Urodynamics, Neurourology and Pelvic Floor Dysfunctions Donatella Pistoles! Male Stress

Functional Devices Jérôme Grall According to the World Health Organisation definition, incontinence is a nonintentional and bothersome loss of urine from the urethral meatus. As a mostly iatrogenic situation (post-radical prostatectomy in a majority of cases), male incontinence has a significant impact on quality of life [1]. Surgical prostate removal, dealing with very close links between prostate, urinary sphincter and neurovascular bundles, always bears high risks on continence. Disappointingly, open and laparoscopic procedures (including robot assisted), do not make any difference on continence,...

and permanent efficacy, no moving parts, no significant voiding obstruction, low cost and minimal morbidity [4]. Research is under way. But so far overall sling results are not as good as expected; the way slings work and the explanations for failures are not always understood and there is still a need for a better patient selection. The huge differences in sling results, when comparing incontinence and cure rates, show how difficult it is to have reliable data based on common definitions and how risky it is to compare study results. As a consequence, the reader must be aware of occasional biases...

As shown by an MRI study of 12 patients before and after sling placement (AdVance®), urethral mobility is not observed in all cases. On cough test, maximum bladder neck movement along the pubococcygeal line ranges from 3 to 7 mm. None of the patients have postoperative urethral mobility, but the lack of preoperative mobility does not appear to be a negative prognostic factor [8]. As a result, urethral and sphincter mobility is not the only incontinence mechanism and therefore urethral repositioning is not the only way slings might act. This study provided interesting images of bulbar support...

incontinence severity on functional result is thus an indication that residual sphincter function (retrograde leak point pressure RLPP or pressure profile) might not be the only explanation for incontinence severity. Data from pre- and postoperative urodynamics [11] indicate modifications in mean urethral closure pressure and functional length, without reaching statistical significance due to the reduced number of patients. Another way to assess sphincter function relies on visible sphincter activity on cystoscopy [2]. Whereas it is a common advice to prefer a good sphincter residual function before...

9.5.1.1 Argus® (Promedón, Córdoba, Argentina) Argus® device features a silicone cushion placed underneath the bulbar urethra (Fig. 9.1), two retropubic silicone columns with multiple cone structure and two silicone rings/washers running on the columns and resting on the rectus fascia for tension adjustment [1]. Surgical procedure: In lithotomy position, a perineal incision exposes bulbar urethra. A transverse suprapubic incision exposes enough rectus fascia bilaterally to accommodate silicone rings. A 90° crochet needle is inserted through perineal membrane between bulbar urethra and ischiopubic...

external radiation for prostate cancer with a poor 15 % success rate [1]. Urethral stricture and bladder neck surgery are also associated with poor prognosis [7]. Complications following Argus placement are as frequent as 55 %, particularly in cases of severe incontinence. They range from urinary retention (16 %), infection, bladder or urethral erosion, to sling rupture, urethral stricture and perineal hypersensitivity and pain, leading to 11 % sling removal. Argus® experiences are not homogeneous. If some data suggest roughly similar cure rates up to 79 % with 38.6 % readjustment (but 15 % perineal...

transverse incision. The same is done on the other side. Cystoscopy checks for bladder integrity. The threads are then pulled upward to be secured into the Varitensor. The external manipulator is left connected to the Varitensor via the uncoupler through suprapubic incision. The morning after tension adjustment is done on the standing patient while performing Valsalva manoeuvre by rotating external manipulator clockwise or counterclockwise. A second adjustment could be done later under local anaesthesia and minimal skin incision [14]. Introduced in the early 2000s, Remeex® provided rather good...

mechanism is certainly different (sphincter deficiency is a very poor prognostic factor for TOT). In a 20-patient clinical study, it appeared for the first time that supporting the urethra could lead to an increase in urethral closure pressure from 13 to 86 cm of water, and in urethral length from 3 to 17 mm. Despite much less convincing results were to come, sling design was aimed since the very beginning to supporting urethra and sphincter in order to lengthen and strengthen the functional area [16]. 9.5.2.1 Advance and Advance XP (American Medical Systems: Minnetonka, Minnesota, USA) AdVance®...

show no difference following sling placement neither in urethral pressure nor in uroflow. Advance® evolved into Advance XP® in late 2010 [19]. Overtensioning of the sling, when removing the Tyvek liners, had been responsible for urinary retention. Modifications were thus designed to secure sling release and anchor it in obturator membrane. The results of a multicentre prospective study at 12 months follow-up show a 67.7 % cure rate and an increase in quality of life. It is a good result, as a matter of fact, but it must be observed that cure rate includes residual urine loss up to 5 g per day,...

Cause of Failure: Slippage The explanation for delayed failures after an initial dry period might be related to sling slippage as they could occur immediately after an increase of physical activity within a month of sling placement. Among the reasons for sling failure are most probably inappropriate indication, misplacement or sling “slippage” [28]. MRI, which has been tested as a tool for assessing sling placement, can help to understand the way sling works in restoring continence. T2-weighted sequence with a 3 T MRI is able to differentiate the sling from the hyper-intense urethral bulb. AdVance®...