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.

INFRA-OBTURATOR TENSION SLING FOR URINARY INCONTINENCE TREATMENT

Stress incontinence occurs due to the inability to control an urge to urinate, which affects the quality of daily life. Although there is an existing therapeutics with polymer mesh tape, it is hard to fix around the urethra to restore the function of the pubourethral ligament. Therefore, in this research, an infra-obturator tension (IOT) sling was introduced to minimize the mobility of the bladder and urethra against intra-abdominal pressure. To verify the IOT performance, two different hypotheses were formulated: The hardness and volume of the IOT support the urethra and help prevent it from deforming by intra-abdominal pressure. The rotatory motion of the IOT can bend the urethra at the contact point and help restore the function of pubourethral ligament to increase vaginal tension. For the first hypothesis, a finite element simulation was conducted using three-dimensional geometrical model obtained by the computed tomography images of patients. For the second hypothesis, surgeons performed an IOT insertion operation and analyzed the sling rotation from the patients’ CT images (mean: 21∘). From the results, the mobility of the urethra was decreased because of IOT insertion. The mobility was also decreased because of the subsequent fibrotic changes from the encapsulation of the IOT.