the ATOMS™ adjustable sling. As preoperative data for the status of incontinence were incomplete in our cohort, the continence results that have been published before were not the primary objective of this study.1,2 Surprisingly the QoL and pain scores were not significantly different although the inguinal port system is combined with a second incision. This resulted only in significantly longer operation times that were however short with respect to this kind of procedure. The complication rates were low in both groups and did not exceed the expected rates of infection that are common in pelvic floor implants, in particular. In the majority of cases this can only be dealt with by implant removal. Minor complications like urinary retention can easily be managed just by loosening of the sling (ATOMS™: deflation of the cushion) in adjustable systems.

The adjustable male continence system ATOMS™ is a reasonable treatment option for medium to severe incontinence with high patient satisfaction. Although the older version with an inguinal port is no longer marketed the results of our study are valuable in particular for future developments. As there are no comparative prospective randomized trials with other implants the treatment decision is mostly influenced by the experience and preference of the surgeon.

Friedl A, Muehlstaedt S, Zachoval R, Giammò A, Kivaranovic D, Rom M, Fornara P, Broessner C. Long-term outcome of the adjustable transobturator male system (ATOMS): results of a European multicentre study. BJU Int. 2017 May;119(5):785-792
Muehlstaedt S, Friedl A, Mohammed N, Schumann A, Weigand K, Kawan F, Goellert C, Kahlert C, Theil G, Fischer K, Fornara P. Five-year experience with the adjustable transobturator male system for the treatment of male stress urinary incontinence: a single-center evaluation. World J Urol. 2017 Jan;35(1):145-151