SLING OPERATION FOR MALE STRESS INCONTINENCE BY UTILIZING MODIFIED STAMEY TECHNIQUE TOSHIYUKI MIZUO, M.D., PH.D. AKIKO TANIZAWA, M.D. TAKUMI YAMADA, M.D., Pr~1.D.
MASAO ANDO, M.D., PII.D. HIROYUKI OSHIMA, M.D., Prr.11.
From the Division of Urology, Tokyo Rosai Hospital, and Department of Urology, Tokyo Medical and Dental University, School of Medicine, Tokyo, Japan
ABSTRACT-A modified Stamey operative technique was applied to 3 lnen with stress incontinence due to transurethral prostatectomy or transurethral resection of bladder neck. Two pieces of polytetrafluoroethylene grafts (Core-Tex) were positioned at the membranous and bulbous urethra as sling loops, and hung up by nylon sutures that were brought to the abdominal wall along each side of the urethra by means of a modified Stamey needle and tied over the rectus fascia. Postoperatively, maximum urethral closure pressure and junctional urethral length were increased, and urinary continence was achieved in all 3 patients, however, urinary retention developed in 1 patient with bladder arefrexia.
When urinary incontinence after transurethral prostatectomy remains refractory to conservative treatment, implantation of artificial prosthetic sphincter is performed.’ 4 On the other hand, female stress incontinence has been SUE cessfully treated with the original or modified Stamey technique. We applied the Stamey technique to 3 cases of male stress incontinence with favorable results.
A 15 or 30-degree angled modified Stamey needle is placed on the anterior rectus fascia at the mid-point of the transverse suprapubic incision. The needle is pushed through the rectus fascia and laid 15 or 20 degree angle on the abdominal wall. The needle is directed toward the inner surface of the pubic bone and passed 2 cm parallel to the periosteum of the symphysis pubis toward the perineum. An index finger is placed at the inferior wall of the urogenital diaphragm between membranous urethra and ischiocavernosus muscle. The needle then penetrates alongside the membranous urethra and through the endopelvic fascia under control of the surgeon’s index finger. The position of the needle is checked endoscopically using a 0” telescope to ensure that the needle is at the level of the membranous urethra and a 70” telescope to see that the needle has not entered the bladder. Two pieces of no. 2 monofilament nylon sutures are then threaded through the eye of the
Operative Technique Under general or epidural anesthesia, the patient was placed in the lithotomy position. Two transverse 2 to 3-cm skin incisions are made 3 to 4 cm from the midline at the upper border of the symphysis pubis, and deepened to the anterior sheath of the rectus muscle. An inverted Y-shaped perineal incision was made to expose the bulbous urethra, inferior fascia of the urogenital diaphragm, and medial edge of ischiocavernosus muscle.
uRoI.O(:Y
MAH(:II1992/ VOLUMEXXXIX,NUMRER
3
211
FIGURE 1. Operative procedures. (A) Route of modified Stamey needle, needle was inserted through small suprapubic incision down toward perineal incision. Ends of two sutures were threaded into eye of needle and pulled up to suprapubic incision. (B) Route of two of nylon sutures shown from perineal side. Dacron sleeves were placed horizontally under the membranous and bulbous urethra. (C) Both ends of each of nylon suture-s were tied together above the anterior sheath of the rectus muscle. Membranous and bulbous urethra were compressed by two pieces of Dacron sleeves. the eye of the needle and pulled up to the suprapubic incision. The intervening subcutaneous connective tissue over the anterior rectus fascia is bluntly dissected from the left suprapubic incision to the right, and the ends of the nylon sutures from the left suprapubic incision are pulled into the subcutaneous tunnel, toward the right suprapubic incision (Fig. 1B). Both ends of each of the nylon sutures are tied together above the anterior sheath of the rectus muscle at the right suprapubic incision. A 16F Foley balloon catheter is left indwelling in the bladder. The perineal incision and two suprapubic incisions are closed (Fig. 1C).
Stamey needle and pulled up from the perineum to the suprapubic incision (Fig. 1A). The perineal end of one nylon suture is stitched through the muscles of urogenital diaphragm and is threaded through a 2-cm tube of 8-mm knitted polytetrafluoroethylene graft to buttress the dorsal membranous urethra. The perineal end of the other nylon suture is also stitched 1 cm distal to the first nylon suture and also threaded through a same size polytetrafluoroethylene graft. The Stamey needle is then reintroduced from the other side of the suprapubic incision in a similar manner. The perineal ends of the two nylon sutures are rethreaded through TABLE I. case
1
2
age
60
74
cause of incontinence
TUR-P
TUR-P
Patient data
degree of incontinence
uroflowmetry
(fllow up period(months)) V.V. R.V. M.F.R. pre-op post-op
total continence ( 19 >
pre-op post-op
total continence
cystometry A.F.R.
