The inside-out transobturator sling for the treatment of male urinary incontinence

Introduction and objective: Sling procedures are currently re-emerging as an attractive alternative to the artificial urinary sphincter for the treatment of post-radical prostatectomy (RP) stress urinary incontinence (SUI), given that they are inexpensive, nonmechanical and allow for physiological voiding without significant obstruction. The aim of this study was to describe a novel transobturator sling procedure for treating post-RP SUI, and to prospectively evaluate its short-term safety and efficacy. Methods: The inside-out transobturator sling technique used specific instruments and a polypropylene mesh with 2 arms that were passed inside to outside through the obturator foramens, pulled for compressing the bulbar urethra upward, and then tied to each other across the midline. Perioperative dual channel urodynamic studies were repeated until tension on both arms of the mesh increased abdominal leak point pressure to approximately 100 cm H2O. The two mesh arms were then tied to each other for maintaining bulbar urethra compression. Patients with detrusor overactivity were excluded. Baseline and followup evaluations included uroflowmetry, and continence, quality of life (QoL), and satisfaction questionnaires. Cure was defined by no pad use and improvement by a number of pads/day ≤2 and reduced by at least 50%. Complications were recorded. The video also illustrates anatomic and physiopathologic differences between male and pelvis in relation with transobturator tapes. Results: From April 2006 through February 2007, 20 consecutive patients suffering from post-RP SUI underwent the sling procedure using the same operative protocol. Preoperatively, 3 (15%), 11 (55%), and 6 (25%) patients were using 2, 3 to 5, and more than 5 pads/day, respectively. The procedure was preceded by an endoscopic urethrotomy in 4 patients. No perioperative complication was noted; 3 patients required suprapubic catheterization. At 6 months, 9 (45%) patients were cured and 8 others (40%) were improved (1 pad/day). QoL was significantly enhanced and 80% patients were moderately to completely satisfied with the procedure. Preoperative and postoperative max flow rate and postvoid residual values were not statistically different. No sling infection, urethra erosion, persistent pain or neurological complication was observed. Conclusions: The inside-out transobturator sling procedure appears to be safe and efficient at short term. Further studies are warranted to determine long term outcome