ATOMS®: A step-by-step surgical video in a difficult preoperative decision-making context upon a case of post-prostatectomy urinary incontinence

ABSTRACT: Stress urinary incontinence (SUI) is a common complication after radical prostatectomy. Placement of artificial urinary sphincter (AUS) is the current gold-standard treatment. Slings are considered as a therapeutic option for stress urinary incontinence, while non-adjustable slings may be considered for mild incontinence. On the other hand, adjustable Transobturator Male System (ATOMS®) consists of a sling that has an adjustable cushion compressing the bulbar urethra ventrally to achieve dryness. ATOMS® achieves continence rates between 64 and 88%, with major complications in only around 3% of the cases. Its market value is around 40% less than AUS.The objective is to show a step-by-step ATOMS® surgery putting forward a standard technique in a challenging preoperative decision-making scenario. For this, we describe a case of a 70-year-old man with right hemiparesis and severe stress incontinence after an open radical prostatectomy, using 6 wet pads per day, who was able to straighten his penis for self-catheterization under supervision while unable to deactivate an AUS pump during a preoperative trial. He underwent an ATOMS® procedure. No intraoperative complications occurred and the patient was discharged 24 h postoperatively. After 3 months, the patient reported using 0 pads per day, and had only occasional small losses of urine with a full bladder. At the 6-month follow-up, he reported being very satisfied with the surgical results, still using 0 pads daily, with no leakages and no storage or voiding symptoms. In conclusion, ATOMS® male adjustable sling may be effective for male stress incontinence, even in severe cases when AUS is not suitable, making it a good alternative in this scenario. Surgical steps shown in this video might be of help to achieve better outcomes.