Sling procedures in men can be performed with little morbidity and few complications. This article discusses treatment of sphincteric incompetence with the bulbourethral sling and treatment of neurogenic bladder with the prostatic urethral sling. Men with mild-to-moderate intrinsic sphincteric dysfunction after prostatectomy seem to be appropriate candidates for the bone-anchored bulbourethral sling, and the prostatic urethral sling may be an acceptable substitute in patients with neurogenic bladder with intrinsic sphincteric dysfunction.
The incidence of urinary incontinence is approximately 1% to 3% after prostatectomy for benign disease, and after radical prostatectomy, the incidence has been reported to range from 2.5% to 87%. This wide discrepancy is a result of varying definitions of incontinence and inconsistent methods of data acquisition. The timing of studies is important, as urinary control may improve with time. Most patients have some degree of incontinence immediately after catheter removal, but a progressive reduction in incontinence may occur up to 1 year after prostatectomy. There is little dispute that the occurrence of incontinence after prostatectomy has a significant negative impact on a patient’s quality of life. In a questionnaire-based study, Herr discovered that incontinence adversely affected the quality of life in 26% of patients, and in a separate survey, patients who underwent radical prostatectomy scored significantly worse on a scale evaluating urinary function compared with controls. Patients should be screened after prostatectomy for these symptoms, which are likely to have a detrimental effect on quality of life.
Cause of incontinence after prostatectomy
Urinary leakage may occur as a result of an abnormality of bladder or sphincteric function. Bladder dysfunction has been documented as the predominant cause of incontinence after prostatectomy. Subsequent reports have disputed this finding, noting that isolated sphincter dysfunction is the major cause of incontinence after prostate surgery. On closer review, many studies documenting a high incidence of bladder dysfunction as the sole cause of incontinence contain a large percentage of patients who have undergone transurethral resection of the prostate (TURP). Bladder dysfunction frequently exists before surgery and may persist after surgery. After undergoing radical prostatectomy, the predominant cause of incontinence is an isolated intrinsic sphincter deficiency. Bladder dysfunction may occur after radical prostatectomy but usually occurs with concomitant sphincter dysfunction. Mixed incontinence, the combination of sphincteric incompetence and bladder dysfunction, that occurs after radical prostatectomy has a reported incidence of approximately 20% to 40%. Bladder dysfunction may improve over time. In patients undergoing urodynamics at least 1 year after radical prostatectomy, sphincteric dysfunction is the most likely cause. Approximately one third of these patients may have coexisting bladder dysfunction, which could greatly affect treatment outcomes. After TURP, a higher incidence of bladder dysfunction is likely present, particularly if studied sooner than 1 year after surgery. As most clinicians have experienced, symptoms do not accurately predict diagnosis. Urodynamic studies are important to characterize the lower urinary tract dysfunction that is present.
Evaluation of postprostatectomy incontinence
A focused history should include detailed information about the precipitants of urinary leakage. One should note when the onset of leakage occurred after surgery and whether incontinence was present before surgery. Associated voiding symptoms are important factors. Validated incontinence questionnaires are an easy way to objectively quantify the severity of incontinence symptoms. Daytime and nighttime pad use should be documented, and a pad weight test should be considered to more accurately quantify urinary leakage. Treatment options may be chosen on the basis of incontinence severity, and these tools are helpful in determining incontinence severity. A physical examination should include rectal examination to assess the size and consistency of the prostate. Sphincter tone should be assessed, and the quality of sphincter contraction should be analyzed by having the patient compress the sphincter. The patient should have an adequate localized contraction of the sphincter muscles without excessive use of accessory muscles. One should observe for the presence of leakage. Does the patient passively leak with standing or when prompted to cough? A urinalysis and residual urine should be obtained, and prostate-specific antigen testing should be considered.
Cystourethroscopy should be performed to rule out the presence of urethral stricture disease or bladder neck contracture. Inspection of the sphincter may reveal gross abnormalities, but cystoscopic examination does not determine sphincter function. After TURP, absence of the verumontanum suggests sphincteric injury, which should prompt further study. After radical prostatectomy, an urethrovesical anastomosis that is at the level of the external sphincter may suggest impairment of the sphincter mechanism.
