IncontinenceTransobturator Sling Suspension for Male Urinary Incontinence Including Post-Radical Prostatectomy
Introduction
The incidence of incontinence following radical prostatectomy is common, with 5–20% of patients reporting the condition [1], [2], [3]. An increased understanding of pelvic anatomy applied to surgical approaches has improved continence rates following radical prostatectomy but it is still perceived as an adverse outcome of this surgery [4]. Post-prostatectomy stress urinary incontinence (SUI) has been attributed to intrinsic sphincter dysfunction (ISD) and/or bladder dysfunction [5]. One study involving 60 patients reported an incidence of incontinence due to ISD of 67% and ISD plus bladder dysfunction in 23% of patients [6]. Conservative therapy is usually the first choice in the management of SUI and this involves Kegel exercises, pharmacotherapy [7], penile clamp and pad use. Second-line therapy involves a surgical procedure, which is usually the placement of artificial urinary sphincter (AUS) or the use of periurethral bulking agents, such as collagen. A more recent development has been the use of a sling consisting of vascular graft material or polypropylene mesh, which is placed under the bulbospongiosus and anchored to the rectus muscle [8], [9], [10], [11]. Such slings cause compression of the urethra to achieve continence. More recently, bone-anchoring techniques have been used to secure a variety of sling materials [12], [13].
The current report is of a new technique involving the placement of polypropylene tape under the proximal part of the urethral bulb using a transobturator approach. Presented here are details of the transobturator tape (TOT) technique based on a cadaver study plus clinical outcome in a patient series.
Section snippets
Cadaver study
Cadaver studies were conducted to allow certain aspects of technique and measurement to be performed in an environment of zero risk to patients as a pilot study. Four prepared and four fresh cadavers were used to demonstrate the principles of the TOT. A median perineal incision was made to expose the bulbospongiosus muscle, which was then split centrally and retracted laterally. The dissection was then extended to the perineal body (Fig. 1). After exposure of the urethral bulb, blunt finger
Cadaver study
Tensioning the TOT resulted in the proximal anterior urethra being pulled into the pelvic outlet by a distance of 3–4 cm. The tensiometer indicated a force of up to 5 kg to relocate the proximal anterior urethra. The tension needed was comparable to the tension applied to tie the knots when closing the abdominal fascia after laparotomy. There was no danger of transmitting too much tension on the posterior surface of the bulb as the angle of the sling between both obturator fossae was wide. The
Discussion
The TOT is based on the hypothesis that relocating the posterior urethra into a more proximal position without disturbing the sphincter mechanism was a potential method of overcoming incontinence. The theory was that male urinary incontinence with residual sphincter function implies a certain degree of urethral or perineal descent, possibly associated with laxity, related to iatrogenic causes or to aging, in the levator ani complex. In support of this rationale, Noguchi et al have reported on a
Conclusion
This pilot study indicates that the TOT, a novel procedure for treatment of post-radical prostatectomy SUI, is safe and in selected patients can result in significant short and longer term improvements in incontinence. Clearly, larger scale studies with longer follow-up are now needed to confirm these findings.
Conflicts of interest
Both authors submitted a patent together with American Medical Systems, Minnetonka, Minnesota, USA, involving the transobturator method in treating male incontinence and inventing a new helical needle device. This publication was made possible by a sponsorship made by the same company.
Acknowledgments
Professor Georg Bartsch, Head of the Department of Urology, Medical University Innsbruck, Innsbruck, Austria, for supporting innovation in urology.
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