[Abstract] OBJECTIVE: To investigate the efficacy of simple suspension for male urinary incontinence. Methods: 44 patients with male acquired urinary incontinence were admitted from October 2000 to July 2009, including 34 cases after prostate surgery and 10 cases after posterior urethral surgery; 11 cases with complete incontinence and 33 cases with stress incontinence, each requiring 1 to 5 diapers/d, with an average of 3±1 diapers/d. 43 cases were treated with composite suspension of heart polyester patch and nylon thread + TVT sling ball urethra, and 1 case The transcatheter route of bulb urethral suspension was used. RESULTS: The composite suspension group was followed up from 6 to 90 months after surgery, with a mean of 52±30 months. 34 cases had complete urinary control, 7 cases had improved urinary incontinence, and 2 cases were ineffective; 1 case had difficulty in urination, and urination was clear after electrodesection of the bladder neck. 1 case with TVT-O suspension was followed up 6 months after surgery, and had good urinary control and no residual urine. Conclusion: Ball urethral suspension is a simple and effective method to treat male urinary incontinence. Liu Ying, Department of Urology, Shanghai Tongji Hospital
[Keywords] Urinary incontinence; male; prostatectomy; urethroplasty
Simple suspension for the treatment of male urinary incontinence
[Abstract] Objective To evaluate the effect of simple suspension in treatment of male urinary incontinence(UI). Methods Between October 2000 and July 2009, 44 patients with acquired UI underwent surgical treatment. The causes of UI were postprostatectomy in 34 patients and post-posterior urethroplasty for urethral stricture in 10. Preopratively, 11 patients had complete UI and 33 patients had stress UI, with 1 Forty-three patients were performed bulbourethral composite sling using a polyester patch plus tension free The patients were treated with a polyester patch plus tension free vaginal tape, and the remainder was performed transobturator bulbourethral sling (TOBS). Results The bulbourethral composite sling group were followed up for 6 to 90 months (mean 52±30 months), complete urinary continence was achieved in 34 The bulbourethral composite sling group were followed up for 6 to 90 months (mean 52±30 months), complete urinary continence was achieved in 34 patients, improved in 7, and failed in 2. One patient was found postoperative difficulty in voiding, and was corrected by transurethral bladder neck The patient underwent TOBS was followed up for 6 months and achieved complete urinary continence with no residual Conclusion Bulbourethral sling procedure is a mini-invasive, safe, effective surgical procedure in the treatment of male acquired UI.
[Key words】 Urinary incontinence; Male; Prostatectomy; Urethroplasty
Male acquired urinary incontinence is one of the common complications after prostatectomy and severe posterior urethral stricture, and its treatment is difficult and seriously affects patients’ quality of life. As a minimally invasive technique, the ball urethral suspension is one of the more popular procedures in recent years because of its simplicity, low cost and reliable efficacy. In 2002, we reported five cases of urinary incontinence after prostatectomy treated by ball urethral suspension under urodynamic monitoring with good results [1], and later expanded the disease to include posterior urethral stricture incontinence [2,3]. Recently, we used a female anterior patch to suspend the bulbous urethra via the closed-hole route to treat one case of stress urinary incontinence, and obtained better results, which are reported below.
1 Clinical data
1.1 General information
From October 2000 to July 2009, 44 patients with male acquired urinary incontinence were admitted, aged 18-81 years, with an average age of 67 years. Etiology: 10 cases after urethroplasty for severe posterior urethral stricture, 34 cases after prostate surgery, including 8 cases after radical prostate cancer surgery, 16 cases after transurethral resection of prostate (TURP), and 10 cases after prostate removal. The degree of urinary incontinence: 11 cases of complete incontinence and 33 cases of stress incontinence, each requiring 1 to 5 diapers/d, mean 3±1 diapers/d. The duration of the disease was 1 to 12 years, mean 4±6 years. The patients were all ineffective with various conservative treatments before surgery. Preoperative urodynamic examination maximum urethral pressure (MUP) 30~87cmH2O, mean 52±19cmH2O (1cmH2O = 0.098kPa); functional urethral length 0.8~2.5cm, mean 1.4±0.8cm.
