Andrew Siegel MD 4/18/20
Surgery is a consideration for treating the rare patient who has persistent, significant incontinence following prostatectomy who has failed to improve after conservative management strategies. Today’s entry examines bulking agents and slings; next week’s topic will be the the artificial urinary sphincter, which is considered the gold standard” for management of post-prostatectomy urinary incontinence.
Before embarking on surgical management of urinary incontinence, it is imperative for the patient to undergo an evaluation to determine the most appropriate type of treatment. This involves a cystoscopy to visually inspect the urethra, sphincters and urinary bladder and urodynamics to provide functional information about bladder storage and emptying. Surgical management is tailored to the extent of the urinary incontinence as well as other factors, including the ability of the bladder to contract properly. The degree of incontinence is best quantified by pad usage, particularly by determining the weight of pads used in 24 hours.
Urethral Bulking Agents
Bulking agents are materials that are injected into the tissues around the urethra to help provide closure and improve urinary control. By plumping up the tissues surrounding the urethra, they can increase the urethral resistance. Bulking agents work in a similar way to collagen that is injected into one’s lips to increase their fullness and bulk.
Injection of a bulking agent is a simple outpatient procedure that often needs to be repeated. The best results are achieved when injecting into healthy and supple tissue. However, many men with incontinence following prostatectomy have scarring of the bladder neck, making the tissues less receptive to bulking agents and accounting for the general less-than-satisfactory results. Most men who receive bulking agents will ultimately need either a male sling or artificial urinary sphincter. Since many patients do not achieve meaningful improvements in urinary control, urethral bulking agents are most commonly used for short-term improvement in men who are poor surgical risks for more invasive treatments.
Macroplastique urethral bulking agent
Male Slings
The male sling, although not as effective as the artificial urinary sphincter (upcoming topic), is less invasive and incurs fewer potential risks and complications. Similar to a female urethral sling, a piece of supportive synthetic material (polypropylene) is strategically positioned beneath the deep, inner portion of the urethra via an incision in the area between the scrotum and anus. This provides control by creating either urethral compression or urethral relocation (support without compression) and is best suited for mild-moderate urinary incontinence as opposed to the artificial urinary sphincter that is used to manage severe urinary incontinence.
Men who have undergone radiation therapy have poorer outcomes with slings than non-radiated patients and are better served with the artificial urinary sphincter since radiation-induced scarring and fixation often limits the mobility of the urethra and hence the ability to relocate the urethra; as well, radiation can interfere with tissue healing. Similarly, because of urethral scarring and fixation, men who have had a prior unsuccessful artificial urinary sphincter implant are not good candidates for a sling.
The array of slings available for the incontinent male include the trans-obturator sling (AdVance sling), the quadratic sling (VIRTUE) and an adjustable sling (Remeex). Success rates (0-1 pads daily) are moderate and complications include failure to improve the incontinence, inability to urinate, pain, infection, erosion and need for revision.
The trans-obturator sling relies on repositioning the urethra and thus requires an adequately mobile urethra that is not fixed and scarred. A fixed and scarred urethra is a situation that would be better served with compression, i.e., the quadratic sling or artificial urinary sphincter. After tensioning the trans-obturator sling, it moves the urethra as much as an inch higher up in the pelvis and functions as a backboard during exertion, providing control dynamically as increases in abdominal pressure displace the urethra into the backboard, pinching the urethra closed.
Trans-obturator sling (AdVance)
The quadratic sling is a four-armed mesh tape that relocates the urethra using a component that is placed via the groin and provides urethral compression using a component placed via the pubic area. Because this particular sling provides compression as well as relocation, it is best suited for men with a bladder that contracts normally as opposed to men with impaired bladder contractility (under-active bladder). An incontinent man who has impaired bladder contractility would be better served with a trans-obturator sling or artificial urinary sphincter. Because of the compression mechanism of action, the quadratic sling is better suited to men with more severe incontinence than could be addressed by the trans-obturator sling.
Quadratic sling (VIRTUE)
The Remeex adjustable sling consists of a short piece of mesh tape positioned under the urethra that is attached to a tensioning device placed in the pubic region. Sling tightening or loosening can be achieved by a minimally-invasive surgical means of accessing the tensioning mechanism.
Remeex adjustable sling
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: adjustable sling, Andrew Siegel MD, Macroplastique, male slings, prostate cancer, Prostate Cancer 20/20, quadratic sling, surgical management of post-prostatectomy urinary incontinence, trans-obturator sling, urethral bulking agents
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