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  • Male Urinary Sling (AdVance Sling)

    About the Authors:

    Dr. Aurthor P. Mourtzinos

    Dr. Aurthur Mourtzinos, MD

    Dr. Jessica Delong on urologybook.com

    Dr. Jessica Delong, MD

    Jessica DeLong MD and Arthur P. Mourtzinos MD

    Arthur P. Mourtzinos MD is a Board Certified Urologist who practices at Lahey.   He attended Boston University School of Medicine, Massachusetts General Hospital (General Surgery) and subsequently completed urology residency training at Lahey Clinic, Burlington, MA.  He is Fellowship trained at University of California Medical Center (Pelvic Reconstruction Surgery),  Los Angeles.  Special Interests include:  Fistula Repairs,  Male urinary incontinence Reconstructive,  Urologic Surgery Stress Incontinence,  Urethral Diverticular Disease,  Urge Incontinence , and Vaginal Prolapse.

    Jessica DeLong MD is currently a Chief Resident in the Department of Urology at The Lahey Clinic Medical Center.  She graduated from Eastern Virginia Medical School and will return there to complete a Female and Reconstructive Urology fellowship in 2013.

     

    In this ~35 minute video,  Dr. A. P. Mourtzinos performs the Advance Sling procedure in a male with urinary incontinence after radical prostatectomy.

    The steps of the procedure as described below follow the steps noted in the video.

    Click on button on bottom right to enlarge to full screen

    Introduction

    Placement of the male perineal sling has become an acceptable alternative to the artificial urinary sphincter (AUS) for male SUI. Its implantation does not preclude future continence procedures (another sling or an AUS)1, carries minimal morbidity, and is well tolerated with encouraging short and mid-term results. Best outcomes are achieved in patients with mild to moderate SUI.  Overall success ranges but can be up to 75% in appropriately selected patients, with high patient satisfaction2-4.  AUS and perineal sling are considered first line therapy for bothersome post prostatectomy incontinence (PPI) extending beyond one year postoperatively.  The AdVance sling is thought to act by repositioning and lengthening the membranous urethra. It also probably provides a small degree of urethral compression.

    Indications: Treatment of male SUI due to intrinsic sphincter deficiency (ISD). Most prevalent cause is PPI5.

    Contraindications (relative): Detrusor hypoactivity (AUS superior in this situation), active bladder cancer, severe SUI, previous pelvic radiation.

    Contraindications (absolute): Poor bladder compliance, VUR at low pressures/associated renal failure.

    Preoperative Assessment

    In addition to a standard history and physical, all patients should undergo urine analysis and culture. BUN/Cr and PSA should be obtained in post-prostatectomy patients. We perform cystoscopy in all patients prior to implantation to rule out any urethral or bladder pathology. Video urodynamics are used for assessment of bladder compliance.

    Surgical Technique

    Preparation

    General or spinal anesthesia can be utilized. Patient is positioned in modified lithotomy, with care to pad all pressure points and avoid pressure on the calves or outer knees. Genitalia and perineum are clipped free of hair. Standard preoperative antibiotics are administered.  Subcutaneous heparin as well as pneumatic boots are used for DVT prophylaxis. Patient is prepped and draped beginning with a Hibiclens wash followed by Betadine scrub. A 12 French urethral Foley catheter is placed to gravity completely emptying the bladder. Scrotal retraction is obtained with two to three 2-0 silk sutures.

    Incision and Dissection

    An approximately 3 cm midline perineal incision is made using a #10 scalpel, 1cm below the dependent portion of the scrotum down to 2cm above the anus. Incision is carried down through the superficial fat and Colles fascia down to the level of the bulbocavernosus muscle using electrocautery. The muscle is elevated away from the urethra and divided in the midline sharply. The urethra is mobilized sharply from the perineal body for approximately 1-2 cm.  This step is important in order to elevate the urethra.  A marker can be used to identify the insertion of the perineal body for later identification.