1.2 Suspension materials
Cardiac polyester patch and nylon thread suspension was used in 12 cases at the early stage of suspension, cardiac polyester patch and nylon thread + TVT sling was used in 31 cases at the later stage, and female anterior patch was used in one case.
1.3 Surgical methods
① Continuous epidural anesthesia or lumbar anesthesia was used. The patient was placed in a lithotomy position with an inverted Y-shaped perineal incision, the bulbocavernosus muscle was incised, the bulbourethra was exposed and slightly separated along the bulbourethra to both sides, and small incisions of about 2.5 cm in length were made on each side of the pubic symphysis close to the superior edge of the pubic symphysis branch, reaching deep into the external sheath of the rectus abdominis muscle.
Two 2-0 nylon threads were sewn on each side of the spacer and the ends of the threads were threaded into the nylon sleeve of the TVT sling and brought out with the TVT sling during puncture. Before puncture, a catheter was inserted into the urethra and left in place after emptying the bladder as a marker to avoid the urethra during puncture. the TVT puncture needle was passed from both sides of the bulbous urethra and immediately adjacent to the pubic arch toward the suprapubic incision on both sides. After suturing the polyester patch to the middle of the TVT sling for fixation, the upper and lower sides of the polyester patch were intermittently sutured to the bulbar urethra with 4-0 absorbable thread to prevent displacement of the polyester patch and to ensure uniform force during suspension. After cystoscopy confirmed that the TVT sling did not penetrate into the bladder and urethra, an intraurethral pressure check was performed as the base pressure before suspension. The bladder was filled with 200 to 300 ml of saline and pressure was applied to the bladder area to observe the urine ejection from the urethral orifice. According to the degree of preoperative urinary incontinence and the level of intraurethral pressure, the nylon threads inside the suprapubic incision on each side were pulled with a tension of 300 to 600g and maintained at this tension, and the intraurethral pressure was measured, and the required pressure (about 90cmH2O or about 40 to 50cmH2O higher than the pre-suspension base pressure) was reached and tied. Ceftazidime powder 1g was left in the wound to prevent infection, and catheterization was left in place.
(③) Transconjunctival route ball urethral suspension
Near the root of the thigh, the midpoint of the lateral margin of the descending pubic bone on both sides (i.e., the medial margin of the closed-hole triangle on both sides) and the lower corner of the closed-hole triangle were touched and marked as perineal skin puncture points (see Figure 1). Before puncture, the urethral catheter was inserted and left in place after emptying the bladder. After exposing the bulbous urethra, the central portion of the butterfly mesh was slightly cut according to the patient’s perineal body area, the guide was placed over the trocar, and the trocar was extended through the incision to pass the trocar from both sides of the bulbous urethra around the descending branch of the pubic bone from inside to outside through the occlusal membrane and muscle through the medial edge of the occlusal triangle to the skin mark, the guide was withdrawn, and after the traction lead was inserted and passed through the trocar, the long arm of the mesh was hooked with the traction lead to pass through the trocar ( see Figure 2). The central portion of the patch is intermittently sutured to the bulbous urethra with 4-0 absorbable thread to prevent displacement of the patch and to ensure uniform force during draping. An intraurethral pressure check was performed as the base pressure before suspension. According to the degree of preoperative incontinence and the level of intraurethral pressure, the long arms of the mesh through the closed-hole incision on both sides were pulled with a tension of 300-600 g and maintained under this tension before performing intraurethral pressure measurement, the tightness of which was appropriate to maintain the intraurethral pressure at about 90 cmH2O or about 40-50 cmH2O higher than the pre-suspension base pressure (see Figure 3), pulling out the cannula and fixing the mesh on both sides through the The subcutaneous tunnel is fixed together, and the excess of the mesh band is cut off. Ceftazidime powder 1g was left in the wound to prevent infection, and catheterization was left in place.
