0022-534 7/79/1215-0605$02. 00/0 Vol. 121, May
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
URETHRAL COMPRESSION PROCEDURE FOR THE TREATMENT OF MALE URINARY INCONTINENCE JOSEPH J. KAUFMAN AND SHLOMO RAZ From the Department of Surgery/Urology, UCLA School of Medicine, Los Angeles, California
ABSTRACT
We believe that there still is a place for passive compression of the bulbous urethra in the treatment of male urinary incontinence after prostatectomy or sphincterotomy. The procedure is simple to do and it is relatively free of complications. However, since it provides only passive resistance and cannot compensate for sudden increases in intravesical pressure, stress incontinence of minor degree is not uncommon. In our series of 184 cases 61 (33 per cent) became completely dry, required no protection and voided with a good stream and without residual urine. Another 51 patients had some stress incontinence but were pleased with the results so that 61 per cent derived definite benefit from the operation. There were 20 (11 per cent) major complications in this series. With recent modifications of the technique and the prosthesis the complication rate has been reduced to 7 per cent in the last 50 cases. The opportunity to adjust the compression postoperatively by injection provides advantages over other passive compression procedures. External trusses were used to compress the bulbous urethra to control incontinence in men as early as 1750.' Perhaps the first attempt to control incontinence by compressing the urethra was made by Young, who narrowed the membranous urethra and approximated the transverse perineal and levator muscles over it to increase urethral resistance.2 Lowsley subsequently constricted the urethra by plicating the bulbocavernosus muscles with ribbon gut.:i Our efforts to restore continence with urethral compression stem from the work of Berry, who devised an operation to implant acrylic and silicone blocks in the perineum to compress the bulbous urethra. 4 Because of migration of the prostheses, urethral erosion and inconstant results this operation gradually fell into disfavor. Girgis and Veenema, 5 Hinman and associates 6 and Puigvert7 and the authors have since worked on the problem of restoring continence in men by passive urethral compression. Our early attempts were aimed at avoiding the implantation of foreign material. Thus, the crura of the penis first were crossed over in the midline to compress the urethra 8 and later they were approximated in the midline. 9 The latter technique was proposed independently by Puigvert, who cut windows in the crura before joining them in the midline to promote good union. 7 However, autologous orthotopic tissue alone failed to provide an adequate compression of the urethra and we subsequently resorted to the use of implantable material because of a fairly high failure rate. By approximating the crura of the penis and implanting a roll of polypropylene mesh we achieved a success rate slightly better than 60 per cent in 42 consecutive cases. 9 This record was confirmed and amplified by the experience of Furlow, w who reported a 60 per cent cure and improvement rate among 66 patients. Furlow and we have acknowledged that passive compression of the urethra is at best a "poor man's sphincter" and that it works best in patients not engaged in occupations requiring great exertion. In the latter case and in patients who have chronic pulmonary disease with cough the spikes of intravesical pressure may overcome the resistance imposed by passive urethral compression. We abandoned the crural approximation in 1972 in favor of using an inert implantable silicone gel prosthesis because we Accepted for publication July 7, 1978. Read at annual meeting of American Urological Association, Washington, D. C., May 21-25, 1978.
thought that this would allow adjustment by injection after edema subsided and scar tissue contracted. About the silicone capsule a velour of polyurethane was placed to encourage fixation by the ingrowth of fibrous tissue. The cushion was fixed by dacron straps placed about the crura until it was held in position by fibrous tissue ingrowth. As with other implants we witnessed urethral erosion in several cases fairly early in our experience. 11 Therefore, we changed the original model from one that was completely coated with velour to one that was coated and reinforced only on the base and sides, leaving the dome of the prosthesis with the silicone exposed to incite minimal reaction against the urethra and, hopefully, to avoid urethral erosion. Reinforcement of the base and sides of the prosthesis allows the device to expand upward against the urethra when it is injected percutaneously, rather than enlarging in all directions as a result of the postoperative injections. Several other minor modifications have been incorporated but the essential design remains unchanged. METHODS AND MATERIALS