    Preparation for Trocar Placement

    Two 2-0 Vicryl sutures are pre-placed in the left and right side of the urethra at the level of insertion of the perineal body. An approximately 5mm incision is made one fingerbreadth below the adductor longus tendon over the obturator foramen on both the patient’s left and right sides. A spinal needle is inserted at this position to confirm the correct placement and trajectory of the passer. The spinal needle should pass easily into and through the obturator foramen.

    Device Placement

    The AdVance helical trocar is placed on the patient’s left side, traversing first skin, obturator foramen, obturator internus muscle, and exiting just below the inferior pubic ramus adjacent to the urethra. The surgeon’s finger protects the urethra from injury; the trocar is guided out the midline on the tip of the index finger, medial to the muscle.  The sling is attached to the trocar and brought out through the cutaneous incision adjacent to the inguinal crease. The same procedure is repeated on the contralateral side, taking care to protect the urethra. Both sides are brought out at the same level.

    The sling is attached to the corpus spongiosum proximally using the 2 preplaced sutures. A French-eye needle can be used to pull the sutures through the mesh. The sling is attached to the urethra distally using two additional interrupted 3-0 Vicryl sutures.

    Prior to tensioning the sling, we ensure that the blue sutures on the sling are facing up and are not twisted or off the midline. The sling is tensioned evenly on either side by pulling up on the trocars, elevating the urethra. A “knuckle” is formed in the proximal bulbous urethra by the tensioning of the sling. Hemostasis is achieved and the wound is copiously irrigated with antibiotic solution.

    Closure

    The bulbocavernosus muscle is closed with running 3-0 Vicryl suture. Using a Kelly clamp, the distal mesh ends are retrieved through the perineal incision, brought out below the skin level and then cut. After each layer is closed, the wound is irrigated with antibiotic solution. Colles fascia is closed in layers with 3-0 Vicryl suture.  The skin is reapproximated with interrupted horizontal mattress 4-0 Vicryl or monocryl sutures.

    Postoperative Care

    The patient is admitted overnight with catheter to gravity.  Subcutaneous heparin is continued TID. The patient is discharged home on postoperative day 1 with the catheter to gravity. He returns in 3 days for a voiding trial with nursing. Follow up with the surgeon occurs at 6 weeks. The patient is advised to avoid strenuous activity until follow up to avoid loosening of the sling.

    Potential Complications (from most to least common)6:

    • Perineal pain – generally resolves within 3 months postoperatively7.
    • Urinary retention – this is generally transient and in our experience portents an excellent long-term prognosis. Clean intermittent catheterization (CIC) can be taught to the patient to be performed until edema decreases and retention is no longer a problem.
    • Persistent  incontinence –  Some men will experience significant improvement but will not be considered socially continent (≤ 1 pad per day).
    • Infection (local wound or UTI) (rare) – very low explantation rate (<1%).
    • Worsening incontinence (rare).

    Conclusions

    The male AdVance perineal sling is a safe and effective procedure for post prostatectomy incontinence.

    References

    1. McCammon K and Haab F: AdVance male sling: surgical technique and postoperative management. Eur Urol suppl 2011; 10: 395-400.

    2. Soljanik I, Becker AJ and Stief CG et al: Urodynamic parameters after retrourethral male sling and their influence on outcome. J Urol 2011; 78(3): 708-712.

    3. Rehder P, Haab F and Cornu J-N et al: Treatment of postprostatectomy male urinary incontinence with the transobturator retroluminal repositioning sling suspension: 3-year follow up. Eur Urol 2012; on line ahead of press.

    4. Li H, Gill BC and Nowacki A et al: Therapuetic durability of the male transobturator sling: midterm patient reported outcomes. J Urol 2012; 187:1331-1335.

    5. Bauer RM, Gozzi C and Hübner W et al: Contemporary management of postprostatectomy incontinence. Eur Urol 2011; 59: 985-996.

    6. Welk BK and Herschorn S: The male sling for post-prostatectomy incontinence: a review of contemporary sling designs and outcomes. BJU Int 2011; 109:328-344.

    7. Migliari R, Pistolesi D and Leone P et al: Male bulbourethral sling  after radical prostatectomy: intermediate outcomes at 2 to 4-year followup. J Urol 2006; 176: 2114-2118.

     

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