Alan Wein: Hi there, I'm Alan Wein from UroToday, and it's my great pleasure today to be interviewing Craig Comiter, who's like the guru of male urinary incontinence, which basically boils down, except for overactive bladder, to stress urinary incontinence. And at Stanford, he's basically become the head of what was then one of the first combined OBGYN, or actually GYN urology fellowships and is in charge of that fellowship, and his research and his communication of knowledge has been very much the majority of work in male stress urinary incontinence and how to fix it.

So I've asked him to concentrate on the background of fixing male stress urinary incontinence, which basically boils down to mostly post-prostatectomy and to comment about some of the lesser-used modalities and what he thinks and then go through the most commonly used sling procedures, the most commonly used sphincter type procedures, both adjustable and non-adjustable. Give us some of the advantages and disadvantages. And then at the end I'm going to ask him a little more about stem cell therapy, which I think is fascinating and also about how he evaluates a given patient and arrives with the patient at a shared decision as to which modality of therapy to pick. Craig, fire away.

Craig Comiter: Well, thank you. Thank you. Thanks for those kind words. And don't forget, well, 37 years ago I was a med student and rotated through Penn and you told me about four things. Inability to store due to the bladder, inability to store due to the outlet, inability to void due to the bladder, and inability to void due to the outlet. And I've spent the last 37 years trying to figure out what you meant about inability to store due to the outlet and hopefully this explains some of it. So we're going to talk about male stress urinary incontinence. We've improved surgical technique and we have lowered the rate of incontinence, but still 6 to 9% of patients leak enough to see the doctor, and about half of those actually will get a surgical treatment for their stress incontinence. The robotic technique does indeed have a lower rate of stress incontinence than the old open technique, better surgery, better techniques, better patients, but we still have low single digits that will need post-prostatectomy incontinence surgery.

The majority of these patients have stress incontinence, but a significant minority also have bladder dysfunction. So while the sphincter is damaged with the surgery, there can be persistent detrusor overactivity, detrusor underactivity, and even poor compliance. In fact, about a third of patients will develop DO DU or diminished compliance, and about a quarter of those have persistent dysfunction. So what do we do for stress incontinence? Well, according to the guidelines, we start with pelvic floor exercises. And while there's no risk, they tend more to facilitate recovery of the pelvic floor. And we don't generally see dramatic improvements in stress incontinence beyond the first six months. There's periurethral bulking agents which are approved by the FDA, but not really efficacious. And in fact, most guidelines, whether they're AUA or European or the International Consult on Incontinence have moved away from bulking agents as a recommendation. But for mild to moderate incontinence, the recommendation is use anything that works. That's the male sling, periurethral balloons or the artificial sphincter. And for the sling, it can be fixed or adjustable.

And for severe incontinence, those who are irradiated or those who have recurrent incontinence, we generally recommend the artificial sphincter. So how do we evaluate this patient? Well, like always, you have to determine the pathophysiology and the vast majority, it's a weak sphincter. Call it what you want. Low maximal urethral closure pressure, shortened functional zone, damage to the sphincter complex, the outlet is weak. But we also have to rule out overactive or underactive bladder and diminished compliance if suspected, usually only in the radiated patient. And per most guideline statements, we always start with a history, a physical, and it's important to demonstrate the leakage. And remember, the symptom of stress incontinence is I leak with cough. The physical exam, the finding is leakage with cough or valsalva, and then it stops at the end of that maneuver. So it's not a prolonged leak, it's a short leak during strain. If suspicious, do cystoscopy to look for a stricture.

And if there's any other questions, urodynamics is a low risk, high yield procedure to evaluate bladder function. So what are the current surgical treatments? There are various male slings, can be transobturator, and the brand names for those are AdVance XP and the ISTOP-TOMS. There's a quadratic sling called the Virtue sling. So this involves the transobturator component as well as a prepubic component for an extra boost of continence. There are several adjustable slings, but only one available in the United States called REMEX. And it uses a veritensor, and I'll show you a picture of that. There's a biologic sling where you could use donated tissue, and this is done only during inflatable penile prosthesis surgery, called the mini-juppet. And that's another bolster that when the IPP inflates, this stretches across the urethra and provides support. There's the artificial sphincter, which has been called the gold standard for stress incontinence treatment. Not quite sure what gold standard means, but it certainly has the most predictably reliable success rate. And then there's periurethral balloons, which recently gained FDA approval.

Outside the country, there are other fixed slings, adjustable slings and even some new artificial sphincters which we will touch on. So where did it all begin? At UCLA with the Kaufman procedure. Basically, Dr. Kaufman crisscrossed the muscles around the perineum and this elevated and compressed the bulbar urethra. And fast-forward about 20 years and you can use a synthetic material either tied to the bones, anchored to the bones or woven through the bones, and that's the modern male sling. But same principle, relocate the urethra, co-apt the lumen urodynamically. We lengthen the sphincter zone, but all in the spirit of avoiding obstruction. So this is the transobturator sling and probably the most popular sling on the market. And what happens is you pass this through the transobturator canal and as you tighten it, you can see elevation of the bulbar urethra. It's not necessarily compressing it and providing obstruction, but it's moving it 2.5 centimeters proximal. The old theories that we've abandoned in female incontinence surgery are valid in the male, that we reposition the proximal urethra into an intra-pelvic high pressure zone.

So again, pull on the sling edges and we relocate it proximally about 2.5 centimeters. Continence rates are about 75% in the short term, but they decrease over five years. Very low complication rate, but we've learned does not work well with severe leakage or radiation. There's the quadratic sling and this is simply a boost on the transobturator sling. So there's a transobturator component but also a prepubic component. And this was invented by tinkering in the cadavers and you could see a four corner based on the four corner cystopexy repair in the woman, transobturator component, prepubic components, providing not just relocation of the proximal urethra, but actual compression of the perineal portion of the urethra. Fixation is important. This is a high tension sling. It's a transobturator and prepubic, but very poor success without proper fixation. Much higher success when you actually put sutures from the sling to the periosteum of the pubic bone.

And then the transobturator portion comes together in the midline and it achieves a success rate greater than 70%, rivaling the transobturator sling. Again, low complication rate of pain and urinary retention. Here's a summary of all the slings and the bottom line is they all work about 75% of the time they have variable follow up and each one may have slightly different complication rates and advantages, but overall slings are useful for mild to moderate stress incontinence and work about 75% of the time at five years.