Surgery treatment of male urinary incontinence MD, Prof. Petrov S.B. EMERCOM of Russia PhD Nosov A.K. Karnaukhov I.V. Research Institute of Oncology named Petrov N .N. St. Petersburg 2011

The incidence of urinary incontinence after prostate surgery Radical prostatectomy (retropubic, laparoscopic, robot-associated): 0.8 - 87% average: 10-15% Other: transurethral resection of the prostate (TURP), adenomectomy. Van Melick H.H. et al., 2003, Hu J.C. et al. 2003, Rassweiler et al., 2006 Burkhard F.C. et al., 2006, Penson D.F. et al. 2005, Bauer R.M. et al., 2009, Ficarra et al., 2009

Mechanisms of postprostatectomy stress urinary incontinence (PPSUI) Sphincter weakness Direct sphincter fibers’ damage Sphincter muscles’ innervation damage Groutz A. et al., 2000, Carlson K.V. et al., 2001, Noguchi N. et al., 2006, Hubner W.A., 2009

Choice of treatment depending on the grade of urinary incontinence >4 pads per day 1 pad per day 2-4 pads per day Conservative treatment Slings, ProAct Artificial urinary sphincter MILD MODERATE SEVERE

Surgical treatment

ProACT system (Uromedica, USA) Year-to-market: 1999 г. First publication: 2005 г. (W.A. Hübner, O.M. Schlarp).

System ProACT: results Average: 64.6

SLINGS

Slings: classification Material synthetic biological Mechanism compressive (obstructive) supporting Method of fixation screws (bone anchored) surgical filaments friction and tissue resistance Localization Sub-(mid) urethral Retrourethral Tension fixed re-adjustable Passage retropubic transobturator

Readjustable Sling Systems Remeex ® (Neomedic, Ltd) Year-to-market: 2000 First publication: 2001 (Franco N. et al.) Average: 62,2

Adjustable sling System Argus ® (Promedon SA, Cordoba, Argentina) Year-to-market: 2003 First publication: 2006 (Romano SV et al.) Average: 68,9

Bone-anchored Sling Systems In Vance ® (American Medical Systems, Inc) Year-to-market: 2000 First publication: 2001 (S. Madjar et al.) Average: 68

Retrourethral Transobturator Sling (American Medical Systems, USA) AdVance® (American Medical Systems, USA) First publication: 2007.    (P. Rehder et al.)

Sling AdVance® Average: 51,2

Adjustable hydraulic System A.M.I. ® ATOMS Results (N = 57) Totally continence: 29 (51%) patients; Improvement: 18 (31%) patients - 1 pad/day First mention of the system: 2009 (Bauer W. et al.,) Bauer W. et al., 2009

Transobturator Sling System I-Stop ® TOMS First publication: 2008 (P. Grise et al.) Results (N=122) Total continence: 51-60 % Improvement: 93% (1pad/day)

Transobturator Synthetic Sling UroSling Male (Lintex, Russia) Year-to-market: 2009 First publication: 2010     (Petrov S.B., et al.) Russian patent № 2425655 (10.08.2011)

UroSling Male: structure Ligature tapes for passing arms of sling Сentral area Arms of sling

UroSling Male: implantation technique Hind arms of sling - for the lower branches of the pubic bone, the front – before and then - stitching Petrov S.B. et al., 2010

UroSling Male: patient characteristics Grade of urinary incontinence Information Grade of urinary incontinence Mild Moderate N = 33 5 28 Mean age 62 (54-73) 69 (53-77) Prostate surgery Radical prostatectomy 4 (80 %) 24 (85,8%) Prostatic adenomectomy - 2 (7,1%) TURP 1 (20,0%) Operating time (mins) 32,6 31,8 Mean bloodloss (мl) 65,8 66,9 Mean interval from RP to Urosling Male implantation (мo) 28,7 (7-68) 42,2 (11-83)

UroSling Male: results Grade of urinary incontinence Information Grade of urinary incontinence Mild (n=5) Moderate (n=28) Total continence 3 (60%) 17 (60,7%) Improved 1 (20%) 6 (21,4%) Non effective 5 (17,9%)

Total continence\cost

Who the best candidate for the sling? Mild and average forms of urinary incontinence (pad-test no more than 400 ml) Presence of residual sphincter function: - ability to reach the toilet with a sufficient volume of urine (200 ml) - ability to close urination - "Dry" night - better continence of urine daytime Who the best candidate for the sling?

Who the best candidate for the sling? Better continence of urine with prolonged sitting than when standing and walking Exclusion of urethral strictures and / or vesico-urethral anastomosis (urethrocystoscopy) Exclusion of overactive bladder (cystometry) Exception of hypo contractility detrusor ("pressure-flow")

Artificial urinary sphincter (AUS) Artificial urinary sphincter (AUS) - «gold standard" surgical treatment of male urinary incontinence Year-to-market: 1973 First publication: 1974 (Scott F.B. et al.) The highest efficiency (average 79%) Recommended for severe urinary incontinence A U S Fulford S.C. et al., 1997; Hajivassiliou C.A., et al., 1999; Venn S.N. et al., 2000; Trigo Rocha F, et al., 2008; Bauer R.M. et al., 2009

Artificial urinary sphincter But! Expensive Patient must be mentally and physically able to handle the sphincter Risk in urgent situations (when the patient is unconscious and can not tell the artificial sphincter) High risk of re-revision and replacement of spincter (mechanical damage, infection, erosion) - 37 - 80% Fulford S.C. et al., 1997; Hajivassiliou C.A., et al., 1999; Venn S.N. et al., 2000; Trigo Rocha F, et al., 2008; Bauer R.M. et al., 2009

Conclusions Sphincteric deficiency as a result of operations on the prostate - the main cause of stress urinary incontinence in men; Radical prostatectomy - the most common operation is the development of stress urinary incontinence;

Conclusions For early PPSUI recommended non-invasive methods of treatment. The combination of pelvic floor muscles training (PFMT) with duloxetin - the most effective; Injection therapy is not widely used because of its low clinical efficacy, the need for repeated injections and the relatively high cost;

Conclusions Patients with mild to moderate urinary incontinence sling surgery are recommended. For patients with severe incontinence recommend implantation of artificial sphincter, which is still the "gold standard" treatment for men with PPI, despite the high risk of complications.

Thank you !