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

==inizio 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.

==fine objective==

==inizio methodsresults==

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. ==fine methodsresults== ==inizio 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.

==fine results==

==inizio 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.

==fine discussions==

==inizio 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.

==fine conclusion==

==inizio 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.

==fine reference==

Mid-urethral slings and sexual function

==inizio objective==

Stress urinary incontinence (SUI) has been reported to have a negative impact on sexual relations in up to 68% of women. Women with SUI report avoiding sexual intercourse because of wetness at night, leakage during intercourse, embarrassment and depression. Disorders of arousal, desire, and lubrication, as well as anorgasmia and dyspareunia, are typical complaints reported on sexual function questionnaires. Aging and the presence of certain comorbid conditions (i.e., cervical cancer or multiple sclerosis) clearly lead to worsened sexual functioning among women.
Other factors, such as hormonal status and absence of a uterus, have also been implicated,
although much less clearly so, in the development of sexual dysfunction.
Sling procedures are a widely proven treatment for stress urinary incontinence.
The effects of outside-in transobturator midurethral sling procedures on women’s sexual function are unclear.
We conducted this study to investigate sexual function alteration among women who underwent TOT for urodynamic stress incontinence.

==fine objective==

==inizio methodsresults==

Patients who underwent transobturator sling surgery were included in the present study if information was available on sexual activity before and 12 months after surgery .We included in the final analysis all the women who are sexually active at baseline.
Between September 2010 and June 2015, 86 patients undergoing TOT were enrolled. An
investigation was conducted using a validated, self-administered questionnaire: Female Sexual
Function Index (FSFI). The evaluation was repeated at the 3(rd), 6(th) and 12(th) months post
surgery and then yearly. The association between midurethral sling surgery and sexual function (coital incontinence, satisfaction, and dyspareunia) was compared.

==fine methodsresults==

==inizio results==

The mean age of patients was 46.7 ± 5.7. The mean follow-up period was 18.2 ± 2.9 months. After the 12-month follow up, 73 out of 86 patients (86%) were dry, 7 improved their symptoms and the remaining 6 were unchanged. After adjusting for multiple testing, only age, menopause, and storage symptoms remained significantly correlated with the FSFI total score post-surgery as independent variable. A significant loss of total FSFI score was observed at postoperative 3 months (P = 0.003), which was regained after postoperative 6 months. In comparison with baseline and postoperative 12 months, total FSFI score showed significant improvement (P < 0.001). There were significant improvements in desire, arousal, orgasm, and satisfaction on FSFI domain. The frequency improved in 60 (70.5%) patients, lubricity improved in 49 (57.1%) patients, orgasm improved in 57 (67.1%) patients, pain improved in 59 (70%) patients, in leaking patients sexual satisfaction improved in 85.7% while in non-leaking patients improvement was seen in 40%. Sexual relation was not satisfactory in 65 (76.4%) of the patients before surgery; of them, 68 (80%) patients had improved sexual satisfaction after surgery. De novo urgency and dyspareunia developed in 6 and 3 patients, respectively. ==fine results== ==inizio discussions== Despite the fact that SUI could be harmful in regard to sexual function, there has been little study of sexual function change after treatment of SUI, with most efforts focusing on incontinence, rather than the effect of cure on sexual function. The sexual satisfaction is a difficult parameter to study. Reports on sexual function after surgery for SUI vary, with some authors reporting improved function and others reporting deterioration of function [1,2]. Improvements in sexual function following vaginal surgery are believed to be due to the cessation of incontinence during intercourse, whereas worsening sexual function is believed to be caused by dyspareunia following colporhaphy [3,4]. This study was undertaken to assess the effect of the midurethral sling procedure for SUI on sexual function using a validated questionnaire. ==fine discussions== ==inizio conclusion== These data show that midurethral sling surgery has an overall positive influence on sexual function in women with stress urinary incontinence. The TOT procedure has no significant negative impact on sexual function and it significantly improves female sexual function and overall sexual satisfaction in majority of the patients with SUI. The transobturator tape procedure has a positive effect on female sexual functioning by reducing urinary leakage and pain during or after sexual activity. Women with coital incontinence show a significant higher improvement in sexual function after surgery for SUI compared to women without coital incontinence. Our results suggest that improvement in coital incontinence results in improvement of sexual function. Therefore, coital incontinence is a prognostic factor for improvement of sexual function following incontinence surgery. ==fine conclusion== ==inizio reference== 1. Ko YH, Song CH, Choi JW, Jung HC, Song PH “Effect on Sexual Function of Patients and Patients' Spouses After Midurethral Sling Procedure for Stress Urinary Incontinence: A Prospective Single Center Study” Low Urin Tract Symptoms. 2016 Sep;8(3):182-5. 2. nKim DY, Choi JD” Change of sexual function after midurethral sling procedure for stress urinary incontinence” Int J Urol. 2008 Aug;15(8):716-9 3. Liang CC, Tseng LH, Lo TS, Lin YH, Lin YJ, Chang SD “Sexual function following outside-in transobturator midurethral sling procedures: a prospective study” Int Urogynecol J. 2012 Dec;23(12):1693-8. 4. Bekker M, Beck J, Putter H, Venema P, Lycklama A, Nijeholt A, Pelger R, Elzevier H “Sexual function improvement following surgery for stress incontinence: the relevance of coital incontinence”. J Sex Med. 2009 Nov;6(11):3208-13. ==fine reference==