Experience with Kaufman's operation for correction of post-prostatectomy urinary incontinence (sagging urogenital diaphragm--a theory for the cause of incontinence)

Slings in the management of male stress urinary incontinence

PURPOSE OF REVIEW

The use of synthetic slings for the treatment of male stress urinary incontinence (SUI) has increased over the last decade. Several sling designs and techniques are now available. The purpose of this review is to summarize the past literature with a focus on more recent contributions.

RECENT FINDINGS

The recent literature focusses on the retrourethral transobturator sling (RTS), which is considered noncompressive. MRI of patients undergoing RTS has shown an increase in membranous urethral length and elevation of the external urethral sphincter, whereas a recent large series demonstrated approximately a half and a quarter of patients are cured or improved, respectively, at 1 year after RTS implantation, with results sustained through to 3 years. Serious complications such as urethral erosion occur rarely.

SUMMARY

The available evidence suggests that male slings can be an efficacious and well tolerated treatment modality for men with SUI. Nevertheless, important questions remain with regard to the durability of repair, device safety and comparative efficacy. The mechanism of action and factors that predict failure remain to be fully elucidated.

Surgery Insight: surgical management of postprostatectomy incontinence--the artificial urinary sphincter and male sling

Stress urinary incontinence in men is usually a result of intrinsic sphincter deficiency following prostate cancer surgery. Active conservative management with fluid restriction, medication management and pelvic floor exercises is indicated for the first 12 months. If bothersome incontinence persists, urodynamic evaluation is indicated in order to assess detrusor storage function, contractility and sphincteric integrity. Standard surgical options include urethral bulking agents, artificial urinary sphincter (AUS) and male sling. Periurethral injection of bulking agents is satisfactory in only a minority of patients, leaving AUS and male sling as the most common surgical treatments. In patients with severe urinary incontinence, AUS seems to have a higher rate of success than the male sling. Furthermore, AUS is indicated in men with detrusor hypocontractility as adequate detrusor contractility is needed to overcome the fixed resistance of the sling. In patients with milder levels of stress incontinence, the two techniques have approximately equal efficacy in the short-to-intermediate term. While current reports of the male sling are generally limited to 1-4 years' follow-up, the infection, erosion, and revision rate for the male sling seem somewhat lower than that for the AUS in appropriately chosen patients.

Suprapubic wad suspension. Combined perineal-abdominal approach for correction of postprostatectomy urinary incontinence

A three-year experience with 20 patients who became incontinent after various types of prostatectomies is described. A new method of repair using a combined approach is presented. The perineal component allows the insertion of a pliable prosthetic "wad." The posterior edge of the wad is held in a position inclined 20 degrees toward the vertical plane of the recumbent patient's perineum by two heavy nylon sutures. The sutures are brought into the previously dissected retropubic space by the use of a 10-cm. long Keith needle which is passed through the urogenital diaphragm. The ends of the sutures are tied over small marlex pledges over the abdominal fascia. There were two failures and one case in which urethral stricture developed among the 20 patients undergoing surgery.

Male incontinence: relationship of physiology to surgery

After prostatectomy it is the passive continence mechanism that maintains continence. Since this mechanism is less effective when the structures are not in the normal elevated position, perineal continence operations are probably successful in proportion to the mobility of the sub-prostatic structures and the ability to keep them elevated.