Pattern
7.0
normal normal
142 89
313 310
47 48
normal normal
120 154
326 461
52 59
areflexia areflexia
512
636
42
508
782
34
not evaluable
217
‘0
14.2
not evaluable
236
10
15.1
7.3
0
25.3
5.0
F.D.V.
B.C.
M.P
( 18 > 3
36
TUR-BN
pre-op post-op
297
partial retention” ( 16 >
not evaluable
KI:~, V.V.: voided urine volume (mL); R.V.: residual urine volume (mL/min); F.D.V.: first desire to void (mL): B.C.: bladder capacity *Intermittent urethral self-catheterization.
212
(mL): M.F.R.: max flow rate (mL/min); (mL): M.P.: max pressure (cm H,O).
UROLOGY
/ MARCH
1992
/
A.ER.:
VOLUME
average
flow rate
XXXIX. NUMBER
3
preoperative
UPP
postoperative
UPP
50cmH20
Case
2
Case
3
_ A -*-
.’ .
* I_..’ :
._
!,
Result
From February 1988 to June 1988, 3 patients had the sling operation (Table I and Fig. 2). All patients have remained completely dr!, for the last sixteen to nineteen months. The preoperati\rc q~stourethrogram of Case 1 shom:ed abnormal width of membranous urethra, and repeated postopt~ra.tive cystourethrograln demonstrated compression of the mem branotIs and bulbous urethra (Fig. 3A, 3s). Cystourethrogram one year after the operation also demonstrated compression of the membranous and MboI~s urethra (Fig. 3C). Erosion of the grafts into the urethra was checked by urethrosc.~q~yand ftrrlnd in none of the patients treated.
Sling method
operation
\vitlI
was successfully
iI Inodificd applied
Stanley
t’or post-TURI’ incontinence in the current report. although the number of cases are still limited. Slillg oI)eration has achieved excellent result:% for the treatment of female stress irlcorltilrc~rlcc~l.’ i The method reported b!. Starlie>. is gas>. and accllrate and has been applied suc:t~tw~f~~llyto female stress incontinence.x ” 70 our knowledge no one has applied the method of Stamcs!. to male stress incontinence. In the present operation, punctllrrb tram suprapubic area to the area het\\,eeri tllc menrbranorIs urethra and ischioca\wnosrl$ r11usc4e c
MASAO ANDO, M.D., PII.D. HIROYUKI OSHIMA, M.D., Prr.11.
From the Division of Urology, Tokyo Rosai Hospital, and Department of Urology, Tokyo Medical and Dental University, School of Medicine, Tokyo, Japan
ABSTRACT-A modified Stamey operative technique was applied to 3 lnen with stress incontinence due to transurethral prostatectomy or transurethral resection of bladder neck. Two pieces of polytetrafluoroethylene grafts (Core-Tex) were positioned at the membranous and bulbous urethra as sling loops, and hung up by nylon sutures that were brought to the abdominal wall along each side of the urethra by means of a modified Stamey needle and tied over the rectus fascia. Postoperatively, maximum urethral closure pressure and junctional urethral length were increased, and urinary continence was achieved in all 3 patients, however, urinary retention developed in 1 patient with bladder arefrexia.
When urinary incontinence after transurethral prostatectomy remains refractory to conservative treatment, implantation of artificial prosthetic sphincter is performed.’ 4 On the other hand, female stress incontinence has been SUE cessfully treated with the original or modified Stamey technique. We applied the Stamey technique to 3 cases of male stress incontinence with favorable results.
A 15 or 30-degree angled modified Stamey needle is placed on the anterior rectus fascia at the mid-point of the transverse suprapubic incision. The needle is pushed through the rectus fascia and laid 15 or 20 degree angle on the abdominal wall. The needle is directed toward the inner surface of the pubic bone and passed 2 cm parallel to the periosteum of the symphysis pubis toward the perineum. An index finger is placed at the inferior wall of the urogenital diaphragm between membranous urethra and ischiocavernosus muscle. The needle then penetrates alongside the membranous urethra and through the endopelvic fascia under control of the surgeon’s index finger. The position of the needle is checked endoscopically using a 0” telescope to ensure that the needle is at the level of the membranous urethra and a 70” telescope to see that the needle has not entered the bladder. Two pieces of no. 2 monofilament nylon sutures are then threaded through the eye of the
Operative Technique Under general or epidural anesthesia, the patient was placed in the lithotomy position. Two transverse 2 to 3-cm skin incisions are made 3 to 4 cm from the midline at the upper border of the symphysis pubis, and deepened to the anterior sheath of the rectus muscle. An inverted Y-shaped perineal incision was made to expose the bulbous urethra, inferior fascia of the urogenital diaphragm, and medial edge of ischiocavernosus muscle.
