[The treatment of postprostatectomy incontinence with the retroluminal transobturator repositioning sling (Advance): lessons learnt from accumulative experience].

OBJECTIVES

To summarize the lessons learnt after having performed more than 250 AdVance sling procedures. Postprostatectomy incontinence is a depressing reality that is often underestimated by the prostate surgeon. The practiced gold standard for treating severe stress urinary incontinence has been the artificial urinary sphincter. No such consensus exists for mild to moderate incontinence. This paper is about an incontinence operation with the goal to support postprostatectomy sphincter laxity.

METHODS

The hypothesis of postprostatectomy sphincter laxity is new, as well as restoring continence by proximal relocation of the proximal corpus spongiosum. Abstracts dealing with these issues are summarized. Selected points of technique are highlighted, including modifications that have been made along the way. Lastly the first and last 20 patients treated in this series of 250 patients are compared in terms of operative indication, surgical technique and treatment outcome. Some definitions are added for clarity.

RESULTS

It could be demonstrated that the final position of the AdVance sling is retroluminal, i.e. 5-10mm dorsal/behind the lumen of the membranous urethra (=sphincteric urethra). Comparing the first 20 to the last 20, there were no treatment failures in the latter. A two year follow-up showed a continence rate of 65% in the first group, compared to a 85% continence rate in the second group taking into account the short median follow- up of 4.1.months in the latter. Tunneling the sling subcutaneously decreased postoperative loosening significantly.

CONCLUSION

The AdVance sling is a safe method of treating mild to moderate postprostatectomy incontinence, with no erosions in this series of patients. The hypothesis of sphincter laxity seems to play a definitive role in the pathophysiology of male incontinence. Correction of this urethral support descent or "prolapse" seems to be highly effective. Further studies are needed to accurately define the exaxt mechanism of action of the AdVance sling.