No patient should be considered for operative correction of postoperative incontinence until 9 months have elapsed. Important in the preoperative evaluation is the urethral pressure profile to determine whether 1) there is any residual passive sphincteric activity, 2) active continence can be demonstrated by voluntarily contracting the pelvic muscles and 3) the closing pressure of the urethra can be raised significantly by manual pressure on the perineum during the performance of the pressure profile. Also relevant is how much intravesical pressure is generated by the patient with coughing, since if the patient has inordinately high intravesical pressures it is unlikely that he will obtain a good result from passive perineal compression. The best candidates for the operation are patients who have post-prostatectomy incontinence and, particularly those uncomplicated by a previous anti-incontinence operation, urethral stricture, radiation to the pelvis and perineum or a history of chronic obstructive pulmonary disease. In our series we had 16 patients with neurogenic bladder disorders who had bladder dysfunction with urinary retention associated with urinary incontinence. The anti-incontinence device increased retention to a complete degree and the patient was then trained to void by Crede's maneuver or to empty the bladder
605
606
KAUFMAN AND RAZ
by intermittent self-catheterization. In our series of 184 patients operated upon from 1972 to 1977, 168 were post-prostatectomy cases. Of these 104 (62 per cent) were incontinent after transurethral resection of the prostate for benign or malignant disease and, among this group, there were 10 patients who had radiation therapy in addition to transurethral resection. Radical prostatectomy for carcinoma accounted for the incontinence in 43 patients (26 per cent). Of these 31 patients had undergone radical retropubic prostatectomy and 12 had undergone a radical perinea! operation on the prostate. Twenty-one patients had had simple retropubic or suprapubic adenectomy leading to incontinence. Previous operations for incontinence had been done on 59 patients, of whom 35 had undergone previous silicone gel procedures. Of these 35 patients 28 had 1 silicone gel prosthesis removed and replaced, and 7 patients had had 2 previous silicone gel prostheses implanted. Six patients had undergone bladder neck reconstruction unsuccessfully and 14 patients were failures after crural cross-over or approximation procedures. Four patients had undergone the Berry prosthesis implant. The patient is given a broad-spectrum antibiotic usually of the aminoglycoside group on the evening before operation. This is repeated on the morning of the operation and continued every 8 hours during hospitalization. An enema is given the night before operation and the perineum is washed carefully with hexachlorophene the night before and the morning of operation. The patient is placed in a standard lithotomy position, the scrotum is elevated onto the pubis and a midline perinea! incision is made. The incision is carried precisely through the midline to the bulbocavernosus muscles. The bulbocavernosus muscle is exposed and on either side the crura are exposed but not dissected. The superficial neurovascular bundles on either side of the midline are retracted to either side and care is taken during the operation and wound closure to avoid incorporating nerves, an event that may produce annoying hypesthesia and paresthesia of the scrotum and penis. The central perinea! tendon is divided and the dissection continues behind the bulb to mobilize it from the central perinea! tendon and to allow its compression upward against the urogenital diaphragm by the prosthesis (fig. 1). We believe that this step provides the best compression of the urethra by approximating it to the urogenital diaphragm. Serrated bone staples are driven into the pubis above the origin of the ischiocavernosus muscles (fig. 2). The staple is inserted on the medial side of the pubic bone near the ischium and hammered into the bone on each side in a lateral direction (fig. 3). When the straps of the prosthesis are laced under the staples it results in a pulling upward of the prosthesis and a compression of the bulb against the urogenital diaphragm. The distal 2 straps of the
~-,
prosthesis are placed about or through the crura with the modified ligature carrier or with a sharp-pointed right angle clamp. If this appears to give inadequate fixation 2 additional bone staples can be used and these are driven into the pubic arch on either side of the ischiocavernosus muscles. The extra large silicone gel prosthesis is used most commonly. The medium-sized prosthesis is used on the small bulbous urethra. The prosthesis is washed and autoclaved for use before immersion in an antibiotic solution of 1 per cent neomycin or kanamycin for at least 5 minutes before being used. The wound is irrigated frequently with this solution during the operation. After the straps have been laced through the crura or through the staples the position of the dome of the prosthesis against the bulbous urethra is ascertained, the straps are pulled up and then the staples are impacted. The staples are left slightly disimpacted to allow some adjustability of the tension on the straps. The straps are then tied over the base of the prosthesis and, usually, the anterior and posterior straps are attached loosely to each other to prevent slipping over the end of the prosthesis. The wound is irrigated again and closed with absorbable interrupted sutures and the subcutaneous tissue is approximated with 3-zero absorbable sutures, after which the skin edges are closed with a subcuticular suture.
~ p;
Fm. 2. Anatomical relationship of corpus spongiosum to crura. Bottom figure left shows silicone gel prosthesis compressing urethra and straps laced through staples, which are inserted above origin of crura to lift prosthesis against urogenital diaphragm.
(
\~
~
Supf. transverse perinea! m.
Fm. 1. A, division of central perineal tendon. B, placement of silicone gel prosthesis with posterior bone staples and anterior lacing through or around crura.
