Update on 3 year outcomes of a trans-obturator and pre-pubic four arm urethral sling for post-prostatectomy stress urinary incontinence

Mauro Seveso1, Sara Melegari1, Giorgio Bozzini1, Oliviero De Francesco1, Pietro Bono1, Alberto Mandressi1, Gianluigi Taverna1
  • 1 Humanitas Mater Domini (Castellanza)

Objective

The risk of persistent urinary incontinence after prostatectomy (PPI) is moderately elevated
varying from 2% to 10%. When present , it can lead to a very relevant reduction in the patient's quality of life (QoL). Mild degrees of PPI in the early postoperative period may be improved by pelvic muscle exercises, physiotherapy, and pharmacological therapy . However, for most patients who have moderate to severe PPI, conservative methods are not sufficient to return to their normal lives. Surgery is usually necessary to treat the more severe cases. Various male slings and devices are available for the treatment of PPI.
In parallel with the successful results obtained with sub-urethral slings in women, similar devices have been developed for male urinary incontinence. The aim of this study is to assess tolerance and mid-term clinical outcomes of treatment with a new four-arm mesh sling of post prostatectomy incontinence (PPI) in men. The trans-obturator pre-pubic four arm sub-urethral sling used in the present study ensures non compressive support of the urethra. It repositions the sphincter complex upwards and stabilized it by firmly fixing the urethral bulb under the pubic symphysis.

Materials and Methods

A total of 31 patients were included in this study between December 2012 and December 2015 . All selected patients had moderate PPI (less than 500 g of urinary loss in 24-h Pad test) for a minimum of 12 months after prostatectomy and after failure of conservative re-education treatment. They all underwent on Surgimesh M-Sling implantation for the treatment of PPI. Objective outcome measures included number of pads per day, 24-h Pad-test, maximum urinary flow rate and urinary retention . We also analysed degree of erectile dysfunction, patients' satisfaction , postoperatively pain and procedure complications. Patients were considered cured if no protection was used and/or daily pad weight <2g. Improved patients reduced their daily losses by more than 50%. Those not included in any of the aforementioned groups were assessed as unchanged or deteriorated, and considered as failures.

Results

Average hospitalization period was 1.57±0.70 days. All patients remained catheterized
for 1.17±0.48 days. On an intention to treat analysis, at 12 months, 31 % were cured, 34 % had improved and 35% were considered failures. Two patients experienced transient urinary
retention. There was a not significant tendency for reduced severe erectile dysfunction (ED), and a shift towards moderate ED was observed. No severe complications occurred. No explantation was necessary. No urethral or bladder injuries related to the device or erosions
occurred. Complications were perineal/scrotal hematoma (9%), pain lasting >6 months (3%), and sling infection (2%); all were managed conservatively.

Discussions

Many studies have been published in recent years on the surgical treatment of post
prostatectomy incontinence and good shortening to mild term results for the implantation of
urethral support slings have been reported [1]. Sling procedures are quicker and less invasive than implanting an AUS. It is generally accepted that patients with mild to moderate incontinence are appropriate candidates for a male sling, and probably those with severe incontinence should be treated with an AUS, although there is no specific recommendation in this context . In particular, we believe that it would be advisable to treat urinary incontinence with an AUS in patients undergoing adjuvant radiotherapy, and to reserve the choice of the sling for those with mild and moderate urinary incontinence with no previous radiotherapy. Our success rate was stable throughout the study and similar to that reported in previous studies [2,3]. The major limitations of our study were the small number of patients and the duration of the follow-up period. Additional follow-up and larger series of patients are necessary to confirm our results.

Conclusion

PPI represents a significant health problem. The rising elderly population and the
increasing number of surgical interventions for prostate cancer mean that the incidence of PPI
will rise. The trans-obturator and pre-pubic four arm urethral sling represents an easy-to-deploy, safe and durable therapeutic alternative for mild to moderate post-prostatectomy incontinence.
Its implantation did not have a negative influence on sexual performance outcomes.

Reference

1. Leruth J, Waltregny D, de Leval J.” The inside-out transobturator male sling for the surgical treatment of stress urinary incontinence after radical prostatectomy: midterm results of a single-center prospective study”. Eur Urol. 2012 Mar; 61(3):608-15.

2. Le Portz, B., Haillot, O., Brouziyne, M. and Saussine, C. (2016) “Surgimesh M-SLING® transobturator and prepubic four-arm urethral sling for post-prostatectomy stress urinary incontinence: clinical prospective assessment at 24 months”. BJU International, 117: 966–975

3. Siracusano S1, Visalli F1, Toffoli “Male incontinence and the transobturator approach: An analysis of current outcomes”. Arab J Urol. 2013 Dec;11(4):331-5.

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