Urethral erosion following autologous rectus fascial pubovaginal sling

Urethral erosion following pubovaginal sling is a rare occurrence. When synthetic sling materials are used urethral erosion often necessitates removal of the sling and urethral reconstruction. The literature is sparse with respect to the best approach to fascial sling erosion. We report a case of a 73 year-old woman who underwent a pubovaginal sling using autologous rectus fascia for treatment of stress urinary incontinence (SUI). She developed urethral erosion following 2 weeks of clean intermittent catheterization (CIC). Visual internal urethrotomy (VIU) was performed to incise the sling and the prolene sutures were removed to eliminate any tension. The patient subsequently voided spontaneously and had resolution of her SUI. This case demonstrates that urethral erosion may occur even when fascial slings are used. Unlike synthetic slings, when autologous fascia is used, the tissue may be left in-situ. A minimally invasive approach may achieve an excellent result without the need for complex surgical repair.     

Use of Injectable Urethral Bulking Agents in the Management of Stress Urinary Incontinence

The use of injectable bulking agents is a well-established approach to management of patients with stress urinary incontinence (SUI). No single bulking agent to date has been shown to be superior or consistently durable in the literature. Novel therapeutic strategies, including the use of injectable, muscle-derived stem cell therapy, have shown promising results in investigational stages. Urethral bulking agent therapy can be helpful in the early management of men with SUI following radical prostatectomy, and in women with SUI due to intrinsic sphincter deficiency, urethral hypermobility, or in the setting of failed midurethral sling placement. Despite their widespread use historically, biocompatible agents have been supplanted in recent years by synthetic agents secondary to their potentially improved durability and nonimmunogenic profiles.     

Simultaneous Treatment of Female Urethral Diverticulum and Stress Urinary Incontinence with Urethral Diverticulectomy and Suburethral Synthetic Mesh Sling

Objectives: Pubovaginal fascial sling along with urethral diverticulectomy has been advised as the most appropriate anti‐incontinence procedure for female stress urinary incontinence (SUI) with concomitant urethral diverticula (UD). We believe that suburethral synthetic mesh tape sling can also be safely used in some patients with concomitant SUI and UD. Herein, we present our experience for simultaneous treatment of UD and SUI with urethral diverticulectomy and suburethral synthetic mesh tape sling. Methods: From 2003 to 2008, there are three patients with UD and SUI in our institution. They received transvaginal urethral diverticulectomy and suburethral synthetic mesh tape sling simultaneously. Videourodynamics was done before and three months after the surgery. Results: Preoperative pelvis magnetic resonance imaging and videourodynamic study showed UD over distal urethra and SUI in all three patients. Urinalysis disclosed mild pyuria in two of the patients, and they both received intravenous antibiotics treatment to eradicate the infection prior to the surgery. They all underwent urethral diverticulectomy with suburethral synthetic mesh tape sling. The postoperative videourodynamic study showed no recurrence of UD and SUI. With a mean follow up of 33.3 months, there was no infection or exposure of synthetic mesh tape. Conclusions: In patients with UD and SUI, suburethral sling using synthetic mesh can be as effective and safe as facial sling in selected patients.     

Evaluation and Treatment of Persistent Stress Urinary Incontinence after Male Anti-Incontinence Procedure – AUS or Sling

The two most common anti-incontinence procedures performed for postprostatectomy incontinence (PPI) are placements of the artificial urinary sphincter (AUS) and male sling. While both procedures offer high success rates, 10-30 % of patients after AUS and 20-45 % of patients after male sling require evaluation for persistent PPI. The goals of evaluation for persistent PPI should be to verify the diagnosis of stress urinary incontinence (SUI) and to assess for concurrent bladder dysfunction. If the initial procedure was an AUS, and recurrent intrinsic sphincter deficiency is diagnosed, it is vital to distinguish among mechanical failure, urethral atrophy and erosion. If a repeat sling is considered, it is necessary to verify the degree of intrinsic sphincter deficiency (ISD) and assess for persistent or recurrent proximal urethral mobility. Because of diminished urethral compliance that results from prior AUS or male sling surgery, implantation of an AUS remains the treatment of choice for persistent SUI, as it is the most reliable method of providing the circumferential urethral compression necessary for adequate coaptation even in the setting of urethral fibrosis.     