.'!'l'~~~.cc.::'f"!""''?~' ,~"'~.r"'t>~-£1:.~·:ic~ 607
URETHRAL COMPRESSION TREATMENT OF MALE URINARY INCONTINENCE
112 cases that could be classified as excellent (completely dry, 33 per cent) or good (uses protection for stress incontinence, up to 4 pads per day, 28 per cent) and 39 per cent of cases were considered failures (see table). These figures include those patients followed between 1 and 5 years who may have had an excellent result at 1 or 2 years but who had regression and required injections subsequently. Postoperative injections, usually monitored by urethral pressure profile, are done with a 23 or 24 gauge needle and using radiographic contrast medium, customarily injecting 5 to 10 ml. at each time. It is easy to palpate the prosthesis in the perineum and to gauge when the needle has punctured the thick base of the prosthesis. The needle should not be advanced deeply into the prosthesis to prevent puncturing the unveloured dome (fig. 4). COMPLICATIONS
Fm. 3. Postoperative x-ray of pelvis shows posterior staples directed laterally and prosthesis partially injected with radiopaque medium. Urethral pressure profile in this case indicates maximum closing pressure of 60 cm. water.
The wound is sprayed and a urethral pressure profile is repeated. Almost invariably moderate tension with the straps will result in a closing pressure of 70 to 90 cm. water. If a closing pressure 120 cm. water be found and the surgeon should consider opening the wound and relaxing tension in the straps if this should occur. A 12 or 14F Foley catheter is left in the bladder for 48 hours. Occasionally, a suprapubic cystostomy with a cystocath is done if a urethral catheter cannot be passed easily. The patient usually voids well on removal of the catheter but 30 per cent or so will require replacement of the catheter because of transient retention. In such cases the catheter is left in place for another 48 hours. Sitz baths 3 times daily are begun 1 day postoperatively and continued for 10 days or so. Antibiotics are used postoperatively: aminoglycosides until the patient is discharged from the hospital and then cephalosporins. Perineal pain generally is not severe and by the time of discharge from the hospital 4 or 5 days postoperatively, the patient is quite comfortable.
In this series there were 20 major complications, including 12 urethral or perineal skin erosions, 2 of which were associated with osteomyelitis requiring prolonged hospitalization for parenteral aminoglycoside therapy. In 2 cases erosions of the Small-Carrion prostheses and the silicone gel prosthesis occurred. Of the patients with urethral erosion 3 required supravesical diversion: 1 had a ureterosigmoidostomy and 2 had ureteroileal cutaneous diversion. Eight patients had infection with draining sinuses ultimately requiring removal of the prostheses. Minor complications occurred in 45 patients and were primarily in the form of urinary retention requiring replacement of the catheter for several days. DISCUSSION
Since 1974 we generally have used staples to fix the posterior straps because we witnessed a fair number of cases in which insufficient compression of the urethra was obtained by placing the straps about the attenuated proximal crura. SerResults of urethral compression procedure for the treatment of male urinary incontinence in 184 cases Early No. Excellent or good* Fair or poort
169
15
Intermediate -Before InJ·ec- Late-After Injection tion No.(%) No. 71 113
112 (61) 72 (39)
* Patient is happy, uses no pads or 4 pads a day for stress incontinence. t Patient is unimproved or uses >4 pads a day.
RESULTS
Of 184 cases done between July 1972 and January 1977 there were 125 primary cases and 59 cases that had had previous unsuccessful operations for incontinence. All patients had either grade II or III incontinence, that is incontinence of nonresistance with or without ability to stop and start the stream but with continual loss of urine between voiding. 12 There were no cases of simple stress incontinence in this group. Of these 184 cases 168 were incontinent after prostatectomy and 16 cases had a neurogenic bladder. The results in the prostatectomy group essentially were the same irrespective of the type of antecedent operation causing the incontinence, transurethral resection or radical prostatectomy comprising the vast majority of cases. Up to 6 weeks postoperatively 169 of the 184 cases had an excellent or very good result, while 15 patients failed to be improved. Followup from 6 weeks to 6 months showed a significant loss of continence in the early improved group with only 72 patients (about 40 per cent) improved, while 113 patients had regressed to the point of requiring >4 changes of pads or an appliance. However, with 1 or more injections of the prosthesis and at 1 year or longer there were
Fm. 4. Same patient shown in figure 3 after injection of contrast medium to raise urethral closing pressure from 60 to 105 cm. water.
~
f
I
(i
608
KAUFMAN AND RAZ
rated 1 x 5 /s-inch bone staples are placed above the origin of the crura into the pubic bone near where it joins with the ischium (fig. 3). The purpose of this placement is to allow the posterior straps to elevate the prosthesis and to obtain better compression of the urethra against the urogenital diaphragm. We believe that it is desirable to divide the bulbocavernosus muscle from the central perineal tendon. It is important to appreciate the anatomical relation of the urethra to the crura and pubic bones to conceptualize optimal compression of the urethra against the urogenital diaphragm by a perineal prosthesis. To obtain satisfactory continence with urethral compression it is necessary that the urethra be supple but still capable of distension when urine is flowing through it. Periurethral fibrosis secondary to a previous operation or radiation therapy, and urethral strictures adversely affect the compressibility of the bulbous urethra. Likewise, factors producing inordinate intravesical pressure tend to impair the continence balance. Patients with chronic pulmonary disease, uninhibited bladder contractions, chronic constipation and stressful occupations are subject to unduly increased intravesical pressure. Moreover, obese patients have high intra-abdominal and intravesical pressures and, for these reasons, such patients are not good candidates for urethral compression anti-incontinence procedures. REFERENCES 1. Heister, D. L.: Institutiones Chirurgicae. Amstelaedami: Jans-
sonio Waesbergios, p. 112, 1750.
