| European Urology - Urethral Compression for the Treatment of Postprostatectomy Urinary Incontinence: Is History Repeating Itself? |
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| Thursday, 01 February 2007 | ||
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Volume 51, Issue 2, Pages 304-305 (February 2007) After more than a century since the first prostatectomy was described by Young, the debate continues regarding the optimal treatment of postprostatectomy incontinence (PPI). PPI remains a devastating and frustrating complication for both patients and urologists alike. Since compressive devices for male incontinence were first described in 1750, the evolution of increased urethral resistance as a means to confer continence has progressed. The work by Fassi-Fehri et al. relays this group's experience with the InVance device [1]. Passive urethral compression, which was once abandoned, has now re-emerged. Urethral resistance can be conceptualized as either dynamic or fixed. Treatment can also be categorized along the same divisions. Fixed compressive devices confer continence by obstructing outflow, but this resistance can be overcome with sufficient elevation of intra-abdominal pressure. Dynamic compressive devices use variations in pressure that can be modified to achieve continence. The first example of this is the Vincent apparatus described in the 1960s [2]. This device was worn externally and a bulb that conferred differing degrees of pressure could be manually adjusted, resulting in variable degrees of perineal compression. This pressure was transmitted to the bulbar urethra with resultant obstruction and thus continence. The first artificial urinary sphincter was described in 1947 by Foley [3]. This was an externally placed device with a controlling apparatus placed in the patient's pocket. In 1973, Scott et al. described the first implantable urinary sphincter [4]. Series from the Mayo Clinic and others have shown the variable success of the AMS sphincter ranging from 20% to 80% [5]. The definition of incontinence before and after implantation varied in each of the series, but all of these studies validated the artificial urinary sphincter as a valuable option for PPI. In the Mayo Clinic series of 323 patients, 72% required no further surgical intervention, confirming the durability of the device. More recently, Webster's group observed that in a total of 554 patients, the 5-yr durability outcomes for primary AMS sphincter placement were 80% with good continence outcomes noted in 90% [6]. The AMS sphincter is reliable, and results in both nonobstructive voiding as well as in urethral coaptation with changes in intra-abdominal pressure. The modern era of implantable fixed compressive devices began in 1961 with Berry. The use of acrylic prostheses was described to compress the urethra against the urogenital diaphragm. Beginning in 1968, Kaufman described three fixed bulbar compression procedures. The Kaufmann I consisted of cavernous crural crossover to compress the bulbar urethra. This resulted in 9 of 28 patients being dry. This procedure was then modified in 1970 and named the Kaufmann II. Rather than separating the crura completely, the bodies of the corpora were only partially detached and approximated in the midline over the urethra. Seven of 11 patients reportedly had “good” or “excellent” results. The Kaufmann III procedure differed greatly from its predecessors in that an implantable silicone gel prosthesis was used to confer bulbar compression. In this series of 184 patients, 33% became completely dry, required no protection, and voided with a good stream and without residual urine. Another 51% of patients had some stress incontinence but were pleased with the results so that 61% derived definite benefit from the operation. Recent reviews have revisited the utility of the Kaufmann prosthesis in the treatment of stress urinary incontinence (SUI) in the male patient. A series by Durrani et al. of 57 patients who underwent implantation of the Kaufman prosthesis for urinary incontinence was reviewed. All except one of the patients were incontinent following prosthetic surgery. Although many of the patients required revision or adjustments after the initial implantation, 55% of the cases eventually had a satisfactory outcome. Patients rendered incontinent after retropubic prostatectomy had a higher success rate with the Kaufman prosthesis than patients after other types of prostatectomy. This group has shown that this simple and relatively inexpensive device still has a useful role in the treatment of patients with mild and moderate SUI following prostatectomy [7]. More creative devices that focus on the same principles of urethral compression to confer continence have been developed. The adjustable continence therapy device (ProACT, Uromedica) is one such device. This consists of two balloons placed via a perineal approach bilaterally at the bladder neck. Titanium ports, attached via discrete tubing to each balloon, are placed in the scrotum, allowing for separate volume adjustments of the balloons at any time during and after surgery. A study from Hubner and Schlarp on patients with PPI looked at 117 patients, 67% of whom were dry, 92% were significantly improved, and 8% showed no improvement [8]. Various sling procedures have also been used and described for the treatment of PPI. The early work of Jorion described the use of a rectus muscle fascial sling performed preemptively in patients undergoing radical retropubic prostatectomy [9]. In 1998, Schaefer et al. described a sling procedure using Dacron graft material to treat PPI. In this technique, resembling the pubovaginal female sling method, 56% were dry and 8% had significantly improved continence [10]. In 2002, Comiter presented a prospective study on the male sling for treating SUI. He showed that incontinence was cured in 76% patients, substantially improved in 14%, somewhat improved in one (5%), with one failure. The Mayo Clinic experience of results of PPI treated with bone-anchored slings revealed 40% socially continent patients and 15% of patients with complete continence [11]. Trans-obturator male slings without bone anchors have also been reported. Treatment of PPI, which began as fixed urethral compression and then evolved to the development of dynamic compression devices, is now trending back toward fixed urethral compression. Overall, the primary advantages of the male sling are physiologic voiding, its minimally invasive nature, lower expense, and provision of immediate results when compared with the artificial urinary sphincter. However, long-term follow-up data are lacking. After a century of PPI therapy are we back to where we started? The answer is an overwhelming “yes.” We are again performing procedures that provide fixed urethral compression after a past experience of long-term failure. We do not know what the long-term outcomes of these novel techniques of passive urethral compression will be. If these results mirror those recently published, then the male sling will likely be effective in patients with mild-to-moderate incontinence. References 1. . Efficacy of the InVance™ male sling in men with stress urinary incontinence. Eur Urol. 2007;51:498–503. 2. . Mechanical control of urinary incontinence. Lancet. 1960;2:292. 3. . An artificial sphincter: a new device and operation for control of enuresis and urinary incontinence. J Urol. 1947;58:250. 4. . Treatment of urinary incontinence by implantable prosthetic sphincter. Urology. 1973;1:252. 5. . Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: a review of 323 cases. J Urol. 1998;159:1206. 6. . Outcomes following revisions and secondary implantation of the artificial urinary sphincter. J Urol. 2005;173:1242–1245. 7. . Does the Kaufman prosthesis still have a place? Review of thirteen years’ experience. Urology. 1991;38:328–331. 8. 9. . Rectus fascial sling suspension of the vesicourethral anastomosis after radical prostatectomy. J Urol. 1997;157:926. 10. . The male bulbourethral sling procedure for post-radical prostatectomy incontinence. J Urol. 1998;159:1510. 11. . The male sling for stress urinary incontinence: a prospective study. J Urol. 2002;167:597–601
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