RE: SURGICAL TECHNIQUE USING ADVANCE^TM SLING PLACEMENT IN THETREATMENT OF POST-PROSTATECTOMY URINARY INCONTINENCE
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DAVID E. RAPP, W. STUART REYNOLDS, ALVARO LUCIONI, GREGORY T. BALES

Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA

Int Braz J Urol, 33: 231-237, 2007

To the Editor:

     The publication of this article follows the recent increase in interest for new minimally invasive solutions in the treatment of post-prostatectomy incontinence (PPI). The authors present a new technique to treat PPI using a polypropylene monofilament mesh via a transobturator approach. The surgical technique is described in detail and so far, 4 patients have been treated. There is no information about postoperative outcomes.
     Patient selection was restricted to mild to moderate PPI, using 3 pads/day on average. Although the artificial urinary sphincter (AUS) is considered the gold standard in the treatment of PPI, there is a need for more minimally invasive treatment options for two reasons. First, many patients do not want to undergo a surgical intervention associated with a reoperation rate up to 37% within 10 years (1). Second, many patients suffer from a mild to moderate incontinence due to an intrinsic sphincter deficiency (ISD) which can be well treated with a less invasive treatment and lower morbidity. Furthermore, if treatment fails an AUS can be implanted in a second stage.
     Minimally invasive procedures for PPI consist of bulking agents, readjustable periurethrally implanted balloons (ProAct®), perineal bone-anchored male slings (Invance®), readjustable retropubic slings (Argus®) and the newly presented transobturator sling (Advance®). Except the AUS all minimally invasive procedures have the limitation that compression can only be exerted in one direction which has to be similarly appropriate for continence and micturition (2-5). This limitation applies also to the transobturator sling.
     After radical retropubic prostatectomy the Retzius’ space is scarred due to dissection of the prostate. One major advantage of the transobturator approach is that bladder perforation can be avoided which is more likely using the retropubic approach.
     The most important issue in male slings seems to be finding the force of compression on the urethra to develop continence and to enable micturition. In this context the transobturator sling shifts the bulbar urethra cranially and serves more as a suspension rather than a compression. The idea behind this sling is to mimic the rectourethralis muscle. Interestingly, after placing the sling a minimal gap remains between the sling and the bulbar urethra giving the impression that the urethra is less or not compressed. A sophisticated tensioning of the sling is not necessary during the procedure.
     It should be considered that the transobturator sling is not readjustable. Further studies are needed to determine whether there is a need for a readjustable sling to maintain continence in the course of several months.
Despite these limitations, the transobturator sling poses a promising option in the field of minimal invasive treatment of post-prostatectomy incontinence.

References
1. Venn SN, Greenwell TJ, Mundy AR: The long-term outcome of artificial urinary sphincters. J.Urol. 2000; 164: 702-6.
2. Comiter CV: The male perineal sling - a viable alternative to the artificial urinary sphincter. Nat.Clin.Pract.Urol. 2006; 3: 118-9.
3. Hubner WA, Schlarp OM: Treatment of incontinence after prostatectomy using a new minimally invasive device: adjustable continence therapy. BJU Int. 2005; 96: 587-94.
4. Romano SV, Metrebian SE, Vaz F, Muller V, D’Ancona CA, Costa de Souza EA, Nakamura F: An adjustable male sling for treating urinary incontinence after prostatectomy: a phase III multicentre trial. BJU Int. 2006; 97: 533-9.
5. Trigo-Rocha F, Gomes CM, Pompeo AC, Lucon AM, Arap S: Prospective study evaluating efficacy and safety of Adjustable Continence Therapy (ProACT) for post radical prostatectomy urinary incontinence. Urology. 2006; 67: 965-9.

Dr. Sebastian Wille
University of Cologne, Department of Urology
Division Gynecology / Neurourology
Cologne, Germany
Email: sebastian.wille@uk-koeln.de