Experience with Tension‐free Vaginal Tape (TVT)‐SECUR for Female Stress Urinary Incontinence

Objectives: Tension‐free vaginal tape (TVT)‐SECUR is a technique specifically designed to place a short suburethral mesh sling for the treatment of female stress urinary incontinence (SUI). The aim of the technique is to decrease surgical morbidity. We report our experience of applying this technique on 10 patients. Methods: From June 2007 to July 2007, 10 female patients with SUI underwent TVT‐SECUR placement operation. The sling was inserted in a suprapubic direction over the inner surface of pubic bone (U‐shaped technique). Nine of the patients underwent videourodynamic study (VUDS). The maximal bladder neck decent distance (MBND) by abdominal straining was determined. We identified intrinsic sphincter deficiency (ISD) as a valsalva leak point pressure lower than 60 cm H₂O and hypermobility as MBND more than 2 cm. Results: Two patients had pure ISD, three had hypermobility, and four had both ISD and hypermobility. All patients remained continent for first month after surgery. SUI recurred in five of nine patients at an average of 2.5 months. The recurrence appeared in all three groups of patients. The recurrent SUI was so severe that three patients required repeat surgery using percutaneous prolene tape sling. After surgery, no further SUI was noted in the three patients. During surgery the TVT‐SECUR sling was found to have firmly adhered to perivesical tissue rather than to the pubic bone. Conclusion: Our experience shows that the current design of the TVT‐SECUR results in unpredictable outcomes. Some placed slings may migrate away from the inner surface of the pubic bone. To act as a reliable “hammock”, the sling must be securely fixed on immobile structures independent from the bladder/urethra.     

Treatment of severe post-prostatectomy stress urinary incontinence using AdVance sling

Severe stress urinary incontinence (SUI) is usually treated by the implant of artificial sphincter positioned around bulbar urethra. AdVance sling is a functional, non-obstructive, anti-incontinence device that showed good results especially for mild and moderate SUI. We present our experience with AdVance sling in 7 patients with severe SUI unfit for artificial sphincter. Our results, after a follow-up of more than 6 months, showed a continence rate of 28% and an improvement rate of 43%, while 2 patients did not show any benefit. The success of AdVance sling depends on the integrity of urethral sphincter and can be applied also in selected cases for the treatment of severe post-prostatectomy stress urinary incontinence.     

Management of Stress Urinary Incontinence in the Neobladder Patient

Considering the intent for provision of near-normal urinary function with an orthotopic diversion, issues with voiding dysfunction and urinary incontinence manifest substantial impact on quality of life for neobladder patients. Following appropriate functional and anatomic evaluation, often employing cystoscopy and urodynamics, multiple treatment strategies are available for treatment of stress incontinence in this complex patient population. Conservative modalities including pelvic floor physical therapy, behavioral therapies, and general education regarding neobladder diversion are foremost. Pharmacologic therapies may be suitable in select circumstances. Minimally invasive treatments such as transurethral bulking agents can provide improvement for women with stress incontinence following orthotopic diversion; however the risk profile may preclude use in many patients. Midurethral tape technologies, including transobturator and single incision slings, represent a comparatively recent iteration of implements to be considered. The pitfalls of fascial pubovaginal sling include navigation of complex anatomy combined with a high rate of urinary retention. In men, artificial urinary sphincter continues to exemplify an effective continence procedure following neobladder diversion with only a modestly elevated complication profile in these high risk patients. Male sling technologies are additionally gaining appreciation as an option for treatment of sphincteric dysfunction following orthotopic neobladder and forgo several drawbacks associated with artificial sphincter placement.     

The Bladder Neck Sling: What Role Remains?

A decade ago, bladder neck slings were recognized as the gold standard technique for a majority of patients. Today, tension-free vaginal tape is widely accepted as the standard approach for index surgery in female stress urinary incontinence. Recently published articles have demonstrated a decrease in the use of bladder neck slings and a significant increase in the use of mid urethral synthetic slings. Currently, bladder neck sling procedures appear to confer a cure rate similar to open retropubic colposuspension and mid urethral sling procedures, but the long-term adverse event profiles are still unclear. Although, bladder neck slings remain in the armamentarium of pelvic surgeons, they are reserved mainly for pediatric patients and for complex patients at high risk for urethral damage, with recurrent urinary incontinence and with low-pressure urethras, as well as for the patients who may refuse having synthetic slings. This article reviews the role of bladder neck slings in the era of the midurethral slings.     

Post Prostatectomy Bladder Dysfunction: Where Are We Now?

