Retropubic TFS Minisling for Postprostatectomy Male Incontinence: First Report

<b><i>Hypothesis:</i></b> A structurally sound puboprostatic ligament (PPL), like the pubourethral ligament in the female, is the core structure for control of stress urinary incontinence (SUI) in males. <b><i>Methods:</i></b> The hypothesis was tested at several levels. Twelve transperineal ultrasound examinations were performed to confirm reflex directional closure vectors around the PPL, with digital support for the PPL rectally and cadaveric testing with a tissue fixation system (TFS) minisling, and finally, 22 cases of postprostatectomy incontinence were addressed only with retropubic insertion of a 7-mm TFS sling between the bladder neck and perineal membrane to reinforce the PPL. <b><i>Results:</i></b> On ultrasound testing, 3 urethral closure muscles were confirmed to act reflexively around the PPL to close the urethra distally and at the bladder neck. A finger was inserted rectally, pressed against the symphysis only on one side of the urethra at the origin of the PPL that controlled urine loss on coughing. The mean pre-op pad loss was 3.8 pads at 9 months; the mean post-op loss was 0.7 pads; 13/22 (59%) patients were 100% improved; 7/22 (31%) improved &#x3e;50% but &#x3c;100%; 2/22 (9.1%) improved &#x3c;50%. <b><i>Conclusions:</i></b> The 7-mm-wide TFS minisling is the first retropubic minisling for postprostatectomy urinary incontinence. It differs significantly from transobturator male operations surgically and in modus operandi. As in the female, reconstruction of the PPL alone was sufficient to cure/improve SUI, suggesting that preservation of the PPL is of critical importance during retropubic radical prostatectomy.

Urinary incontinence and female urology

All aspects of female and male urinary incontinence assessment, investigation, and management are outlined. Definitions of incontinence are provided, with a review of the epidemiology, risk factors, and management of stress urinary incontinence (SUI), post-prostatectomy (male) incontinence, overactive bladder syndrome (OAB), mixed urinary incontinence, and incontinence in older populations. Conservative, drug, and surgical therapies are explored, including bulking agents, synthetic mid-urethral tapes, colposuspension, autologous fascial slings, and artificial urinary sphincters (AUS) for female SUI, and urethral slings and AUS for male incontinence, and botulinum toxin, ileocystoplasty, and sacral nerve stimulation for OAB. Clear management pathways are included which are supported by the International Continence Society, with guideline recommendations from the National Institute for Health and Care Excellence and European Association of Urology. Vesicovaginal fistula, urethral diverticulum, and pelvic organ prolapse (POP), are illustrated, and controversies including the use of mesh in POP and incontinence surgery, and anticholinergic drug burden in OAB are discussed.