uRoI.O(:Y
MAH(:II1992/ VOLUMEXXXIX,NUMRER
3
211
FIGURE 1. Operative procedures. (A) Route of modified Stamey needle, needle was inserted through small suprapubic incision down toward perineal incision. Ends of two sutures were threaded into eye of needle and pulled up to suprapubic incision. (B) Route of two of nylon sutures shown from perineal side. Dacron sleeves were placed horizontally under the membranous and bulbous urethra. (C) Both ends of each of nylon suture-s were tied together above the anterior sheath of the rectus muscle. Membranous and bulbous urethra were compressed by two pieces of Dacron sleeves. the eye of the needle and pulled up to the suprapubic incision. The intervening subcutaneous connective tissue over the anterior rectus fascia is bluntly dissected from the left suprapubic incision to the right, and the ends of the nylon sutures from the left suprapubic incision are pulled into the subcutaneous tunnel, toward the right suprapubic incision (Fig. 1B). Both ends of each of the nylon sutures are tied together above the anterior sheath of the rectus muscle at the right suprapubic incision. A 16F Foley balloon catheter is left indwelling in the bladder. The perineal incision and two suprapubic incisions are closed (Fig. 1C).
Stamey needle and pulled up from the perineum to the suprapubic incision (Fig. 1A). The perineal end of one nylon suture is stitched through the muscles of urogenital diaphragm and is threaded through a 2-cm tube of 8-mm knitted polytetrafluoroethylene graft to buttress the dorsal membranous urethra. The perineal end of the other nylon suture is also stitched 1 cm distal to the first nylon suture and also threaded through a same size polytetrafluoroethylene graft. The Stamey needle is then reintroduced from the other side of the suprapubic incision in a similar manner. The perineal ends of the two nylon sutures are rethreaded through TABLE I. case
1
2
age
60
74
cause of incontinence
TUR-P
TUR-P
Patient data
degree of incontinence
uroflowmetry
(fllow up period(months)) V.V. R.V. M.F.R. pre-op post-op
total continence ( 19 >
pre-op post-op
total continence
cystometry A.F.R.
Pattern
7.0
normal normal
142 89
313 310
47 48
normal normal
120 154
326 461
52 59
areflexia areflexia
512
636
42
508
782
34
not evaluable
217
‘0
14.2
not evaluable
236
10
15.1
7.3
0
25.3
5.0
F.D.V.
B.C.
M.P
( 18 > 3
36
TUR-BN
pre-op post-op
297
partial retention” ( 16 >
not evaluable
KI:~, V.V.: voided urine volume (mL); R.V.: residual urine volume (mL/min); F.D.V.: first desire to void (mL): B.C.: bladder capacity *Intermittent urethral self-catheterization.
212
(mL): M.F.R.: max flow rate (mL/min); (mL): M.P.: max pressure (cm H,O).
UROLOGY
/ MARCH
1992
/
A.ER.:
VOLUME
average
flow rate
XXXIX. NUMBER
3
preoperative
UPP
postoperative
UPP
50cmH20
Case
2
Case
3
_ A -*-
.’ .
* I_..’ :
._
!,
Result
From February 1988 to June 1988, 3 patients had the sling operation (Table I and Fig. 2). All patients have remained completely dr!, for the last sixteen to nineteen months. The preoperati\rc q~stourethrogram of Case 1 shom:ed abnormal width of membranous urethra, and repeated postopt~ra.tive cystourethrograln demonstrated compression of the mem branotIs and bulbous urethra (Fig. 3A, 3s). Cystourethrogram one year after the operation also demonstrated compression of the membranous and MboI~s urethra (Fig. 3C). Erosion of the grafts into the urethra was checked by urethrosc.~q~yand ftrrlnd in none of the patients treated.
Sling method
operation
\vitlI
was successfully
iI Inodificd applied
Stanley
t’or post-TURI’ incontinence in the current report. although the number of cases are still limited. Slillg oI)eration has achieved excellent result:% for the treatment of female stress irlcorltilrc~rlcc~l.’ i The method reported b!. Starlie>. is gas>. and accllrate and has been applied suc:t~tw~f~~llyto female stress incontinence.x ” 70 our knowledge no one has applied the method of Stamcs!. to male stress incontinence. In the present operation, punctllrrb tram suprapubic area to the area het\\,eeri tllc menrbranorIs urethra and ischioca\wnosrl$ r11usc4e c
![[Postoperative male stress urinary incontinence: outcomes of treatment by I-STOP TOMS® transobturator sling].](/assets/img/hold.png)