Urodynamic evaluation is essential to determine the cause of incontinence after prostatectomy and must be performed in patients for whom invasive therapy is considered. The investigation should provide information regarding bladder and sphincteric function during filling and should assess bladder contractility and flow during voiding. A multichannel urodynamic study most optimally provides this information. The use of electromyography of the pelvic floor is indicated in cases complicated by neurologic dysfunction. Urethral pressure profilometry can provide information regarding urethral closing pressures and functional urethral length. Videourodynamics provides the most complete evaluation, combining the anatomic detail of voiding cystourethrography with the functional assessment of pressure-flow studies.
During bladder filling, information regarding detrusor overactivity, compliance abnormalities, sensation, and cystometric capacity specifically is noted. The Valsalva leak point pressure (VLPP) is determined. If leakage occurs during straining in the absence of an increase in detrusor pressure, sphincteric incompetence is demonstrated. The exact numerical value of the VLPP has not been correlated to the severity of incontinence but is an area of considerable research. As new treatment options for sphincteric incompetence in men emerge, VLPP values may facilitate proper selection of patients for different procedures. The filling phase of the urodynamic study is critical, as one should determine whether the bladder is stable with normal storage pressures and of adequate storage capacity. Patients with an abnormality of compliance, significant motor detrusor overactivity, or decreased cystometric capacity should be offered initial therapy that is directed at bladder management. If bladder storage abnormalities remain undetected, treatment for sphincteric incompetence may fail and/or detrimental changes to the upper urinary tract may develop. The voiding phase of the pressure-flow study provides valuable information regarding bladder contractility and voiding dynamics.
Evaluation of postprostatectomy incontinence
A focused history should include detailed information about the precipitants of urinary leakage. One should note when the onset of leakage occurred after surgery and whether incontinence was present before surgery. Associated voiding symptoms are important factors. Validated incontinence questionnaires are an easy way to objectively quantify the severity of incontinence symptoms. Daytime and nighttime pad use should be documented, and a pad weight test should be considered to more accurately quantify urinary leakage. Treatment options may be chosen on the basis of incontinence severity, and these tools are helpful in determining incontinence severity. A physical examination should include rectal examination to assess the size and consistency of the prostate. Sphincter tone should be assessed, and the quality of sphincter contraction should be analyzed by having the patient compress the sphincter. The patient should have an adequate localized contraction of the sphincter muscles without excessive use of accessory muscles. One should observe for the presence of leakage. Does the patient passively leak with standing or when prompted to cough? A urinalysis and residual urine should be obtained, and prostate-specific antigen testing should be considered.
Cystourethroscopy should be performed to rule out the presence of urethral stricture disease or bladder neck contracture. Inspection of the sphincter may reveal gross abnormalities, but cystoscopic examination does not determine sphincter function. After TURP, absence of the verumontanum suggests sphincteric injury, which should prompt further study. After radical prostatectomy, an urethrovesical anastomosis that is at the level of the external sphincter may suggest impairment of the sphincter mechanism.
Urodynamic evaluation is essential to determine the cause of incontinence after prostatectomy and must be performed in patients for whom invasive therapy is considered. The investigation should provide information regarding bladder and sphincteric function during filling and should assess bladder contractility and flow during voiding. A multichannel urodynamic study most optimally provides this information. The use of electromyography of the pelvic floor is indicated in cases complicated by neurologic dysfunction. Urethral pressure profilometry can provide information regarding urethral closing pressures and functional urethral length. Videourodynamics provides the most complete evaluation, combining the anatomic detail of voiding cystourethrography with the functional assessment of pressure-flow studies.
During bladder filling, information regarding detrusor overactivity, compliance abnormalities, sensation, and cystometric capacity specifically is noted. The Valsalva leak point pressure (VLPP) is determined. If leakage occurs during straining in the absence of an increase in detrusor pressure, sphincteric incompetence is demonstrated. The exact numerical value of the VLPP has not been correlated to the severity of incontinence but is an area of considerable research. As new treatment options for sphincteric incompetence in men emerge, VLPP values may facilitate proper selection of patients for different procedures. The filling phase of the urodynamic study is critical, as one should determine whether the bladder is stable with normal storage pressures and of adequate storage capacity. Patients with an abnormality of compliance, significant motor detrusor overactivity, or decreased cystometric capacity should be offered initial therapy that is directed at bladder management. If bladder storage abnormalities remain undetected, treatment for sphincteric incompetence may fail and/or detrimental changes to the upper urinary tract may develop. The voiding phase of the pressure-flow study provides valuable information regarding bladder contractility and voiding dynamics.
