A. Shahrazad MD Shahid Chamran hospital 2011 Iranian continence society

Khan URO. NOV 2009  45-50% Sole cause is DO  35-45% Sphincter mechanism damage  5-10% Mixed It appears that post- PPI is not always due to a surgical misadventure

SUI \  Post prostatectomy SUI due to sphincter dysfunction minimum delay of 6-12 mo before an active treatment  TUR 1% to 3% RP up to 33% Different degrees of INCONT.  QOL deeply affected by this side effect

 Mild Incont. : The use of one to two pads per day (<100cc) (Cornu)  Moderate Incont. : The use of three to four pads per day( cc) (Cornu)  Sever Incont. : The use of six pads per day( >400cc)/day

 Nonsurgical  Surgical

 Non surgical options: PFMT moderate success for mild incont. No pharmacologic success ( In PPI Duloxetine could be helpful ) schlen 2006 Pads, clamps, condom cath.

 Slings InVance AdVance Argus  Bulking agents  Artificial sphincter Pro Act ZSI AMS

Surgical options : per urethral injection of bulking agents weak success rate ( 10% cure & 35% improve ) J urol, 2006 sanches / USA Artificial urinary sphincter implantation ( AUS ) has good results in long term( GOLD STANDARD)

BUT  Expensive  Infection  Erosion & Pain  Certain skill is required  Mechanical failure 15% in 5/y  Require manual manipulation

SLING

 Date back to 1951 Berry & Kaufman  Failures let to AUS Two kinds Compressive Sling Stamey, Madjar Repositioning or adjustable Sling Montague 2009

Male sling procedures helps men with UI due to sphincter weakness or insufficiency in the setting of prior pelvic surgery

 Short surgery  May be perform under G/A or S/A  Rapid recovery  Often no cath.  Restore Q/L

Male slings have been included Into The EAU guidelines For Treatment male SUI

 1-5 pads /d OR < 200g pad weight /d  Residual sphincter function

 Recurrent UTI  Blood coagulation disorders  Renal insufficiency  Upper tract urinary OB.  Previous RT

Infection OR erosion OR transient retention IS very low BUT Success continence rate is 80% Romano BJU 2009

 ( In Vance)  ( Ad Vance) U OR V Sling tension ( MUP, ALPP ) 100 cm H2O intraoperatively Jean Leval 2008  Repositioning Sling ( Adjustable) V OR U

A sling attached to the pubic bone Success rate in mild to moderate SUI 75% Success rate in sever incontinence 50% or less With pain and pubic osteitis Must perform sphincterometry during op. a pressure cm H2O

Patients with mild, moderate UI without urodynamic anomalies nor previous RT are the ideal candidates Gomes,urol, 2009

Transobturator male sling or V  A new approach to treat PPI  Safe & satisfactory cure rate  An alternative for AUS  Simple J Urol, dec 2010 Wadie /Egypt  Few complications  Valid for mild to moderate incont…80%

 Mid- Term follow up, safe & a good alternative treatment for PPI ( SUI ) Bauer/Urol, 2010  50% Success rate in patients after adjuvant RT up to 18 mo Bauer / J Urol, 2010  Success after AUS operation failure Cornel J Urol, 2010

 Until recently, all male sling operations compressed the fixed bulbous urethra with different composition and method of anchoring…… Simple & less expensive  But how much compression? Too much== sling erodes, unable to void Too little Remains incontinence

 Repositioning sling : Repositions the bulbomembranous urethra 2-3 cm toward the bladder neck Free bulbo., By dividing bulbospongiosus M. and advanced by finger 2-3 cm deeper Sling is then fixed to the bulbous U. U or V arms advanced the sling

 It augment s existing sphincter function when it is incomplete rather than replacing it  Previous radiation is suggested as a exclusion criteria  Follow –up median 13months Success rate 80% Conu Baure Montague Urban