During the prostate-specific antigen (PSA) era, the prevalence of male stress urinary incontinence (SUI) continues to rise as more prostatectomies are performed. Treatment of male SUI is a multifactorial decision depending not only on bladder and sphincteric function, but also patient choice. Due to the economic burden and strain on quality of life, procedures and devices have been developed to help patients alleviate their symptoms. Mainstays of treatment include conservative management with biofeedback and Kegel exercises, periurethral bulking agents, or surgical procedures such as the male urethral sling or the artificial urinary sphincter. A proper evaluation is important as bladder dysfunction in the form of detrusor overactivity, detrusor underactivity, and poor bladder compliance can occur independently or coexist with intrinsic sphincter deficiency. Thus, it is important to clearly define patient symptomatology to optimize outcomes.     

Efficacy of Synthetic Suburethral Slings in Female Urinary Stress Incontinence with Overactive Bladder

Objectives: The aim of the present study was to investigate the efficacy of synthetic suburethral slings in female stress urinary incontinence (SUI) patients with overactive bladder (OAB). Methods: From May 2002 to April 2005, a total of 295 women with SUI underwent suburethral sling procedure. Of the 295 women, only those who were followed up for at least 12 months were included in the study, yielding 236 patients. The patients were divided into three groups: pure SUI; SUI with OAB dry; and SUI with OAB wet. Telephone questionnaires by were used to evaluate the postoperative improvement of SUI and storage symptoms. Results: There were significant differences in preoperative symptom score, quality of life (QoL) score, and preoperative voided volume among the three groups. There were no significant differences among the three groups in terms of the cure rate for the stress component (group 1, 88.6%; group 2, 86.2%; group 3, 86.7%; P = 0.943). Eighty percent of group 1 patients improved in frequency, but two patients (2.3%) complained of de novo urgency. In group 2, 81.5 and 82.7% improved in frequency and urgency, respectively, but one patient (1.7%) complained of de novo urge incontinence. In group 3, 76.9 and 84.4% improved in frequency and urge incontinence, respectively. Conclusion: Suburethral slings are simple, safe and highly effective in treating SUI with OAB.     

Slings for Stress Urinary Incontinence in Men: An Update

Stress urinary incontinence is usually caused by iatrogenic injury during prostate cancer surgery. Most treatment options are surgical in nature and include periurethral bulking, artificial urinary sphincter, and male slings. During the past decade, innovations in male sling surgery have contributed to an increased interest in their use among treating urologists and their patients. Currently, male slings are most efficacious in men with mild to moderate stress incontinence, with no prior history of pelvic radiation, and without prior artificial sphincter placement. In this population, high efficacy rates and low complication rates are typically achieved.     

Management of Male Voiding Dysfunction after Radical Cystectomy and Neobladder Reconstruction

At centers orthotopic bladder substitution (OBS) is the preferred method of urinary diversion following radical cystectomy (RC). Daytime and nighttime incontinence (UI) are reported in up to 13?% and 28?% of cases, respectively. SUI is the most common reason for daytime leakage, while an absent vesicourethral reflex with reduced external sphincter tone is associated with nighttime UI. A PubMed search disclosed a paucity of data for any treatment modality, the absence of prospective randomized trials and the existence of few retrospective case reports or small case series with limited follow up. Conservative management has limited value. Pharmacologic treatment for enuresis is effective in select OBS patients, while the off label use of Duloxetine for SUI seems promising. Surgical approaches include adjustable and nonadjustable slings as well as the ProACT system in mild stress UI. The need of intermittent self catheterisation (ISC) after slings seems to be very high. Implantation of the artificial urinary sphincter AMS 800 (AUS) is the standard treatment for severe stress (UI). AUS is a relatively safe, effective continence procedure for patients with OBS and severe SUI. Complication rate, urinary symptoms, and quality of life of these patients as determined by validated questionnaires are acceptable.     

Mesh for Stress Incontinence

Stress urinary incontinence (SUI) is quite common, such that about 50 % of women with urinary incontinence report SUI as their primary symptom. Once behavioral modifications and pelvic floor muscle training have failed, surgical management is the mainstay of treatment for SUI, and mid-urethral synthetic slings (MUSS) have been established as the surgical intervention of first choice. All commercially available MUSS are made from uncoated, knitted, macroporous, type 1 polypropylene mesh. With the evolution of mesh, the evolution of the surgical treatment of SUI has evolved in tandem. The popularity of MUSS has come under scrutiny with the US Food and Drug Administration (FDA’s) public health notification. While the FDA has not yet released its final recommendations on these devices, the American Urological Association has adopted position statements on the use of mesh for the surgical treatment of SUI.     

