UROLOGICAL SURVEY
Reconstructive urology
Efficacy of the InVancetrade mark Male Sling in Men with Stress Urinary Incontinence
Fassi-Fehri H, Badet L, Cherass A, Murat FJ, Colombel M, Martin X, Gelet A
Department of Urology and Transplantation, Edouard Herriot Hospital, Lyon, France
Eur Urol. 2007; 51: 498-503
OBJECTIVES: To evaluate the efficacy and safety of the InVancetrade mark bulbourethral sling in male stress urinary incontinence.
MATERIALS AND METHODS: Between June 2003 and April 2005, the InVancetrade mark bulbourethral sling was implanted into 50 patients with urinary incontinence after prostate surgery in 49 cases and pelvic trauma in 1 case. The patients were monitored and evaluated in a prospective manner (continence, tolerance, and satisfaction). The treatment was considered to be successful if the patient stopped wearing any kind of continence pad (patient cured) or only one pad per day (patient improved), with no de novo urinary disorders and without significant postvoid residual urine. Patient satisfaction with the procedure was assessed.
RESULTS: After a median follow-up of 6 mo, 50% of patients were dry, 26% had improved, and 24% suffered treatment failure. The success rates for the patients with severe incontinence and those who had undergone radiation therapy were 50% and 25%, respectively. All patients who were dry or had improved were satisfied and presented no obstructive or irritative de novo urinary disorders. The overall success rate for the 51 procedures conducted was 74.5%. Six cases of transitory acute urine retention and six cases of persistent perineal pain were reported. Explantation was necessary because of suppuration of the sling in three patients and of a de novo irritative urinary disorder in one patient. No cases of pubic osteitis or urethral erosion were reported.
CONCLUSIONS: The InVancetrade mark bulbourethral sling procedure makes it possible to treat stress urinary incontinence after prostate surgery with satisfactory and lasting short-term results. Severe incontinence and a past history of pelvic radiation therapy seem to be factors contributing to the failure of this procedure.
Editorial Comment
Male urinary stress incontinence is often an aftereffect of a necessary prostate treatment. Such as transurethral resection of the benign enlarged prostate, radical prostatectomy or irradiation treatment for prostate cancer.
If iatrogenic caused incontinence does not disappear within a year under conservative treatment (pelvic floor exercise and the use of drugs like duloxetin) surgical approaches need to be discussed with the patient. Most of these patients are afraid of the implantation of an artificial sphincter hoping for a minimal invasive approach to treat their urinary stress incontinence.
Besides injectables (1), which demonstrate usually only a short term improvement, micro balloons and different kinds of urethral sling were introduced as a treatment option.
Fessi-Fehri et al. (2) extended their study of the use of a bow-anchored sling. Although the outcome seems to be almost identical in comparison to their first report with a follow-up of 3 months the enlarged groups of now 50 patients have a similar pleasing outcome of success even with a 6 months mean follow-up (1 - 22 months). It is remarkable that those who have now a follow-up of over 6 months 16 of 17 patients (94%) were dry or at least improved.
The authors mention a critical point: that those patients after radiotherapy or with the severe incontinence might still benefit most with an artificial sphincter. With the increased anatomical knowledge of the external urethral sphincter (3) and the satisfying published outcome of the TOT in female, the Advanced Male Sling System® of AMS might be the needed male version. It was just introduced to clinic but its primary data still needs to be confirmed. The attending urologist can offer today a cascade of treatment options, which might even further improve the outcome in a combination based on the cause of the urinary incontinence and its severity.
References
1. Onur R, Singla A: Comparison of bone-anchored male sling and collagen implant for the treatment of male incontinence. Int J Urol. 2006; 13: 1207-11.
2. Fassi-Fehri H, Cherasse A, Badet L, Pasticier G, Landry JL, Martin X, Gelet A: [Treatment of postoperative male urinary incontinence by INVANCE prosthesis: preliminary results]. Prog Urol. 2004; 14: 1171-6. French.
3. Strasser H, Ninkovic M, Hess M, Bartsch G, Stenzl A: Anatomic and functional studies of the male and female urethral sphincter. World J Urol. 2000; 18: 324-9.
Dr. Karl-Dietrich Sievert & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
The Hormonal Regulation of Cutaneous Wound Healing
Gilliver SC, Ashworth JJ, Ashcroft GS
Faculty of Life Sciences, Michael Smith Building, M13 9PT Manchester, United Kingdom
Clin Dermatol. 2007; 25: 56-62
Conditions of impaired wound healing in the elderly are associated with substantial morbidity and mortality and impose a significant financial burden upon the world's health services. The findings of a series of recent studies have served to highlight the contrasting contributions made by sex steroid hormones to the regulation of cutaneous repair processes. Although estrogens accelerate healing, the actions of the "male" sex hormones 5alpha-dihydrotestosterone and testosterone are primarily deleterious. The shift that occurs in the balance between serum estrogen and androgen levels as a normal feature of human aging may therefore have important consequences for fundamental tissue repair processes.
Editorial Comment
The paper outlines nicely the effect of sex hormones on wound healing. Topical and systemic estrogen applications have been shown to both increase acute healing and to prevent the development of a chronic wound status. A similar beneficial effect for wound healing was seen with the precursor of both androgenic and estrogenic effector molecules, dehydroepiandrosterone (DHEA). Both estrogens and DHEA dampen local inflammation and promote matrix deposition. The modulation of inflammatory responses by sex hormones is partially regulated by modulating macrophage function, which in turn leads to changes in TNF-alpha production, macrophage migration inhibitory factor secretion, and IL-6 expression.
In contrast, androgens seem to be negative regulators for wound healing suggesting that they retard repair processes and enhance the local inflammatory response. All surgeons including those dealing with flaps used in reconstructive urology are confronted with impaired wound healing possibly resulting in chronic wound healing states. Topical and systemic estrogen treatment as well as dehydroepiandrosterone may help to overcome some of the problems of flap or other reconstructive interventions and its sometimes peculiar problems regarding healing. This may be of particular importance in elderly patients were particularly estrogen and DHEA deficiency is thought to be the cause of age-related impaired wound healing. One should also think about using systemic hormonal replacement therapy in female patients prior to complex reconstructive surgery in order to reduce chronic wound problems.
Dr. Karl-Dietrich Sievert & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
Publication Dates
-
Publication in this collection
04 Apr 2007 -
Date of issue
Feb 2007
