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Management of Male Urinary Incontinence POST Prostatectomy

Management of Male Urinary Incontinence POST Prostatectomy. A. Shahrazad MD Shahid Chamran hospital 2011 Iranian continence society. PPI. Khan URO. NOV 2009. 45-50% Sole cause is DO 35-45% Sphincter mechanism damage 5-10% Mixed

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Management of Male Urinary Incontinence POST Prostatectomy

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  1. Management of Male Urinary Incontinence POST Prostatectomy A. Shahrazad MD Shahid Chamran hospital 2011 Iranian continence society

  2. PPI 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

  3. PPI 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

  4. Incontinence & Degree Mild Incont. : The use of one to two pads per day (<100cc) (Cornu) Moderate Incont. : The use of three to four pads per day(100-400cc) (Cornu) Sever Incont. : The use of six pads per day( >400cc)/day

  5. Management Nonsurgical Surgical

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

  7. PPI Surgical Management Slings InVanceAdVance Argus Bulking agents Artificial sphincter Pro Act ZSI AMS

  8. PPI Management Surgical options : per urethral injection of bulking agentsweak success rate (10% cure & 35% improve) J urol, 2006 sanches / USA Artificial urinary sphincter implantation ( AUS ) has good results in long term( GOLD STANDARD)

  9. Perfect AUS over the last 20 /y

  10. New AUS Zephyr Hydrolic pump 60-100 cm H2o /p

  11. ProAct balloon Artificial sphincter seems not successful

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

  13. SLING

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

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

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

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

  18. GOOD Candidates 1-5 pads /d OR < 200g pad weight /d Residual sphincter function

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

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

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

  22. I nVance ™ compressive sling 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

  23. Six titanium bone screws

  24. Sling in position compressing urethra

  25. In Vance Sling Patients with mild , moderate UI without urodynamic anomalies nor previous RT are the ideal candidates Gomes,urol, 2009

  26. AdVance Sling 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 incont…80%

  27. Ad Vance TOT for PPI 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

  28. AD Vance --Sling moving back urethra into the natural position

  29. Compressive Versus Repositioning 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

  30. Compressive Versus Repositioning 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

  31. Repositioning & Adjustable Sling ( ARGUS) 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% ConuBaure Montague Urban 2009-2010

  32. Thank you for your attention

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