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Incontinence
Four-arm Transobturator Male Sling for
Post-prostatectomy Urinary Incontinence
Philippe Grise
Professor of Urology, Rouen University
Abstract
Incontinence post-prostatectomy remains a problem, even when minor or moderate. In order to minimise surgical morbidity and costs,
sling procedures have been proposed. The authors have developed a new transobturator male sling (TOMS) procedure and reported their
results after one-year experience. Materials and Methods: A prospective multicentre study was conducted in 96 patients suffering from
minor or moderate post-prostatectomy incontinence. Evaluation of the I-Stop™ two-arms bulbar TOMS was based on clinical form
assessment using the Incontinence Questionnaire-Short Form 36 (ICIQ-SF 36) questionnaire pre- and post-operatively, and at three, six, nine
and 12 months. Results: The surgical procedure was considered easy to perform and no post-surgery complications were reported except
for one retention. The median number of pads per day decreased significantly from two pads before surgery to one during the follow-up
period. The SF-36 continence and quality of life score improved from a median of 117 to 308, and the median ICIQ and quality of life score
decreased from 15 to 5 one year after the intervention. Conclusion: The I-Stop TOMS is an attractive, simple sling technique for moderate
or minor post-prostatectomy stress incontinence and offers an improvement in the quality of life.
Keywords
Urinary incontinence, sphincter deficiency, prostatectomy, surgery, sling
Disclosure: Philippe Grise is the main investigator of the I-Stop™ TOMS study (CL Medical), in which he has no financial interest.
Acknowledgements: Philippe Grise would like to thank Vincent Goria (CL Medical) for assistance with TOMS data management, and Richard Medeiros (Rouen University
Hospital) for editing the manuscript.
Received: 18 May 2009 Accepted: 10 July 2009
Correspondence: Philippe Grise, Department of Urology, Rouen University Hospital-Charles Nicolle, rue de Germont, 76031 Rouen, France. E: philippe.grise@chu-rouen.fr
The number of patients suffering from post-prostatectomy (incontinence only with severe stress, such as coughing or sneezing),
incontinence is increasing. Despite improvement in surgical moderate (incontinence with minimal stress, including walking) or
techniques, the number of such patients has increased with the severe (major incontinence and incontinence during the night).
progression of early-detected localised prostate cancer in men. Practically, severe incontinence is suspected when the number of
Depending on the study and definition of incontinence, the incidence totally wet pads used is more than four per day, or when there is over
of post-prostatectomy incontinence is estimated to be from 1 to 55% 200ml of urine during the 24-hour pad test.
of men.
1
The wide range of reported rates of incontinence early after
surgery decreases during the one-year post-surgery period and with After first-line treatment with pelvic floor exercises, the persistence of
physiotherapy sphincter exercise. Incontinence that persists after one incontinence requires complementary examinations. Ultrasound
year is estimated to affect fewer than 5% of patients.
2
Quality of life is evaluates residual urine, and a urethrocystoscopy evaluates the
strongly affected, and even a minor leakage requiring one pad a day sphincter and anastomosis. Urodynamics is indicated before surgery to
may be highly bothersome.
3
Transurethral prostatectomy or high- determine bladder capacity and activity. However, a sphincter deficiency
frequency ultrasounds are rarely causes of incontinence. is difficult to determine. Low maximal urethral closure pressure suggests
a sphincter deficiency, but a normal value may be associated with a
Clinical symptoms are stress urinary incontinence (SUI) that weak sphincter. An associated overactive bladder or anastomosis
increases with physical effort during the day, but for some patients strictures must be ruled out and treated before incontinence surgery.
urine may be expressed mainly during the afternoon. Initial The pathophysiology of male stress SUI is mainly a sphincter
assessment includes a urinary diary, a questionnaire in order to deficiency, but an excess of mobility of the bulbar and membranous
gauge the precise type of incontinence and severity and number of urethra may be an associated factor.
pads used or, optimally, a pad test. The International Consultation on
Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire is a A transobturator sling is the logical progression in minimally invasive
very simple and useful tool recommended by the European treatment for mild or moderate male incontinence. For severe SUI,
Urological Association. Urge incontinence may be associated with an an artificial sphincter
4
remains the gold standard technique for
overactive detrusor. The severity of incontinence affects quality of severe incontinence due to sphincter deficiency, with an 80%
life. According to Stamey, the grading of SUI can be mild continence rate, despite a high cost and risk of erosion or infection.
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