Treatment of sphincteric incompetence with the bulbourethral sling
The many options in the management of patients with incontinence after prostatectomy include: pharmacotherapy, pelvic floor physiotherapy, electrical stimulation, and urethral injection therapy. The gold standard of the surgical management of postprostatectomy incontinence is the artificial urinary sphincter. Patient satisfaction rates are high after artificial sphincter implantation; however, problems such as urethral erosion and tissue atrophy, which require reoperation, may occur. Although modifications to the cuff design may reduce the overall incidence of revisions, some patients will continue to require reoperation, especially if the sphincter has been implanted for a long time. For these reasons, the concept of sling procedures to provide urethral compression has emerged. Although sling procedures in women and men differ, they involve the same principles to create broad-based uniaxial compressive forces on the urethra to maintain continence.
Schaeffer and colleagues described a male bulbourethral sling procedure using synthetic bolsters passed beneath the bulbar urethra and suspended by the rectus fascia. A midline perineal incision is created, and three tetrafluoroethylene bolsters are placed below the bulbar urethra. A small suprapubic incision is created, and a modified Stamey needle is passed from the suprapubic incision into the perineal incision. Nonabsorbable sutures that are attached to the bolsters are transferred to the suprapubic incision and tied over the rectus fascia. Bone anchors that are inserted into the pubic bone can be added for additional support. Intraoperative measurements of urethral pressures or abdominal leak point pressures can be performed to assist in judging appropriate sling tension. This procedure demonstrated that bulbourethral slings can be used successfully to treat postprostatectomy incontinence.
Technique of the Bone-Anchored Perineal Sling Procedure
Many surgeons perform a bone-anchored sling implanted by way of a perineal incision. Advantages of this approach include a single incision, stable anchor fixation to the bony pelvis, and no risk for bladder injury. The basic principles of this procedure are stable fixation of the sling material to the bony pelvis, broad-based compression of the urethra, and preservation of the bulbospongiosus muscule. If these principles are met, compression of the urethra facilitating continence should be created with little risk for erosion or urinary retention.
The patient is positioned in the dorsal lithotomy position and, a Foley catheter is inserted. The operation is begun by creating a midline perineal incision ( Fig. 1 ). The bulbospongiosus muscle is identified and preserved. The dissection proceeds laterally toward the medial aspect of the descending pubic ramus, which is located by palpation ( Fig. 2 ). The junction of the descending pubic ramus and the pubic tubercle should be located. During this dissection, a finder needle can assist in localizing the bone ( Fig. 3 ) under the soft tissues. The first set of bone anchors should be placed as high on the pubic ramus (at the level of the pubic symphysis) as possible. Electrocautery and scissor dissection should continue until the soft tissues are cleared from the periosteum, allowing direct visualization and precise anchor placement into the bone. Two or three sets of anchors are to be implanted into the bone. I prefer positioning three anchors on each side, as this method facilitates stronger fixation and allows for more compression. Several investigators successfully used two anchors on each side. Anchor positioning starts at the level of the pubic symphysis and proceeds caudally toward the ischial spines ( Fig. 4 ). The anchors are positioned just over 1 cm apart, proceeding caudally. Anchors are implanted in a similar location on the contralateral side. The anchors are placed using a straight drill, placing anchors preloaded with polypropylene sutures. The sling graft is fashioned in a trapezoid shape to accommodate the shape of the bony pelvis. The graft should measure approximately 4 × 6 × 4 cm. Various graft materials have been used, including cadaveric fascia, cadaveric dermis, polypropylene mesh, and silicone. I prefer a synthetic graft, as biologic materials may tear or stretch excessively when achieving the proper compression. The graft material is attached to the three anchors on one side. The material then is positioned on the opposite side after determining proper tension. Securing a clamp to the graft allows proper positioning of the graft on the bone ( Fig. 5 ). The Foley catheter is withdrawn into the fossa navicularis where the balloon is reinflated. A retrograde perusion test is performed by connecting an infusion bag of normal saline, and the drip chamber is positioned 60 cm above the pubic symphysis (see Fig. 5 ). The sling is positioned on the contralateral bone with enough tension to stop the infusion of saline. At this point, the sutures are brought out through the graft medial to the clamp ( Fig. 6 ). A single throw of the prolene suture is placed over a silk suture. This step allows reversal of the knot if the suture needs to be repositioned. The retrograde perfusion pressure is repeated to insure a retrograde perfusion pressure of at least 60 cm of water. The sutures are tied, and any excess graft is trimmed ( Fig. 7 ). The wound is closed in multiple layers after copious irrigation with antibiotic solution. The catheter may be removed the next day, and intermittent catheterization may be performed if the patient is unable to void.