1.4 Evaluation of efficacy and follow-up
After removal of the catheter after surgery, if the patient did not need pads while walking or required diaper pads for complete incontinence ≤1 pad/d was considered cured; ≥50% reduction in the amount of urine leakage or the number of pads used compared with that before surgery was considered improvement; minimal change in the amount of urine leakage was considered surgical failure. Postoperative reviews were performed at 2 to 4 weeks, 3, 6, and 12 months, and annually thereafter.
2 Results
All 44 patients had no incisional infection after surgery, and the catheter was removed 3 to 5 d after surgery. Follow-up ranged from 6 to 90 months, with an average of 52 months, of which 40 cases were followed up for more than 1 year. There were 35 cases of complete urinary control in the early postoperative period, 7 cases of improvement in urinary incontinence and 2 cases of ineffectiveness; 1 case of dyspareunia, and the urine was voided smoothly after electrodesection of the bladder neck. The overall efficiency was 95.4% (42/44), including 81.8% (9/11) for complete urinary incontinence and 100% (33/33) for stress urinary incontinence. The overall efficiency of patients with more than 1 year postoperative follow-up was 90.0% (36/40), of which the efficiency of complete incontinence was 80.0% (8/10) and the efficiency of stress incontinence was 93.3% (28/30). Two of the patients with initial stress incontinence had recurrence 1 and 2 years after surgery, respectively. One of them was found to have a looser suspension line than the initial postoperative period and was able to control urine after tightening; the other case was still under observation and was proposed to be treated by suspension again. Five cases had pain and discomfort in the perineum after surgery, and local physiotherapy was performed, which improved after 2 months. All patients had a postoperative ultrasound examination of residual urine <20 ml. 32 patients had a urinary flow rate examination, and the maximum urinary flow rate (Qmax) was 15.2±2.8 (12-19) ml/s on average. no urethral erosion occurred in all patients after surgery.
Patients who underwent urethral suspension by the trans-occlusive route of the bulb were able to have complete urinary control at 6 months postoperative follow-up, with no residual urine on postoperative ultrasound and Qmax 18 ml/s on urinary flow rate examination.
3 Discussion
Male acquired urinary incontinence is one of the common complications after prostatectomy and complex posterior urethral surgery and is more difficult to treat. Artificial sphincter (AUS) implantation is efficacious and effective for urinary control, but it is indicated for severe incontinence, followed by expensive and prone to complications such as urethral erosion, atrophy, mechanical failure, and a high rate of reoperation risk [4-6]. Ball urethral suspension is not a mechanical device, and as a minimally invasive technique that is simple to perform, inexpensive, reliable, and more acceptable to patients, it is a new and more popular method for the treatment of male urinary incontinence in the last decade or so.
The ball urethral suspension, although simple to perform, requires care. After piercing the needle from the perineal incision into the suprapubic incision on both sides, cystourethroscopy must be performed to check for the occurrence of bladder perforation. In the early stage of this group, there were 2 cases of re-piercing with nylon thread penetrating into the bladder on one side. The biggest difficulty of this procedure is how to control the tension of the suspension [3]. According to Schaeffer et al [7], the degree of suspension tightness can be determined by the operator’s experience, and the catheter is removed on the first postoperative day to observe urination, and if incontinence is still present, the nylon wire is returned to the operating room to open the suprapubic incision and tighten the suspension. Onur et al [8] used intraoperative coughing to adjust the sling tension by asking the patient to cough during the suspension and marking the sling to determine the suspension tightness if there was no urine flow, with a failure rate of 24%. Most studies used maximum urethral pressure (MUP), maximum urethral closure pressure (MUCP) or abdominal leakage point pressure (ALPP) as reference indicators. Our group used to determine the suspension tension under urodynamic monitoring, which can reflect the intraurethral pressure more objectively, but the choice of how much pressure is more appropriate is still controversial. john [9] believed that MUCP over 100 cmH2O may cause urinary retention and urethral erosion, while 60 cmH2O is more appropriate. In his study group of 16 patients, 11 cases had complete urinary control, 1 case improved, and the remaining 4 cases had insignificant improvement in urinary incontinence after surgery. In this group, MUP 90cmH2O or 40-50cmH2O higher than the pre-suspension base pressure was used as the standard for satisfactory postoperative results. All patients had postoperative ultrasound examination of residual urine <20 ml. 32 urinary flow rate examinations were performed and the maximum urinary flow rate was 12-19 ml/s. No urethral erosion has occurred in all patients to date postoperatively.
