Refers to article:
Prospective Evaluation of the Functional Sling Suspension for Male Postprostatectomy Stress Urinary Incontinence: Results after 1 Year
Accepted 21 July 2009
December 2009 (Vol. 56, Issue 6, pages 928 - 933)
Refers to article:
The AdVance Transobturator Male Sling for Postprostatectomy Incontinence: Clinical Results of a Prospective Evaluation after a Minimum Follow-up of 6 Months
Accepted 2 September 2009
December 2009 (Vol. 56, Issue 6, pages 923 - 927)
Refers to article:
Males Slings: Compressive versus Repositioning
December 2009 (Vol. 56, Issue 6, pages 934 - 935)
Stress urinary incontinence following radical prostatectomy is often a challenge for the urologist. With erectile dysfunction, it remains the most serious and common complication of curative treatment of localized prostate cancer and has a major impact on quality of life .
Artificial urinary sphincter remains the gold standard for surgical management of postprostatectomy incontinence (PPI) , especially in cases of severe incontinence. The recent surgical techniques using male sling opened up new horizons in the field of PPI management of cases with mild to moderate symptoms; however, the success rate was variable and major complications sometimes occurred . The AdVance male retrourethral sling was introduced 2 yr ago . Unlike other male slings, this one is not compressive but instead aims to reposition the urethra closer to the bladder neck. This truly original technique is considered to be innovative, and the first results after 1-yr follow-up have been presented and assessed .
We are well aware that our results obtained with the AdVance male sling are preliminary . Even if strong efficacy of this procedure is highly suggested by our work and supported by other reports , some issues remain.
The first main issue is that patients who are supposed to benefit from this retrourethral sling must be selected carefully. Selection should be based on medical history, clinical examination, severity of incontinence, endoscopic evaluation, and urodynamic parameters . We determined that previous radiation was associated with an important rate of failure. We suppose that this fact may be related to changes in the periurethral tissue, which plays an important role in this technique . Only a larger evaluation with a longer follow-up can precisely determine the preoperative parameters that are significantly associated with failure of the procedure and, thus, permit better patient selection.
The second main issue deals with the operative technique and the tension of the sling.
Achieving perfect positioning of the sling after dissection of the bulbomembranous urethra is a major concern. Indeed, the accurate retrourethral placement of the sling, in order to reposition the urethra, is crucial to get the therapeutic effect. In the field of female incontinence, even if the problem is a bit different, precise standardization of positioning and tensioning of transobturator tape has been difficult to define. Sling techniques are bound to remain partly dependent on the surgeon's experience. The impact of this variability for the AdVance male sling is not already determined.
Moreover, the durability of our results has not yet been well assessed because of limited follow-up due to the recent publication of the technique . The limited cases of early failure in our initial experience, which are mainly due to patient selection or to the procedure itself, constitute encouraging results. Our work shows a small number of late failure cases, and these cases potentially implicate both the local conditions and the durability of the effect. Only longer follow-up will permit analysis of the reappearance of incontinence and determination of the factors associated with delayed failure.
The two papers presented in this issue show similar results. The data of efficacy are encouraging and should inspire other practitioners to experience this technique and to communicate on their series with precise results and indications for the AdVance transobturator male sling.
Conflicts of interest
Francois Haab is a consultant for American Medical Systems, Minnetonka, MN, USA.
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Department of Urology, Tenon Hospital, Groupe Hospitalo-Universitaire EST, Assistance Publique-Hôpitaux de Paris (AP-HP), University Paris VI, Paris, France
© 2009 European Association of Urology, Published by Elsevier B.V.