Article

The male perineal sling - a viable alternative to the artificial urinary sphincter

University of Arizona Health Sciences Center, Tucson, AZ, USA.
Nature Clinical Practice Urology (Impact Factor: 4.07). 04/2006; 3(3):118-9. DOI: 10.1038/ncpuro0429
Source: PubMed
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    ABSTRACT: The authors investigated the anatomical basis for prolonged perineoscrotal pain after InVance bone-anchored male sling for the treatment of urinary incontinence after prostatic surgery in order to propose technical advice to reduce the frequency of this complication. The authors dissected three formalin-preserved male cadavres and reviewed the literature on perineal anatomy and complications of the surgical technique. Cadavre dissections demonstrated the origin, course and termination of the perineal nerve, a branch of the pudendal nerve derived from the S2-S3-S4 sacral nerve roots. Its superficial branch, accompanied by its blood supply, ensures sensory innervation of the anterior part of the perineum and posterior surface of the scrotum. This branch is situated in the zone of lateral dissection towards ischiopubic rami. Potential lesions of this nerve could be due to coagulation of the vascular pedicle, stretching during lateral dissection towards ischiopubic rami, or damage to its anastomoses with the scrotal branch of the lateral cutaneous nerve of the thigh during exposure of the sites of implantation of ischiopubic screws. Trauma to the superficial perineal nerve is probably responsible for perineoscrotal pain after InVance perineal surgery. This operative trauma must therefore be reduced by identifying the bulbourethral muscle before dissecting laterally and by limiting the use of coagulation.
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    ABSTRACT: Transobturator slings are currently promoted for the treatment of stress urinary incontinence (SUI) after radical prostatectomy (RP), but data on outcome remain limited. To assess, at midterm, the efficacy and safety of the inside-out transobturator male sling for treating post-RP SUI and to determine factors associated with failure. Prospective one-center trial involving 173 consecutive patients without detrusor overactivity, treated between 2006 and 2011 for SUI following RP. Placement of an inside-out transobturator sling. Baseline and follow-up evaluations included uroflowmetry and continence and quality-of-life (QoL) questionnaires. Cure was defined as no pad use and improvement as a number of pads per day reduced by ≥50% and two or fewer pads. Complications were recorded, and factors associated with treatment failure were evaluated. Preoperatively, 21%, 35%, and 44% of the patients were using two, three to five, and more than five pads per day, respectively. After a median follow-up of 24 mo (range: 12-60 mo), 49% were cured, 35% improved, and 16% not improved. QoL was enhanced (p<0.001), and 72% of patients were moderately to completely satisfied with the procedure. Maximum flow rates were slightly reduced (p=0.004); postvoid residual volumes were similar (p=0.097). Complications were urinary retention after catheter removal (15%), perineal/scrotal hematoma (9%), pain lasting >6 mo (3%), and sling infection (2%); all were managed conservatively. Severe SUI before sling surgery was not associated with a worse outcome, whereas obesity and a history of pelvic irradiation or bladder neck stenosis were independent risk factors of failure, with risk ratios of 7.9 (95% confidence interval [CI], 3.3-18.9), 3.3 (95% CI, 1.4-7.8), and 2.6 (95% CI, 1.1-6.5), respectively. The inside-out transobturator male sling is an efficient and safe treatment for post-RP SUI at midterm. Patients with prior pelvic irradiation may not be suitable candidates.
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