Although studies have compared ball urethral suspension with AUS implantation with intermediate and long-term follow-up (≥4 years) [10,11], there is considerable variability in the detailed surgical technique, surgical success criteria, severity of incontinence, and operator experience in the relevant reports. The follow-up results of our patients showed an overall efficiency of 95.4% (42/44), including a cure rate of 79.5% (35/44) and an improvement rate of 15.9% (7/44).
Trans-occlusive route suspension is widely used in the treatment of female SUI, showing its advantages of good efficacy and few complications, which can reduce complications such as bladder and pubic bone injury and excessive bleeding [12]. There are 2 issues to be considered when using transconjunctival route suspension in men. (1) anatomically, the anterior pubic branch is thicker and the pubic arch is narrower in men, so the procedure should be fully considered to improve the specific operation method; (2) from the pathophysiological point of view, tension-free urethral suspension is effective for the treatment of SUI in women, but in men with urinary incontinence treated by suspension, a greater tension is often required rather than tension-free. In 2005, Bauer et al [13] proposed the concept of using a closed-hole bulb urethral suspension. Thereafter de Leval et al [14] applied trans-occlusive suspension technique to clinical practice and treated 20 patients with SUI after radical prostatectomy, 45% were cured, 40% improved (urinary pad 1/d), and most patients (80%) had significantly improved quality of life without complications such as infection, urethral erosion, and persistent pain. We found a low risk of injury to sensitive structures such as the bladder, bowel, and blood vessels by suspension via the closed-hole route. In this case, with a history of multiple failed incontinence surgeries, more local tissue damage and surgical scarring, and older age, we used an anterior pelvic floor repair mesh that was wider than the traditional TVT-O sling, allowing it to better fix the local supporting tissues, support the local mechanical architecture, and strengthen the local tolerance tension. Postoperatively, the patient had good urinary control, no residual urine, and a Qmax of 18 ml/s. The short-term follow-up results were satisfactory. However, the efficacy of this procedure has just been developed, and more clinical trials and long-term follow-up are still needed to confirm its efficacy.
The problem of perineal wound infection must also be taken into account. In the study by Schaeffer et al [7], there were 2 cases (3%) of surgical failure due to infection. Therefore, in this study, strict disinfection of the surgical area and topical antibiotic powder before intraoperative closure of the incision were used to help prevent incisional infections. In addition, interrupted suturing of both sides of the polyester sheet or the central part of the butterfly mesh to the outer membrane of the bulbous urethral spongiosa with 4-0 absorbable thread before suspension can prevent the displacement of the polyester sheet and uniform tension during suspension to avoid the effect of too narrow tension point due to sling curl.
Our study also found a relationship between surgical efficacy and the degree of preoperative urinary incontinence in patients. The results of more than 1-year follow-up of patients who underwent cardiac polyester patch and nylon thread + TVT sling surgery showed that the effective rate of stress incontinence was 93.3%, while the effective rate of complete incontinence was only 80.0%. john [9] found that the treatment failure rate for severe incontinence was 50%, while the success rate for moderate and mild incontinence was 95%. fischer et al [15] concluded that preoperative 24-h urinary pad test is the only factor predicting the efficacy of surgery. lee et al [16] showed that the cure rate was significantly higher in patients with ALPP > 60 cmH2O (82.8%) than in patients with ALPP ≤ 60 cmH2O (51.6%). In addition, important factors may include a history of pelvic radiotherapy and bulbar urethral scarring.
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