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A. Shahrazad MD Shahid Chamran hospital 2011 Iranian continence society

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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

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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

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Mild Incont. : The use of one to two pads per day (400cc)/day

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Nonsurgical Surgical

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

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

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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)

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

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SLING

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Date back to 1951 Berry & Kaufman Failures let to AUS Two kinds Compressive Sling Stamey, Madjar 1994-2001 Repositioning or adjustable Sling Montague 2009

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

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

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

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

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

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

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

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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 50-70 cm H2O

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

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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 incont80%

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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

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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

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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

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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 2009-2010

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