Urinary incontinence: sphincter functioning from a urological perspective

Stress urinary incontinence (SUI) is a debilitating disorder caused by malfunctioning of the urethral sphincter. Anatomical and histological properties of the sphincter, its innervation and supporting structures are explained in relation to the closing mechanism of the bladder outlet. Urethral sphincter function is discussed from the passive concept of urethral pressure transmission to the 'hammock theory' and the role of the pubococcygeus muscles. SUI is caused by a combination of intrinsic sphincter deficiency and urethral hypermobility. The difficult interpretation of the parameters in urodynamic investigation to assess intrinsic sphincter deficiency (ISD) and/or urethral hypermobility is discussed. Electromyography (EMG) is valuable in the assessment of the overall urethral sphincter in relation to maneuvers (kinesiological EMG) and at the level of the muscle fiber (needle EMG). The diagnostic potential of circumferential surface EMG in the urethral sphincter is reviewed in relation to the EMG features of ISD.     

An overview of stress urinary incontinence treatment in women

Stress urinary incontinence (SUI) is common in women, but it is under-reported and under-treated. We review here the management of SUI in women. Pelvic floor muscle training treats SUI in the majority of female patients, whereas anti-SUI devices are not widely accepted. Duloxetine has been approved for treating SUI. Suburethral slings have revolutionized the surgical management of SUI with durable efficacy, in contrast with injectable bulking agents.     

Clinical utility of urodynamics for postprostatectomy incontinence

Understanding the role of urodynamics in postprostatectomy incontinence helps urologic clinicians determine optimal treatment choices. The most common urodynamic diagnosis in men with leakage after prostatectomy is urodynamic stress incontinence usually due to intrinsic sphincter deficiency. Findings of detrusor overactivity and bladder outlet obstruction often coexist. Only urodynamics with pressure-flow study allow accurate diagnosis of physiologic bladder outlet obstruction. Simultaneous fluoroscopy may be useful in further defining or diagnosing clinically significant obstruction. By employing specific urodynamic techniques, one avoids misdiagnosis of incontinence and overdiagnosis of obstruction. Decreased bladder compliance is rare in recent urodynamic studies. With the advent of new surgical techniques for postprostatectomy incontinence such as male perineal and transobturator slings, it is imperative to understand bladder, sphincter, and bladder outlet function. Underlying pathologic conditions may be caused by the treatment of prostate cancer, as well as the treatment of incontinence itself.     

Complications of male incontinence surgery

Urinary incontinence can result following surgical treatment of benign prostatic hyperplasia or prostate cancer and has a significant impact on quality of life. The artificial urinary sphincter and male sling are the current surgical treatment options for post-prostatectomy incontinence. It is important that physicians and patients are aware of the potential risks associated with these procedures. This article discusses the recognized complications of the artificial urinary sphincter and the male sling with respect to temporal occurrence (intraoperative, early postoperative, and delayed or long term).     

Complications of Male Incontinence Surgery

Urinary incontinence can result following surgical treatment of benign prostatic hyperplasia or prostate cancer and can be associated with significant morbidity and decreased quality of life. The artificial urinary sphincter and male sling are the current surgical treatment options for male stress urinary incontinence. Physicians and patients must be fully aware of the potential risks, shared and unique, of each procedure. This article will discuss recognized complications of the artificial urinary sphincter and the male sling with respect to temporal occurrence (intraoperative, early post-operative and delayed/long-term).     

Biomaterials in the treatment of pelvic organ prolapse and stress urinary incontinence: An update

Pelvic reconstructive surgeons use biomaterials in many surgical techniques for various indications. Synthetic meshes and biologic grafts have been incorporated in the surgical treatment of pelvic organ prolapse. These materials are also used to correct stress urinary incontinence in men and women. In women, suburethral slings are placed via a number of techniques (retropubic, transobturator) to provide support and facilitate urethral coaptation. In men, support is achieved through mechanical compression and membranous urethra elongation. Recent innovations include a transobturator sling for male stress urinary incontinence, suburethral mini slings for female stress incontinence, and transvaginal mesh to treat pelvic organ prolapse. However, available data on newer techniques are short-term and lack prospective studies and case reports are beginning to emerge describing rare, though serious, complications unique to these newer techniques.