RECONSTRUCTIVE UROLOGY

Urodynamic changes and initial results of the AdVance male sling
Davies TO, Bepple JL, McCammon KA
Eastern Virginia Medical School, Norfolk, USA
Urology. 2009; 74: 354-7

• Objectives: To present the urodynamic changes and early results associated with the AdVance male sling. The AdVance male sling is a treatment option for postprostatectomy incontinence (PPI), with the goal of eliminating urinary incontinence without affecting voiding parameters. A concern of any procedure in treating men with PPI is whether the treatment induces obstruction and causes retention.
  Methods: Data were prospectively collected from 13 patients undergoing AdVance male sling placement for PPI. Urodynamic testing was performed at baseline and repeated at 6 months postoperatively. A 24-hour pad test and the Incontinence Quality of Life questionnaire were completed preoperatively and at 3 and 6 months postoperatively.
  Results: The median age at the procedure was 63.3 years (range 44.7-74.7). The mean preoperative and 6-month postoperative patient-reported pad use was 4.52 and 1.04, respectively (2-tailed t test, P = .0009). The 24-hour pad test, performed preoperatively and at 6 months postoperatively, yielded a pad weight of 779.3 and 67.6 g, respectively (P = .03). The Valsalva leak point pressure improved significantly (P = .032), but the detrusor voiding pressure, postvoid residual urine volume, and maximal and average flow rates remained relatively unchanged. At 3 and 6 months postoperatively, the Incontinence Quality of Life scores had improved significantly compared with the preoperative scores (P < .01).
  Conclusions: These results are encouraging, because this series has demonstrated a significant improvement in patient-reported pad use, 24-hour pad test weights, and Valsalva leak point pressure without signs of obstruction. The improvement in incontinence was accompanied without any changes in the other voiding parameters and with significant improvement in the quality-of-life measures. Ongoing studies with longer follow-up are pending to compare their results with these promising early results.

• Editorial Comment
  The authors present urodynamic data supporting the concept that the transobturator sling achieves continence by means other than compression. Original reports from developers of the sling (1) supported the concept that it achieved continence by lengthening of the membranous urethra. The current article does not shed light on whether that is indeed the mechanism but it does show that pressure-flows studies are not consistent with obstruction. Curiously, 2 of 13 patients had to perform intermittent catheterization postoperatively for urinary retention lasting up to 2 weeks. It would be interesting to know whether the urodynamic outcomes of these 2 patients were any different from the rest. With only 13 patients and large standard deviations around the variables of interest, the study is underpowered to test anything but an enormous difference in voiding parameters; however, with pre- and post-op flow rates and pressures so close to each other it is hard to believe the findings would be clinically significantly different even with a larger cohort. While the findings deserve to be validated by other centers, the conclusions remain important.

Reference

1. Rehder P, Gozzi C: Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol. 2007; 52: 860-6.

Dr. Sean P. Elliott
Department of Urology Surgery
University of Minnesota
Minneapolis, Minnesota, USA
E-mail: selliott@umn.ed