2. Young, H. H.: Suture of urethral and vesical sphincters for cure of incontinence of urine, with report of a case. Trans. South Surg. Ass., 20: 210, 1907. 3. Lowsley, 0. S.: New operations for the relief of incontinence in both male and female. J. Urol., 36: 400, 1936. 4. Berry, J. L.: A new procedure for correction of urinary incontinence: preliminary report. J. Urol., 85: 771, 1961. 5. Girgis, A. S. and Veenema, R. J.: Perinea! urethroplasty: a new operation for correction of urinary incontinence in the male patient. J. Urol., 93: 703, 1965. 6. Hinman, F., Jr., Schmaelzle, J. F. and Cass, A. S.: Autogenous perinea! bone graft for post-prostatectomy incontinence. II. Technique and results of prosthetic fixation of urogenital diaphragm in man. J. Urol., 104: 888, 1970. 7. Puigvert, A.: Surgical treatment of urinary incontinence in the male. Urol. Int., 26: 261, 1971. 8. Kaufman, J. J.: A new operation for male incontinence. Surg., Gynec. & Obst., 131: 295, 1970. 9. Kaufman, J. J.: Surgical treatment ofpost-prostatectomy incontinence: use of the penile crura to compress the bulbous urethra. J. Urol., 107: 293, 1972. 10. Furlow, W.: Second Urodynamic Workshop, Mayo Clinic, Rochester, Minnesota, January 1976. 11. Kaufman, J. J. and Richie, J. P.: Urethral erosion. Complications of Kaufman anti-incontinence operation. Urology, 3: 218, 1974. 12. Kaufman, J. J. and Raz, S.: Passive urethral compression with a silicone gel prosthesis for the treatment of male urinary incontinence. Mayo Clin. Proc., 51: 373, 1976.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
URETHRAL COMPRESSION PROCEDURE FOR THE TREATMENT OF MALE URINARY INCONTINENCE JOSEPH J. KAUFMAN AND SHLOMO RAZ From the Department of Surgery/Urology, UCLA School of Medicine, Los Angeles, California
ABSTRACT
We believe that there still is a place for passive compression of the bulbous urethra in the treatment of male urinary incontinence after prostatectomy or sphincterotomy. The procedure is simple to do and it is relatively free of complications. However, since it provides only passive resistance and cannot compensate for sudden increases in intravesical pressure, stress incontinence of minor degree is not uncommon. In our series of 184 cases 61 (33 per cent) became completely dry, required no protection and voided with a good stream and without residual urine. Another 51 patients had some stress incontinence but were pleased with the results so that 61 per cent derived definite benefit from the operation. There were 20 (11 per cent) major complications in this series. With recent modifications of the technique and the prosthesis the complication rate has been reduced to 7 per cent in the last 50 cases. The opportunity to adjust the compression postoperatively by injection provides advantages over other passive compression procedures. External trusses were used to compress the bulbous urethra to control incontinence in men as early as 1750.' Perhaps the first attempt to control incontinence by compressing the urethra was made by Young, who narrowed the membranous urethra and approximated the transverse perineal and levator muscles over it to increase urethral resistance.2 Lowsley subsequently constricted the urethra by plicating the bulbocavernosus muscles with ribbon gut.:i Our efforts to restore continence with urethral compression stem from the work of Berry, who devised an operation to implant acrylic and silicone blocks in the perineum to compress the bulbous urethra. 4 Because of migration of the prostheses, urethral erosion and inconstant results this operation gradually fell into disfavor. Girgis and Veenema, 5 Hinman and associates 6 and Puigvert7 and the authors have since worked on the problem of restoring continence in men by passive urethral compression. Our early attempts were aimed at avoiding the implantation of foreign material. Thus, the crura of the penis first were crossed over in the midline to compress the urethra 8 and later they were approximated in the midline. 9 The latter technique was proposed independently by Puigvert, who cut windows in the crura before joining them in the midline to promote good union. 7 However, autologous orthotopic tissue alone failed to provide an adequate compression of the urethra and we subsequently resorted to the use of implantable material because of a fairly high failure rate. By approximating the crura of the penis and implanting a roll of polypropylene mesh we achieved a success rate slightly better than 60 per cent in 42 consecutive cases. 9 This record was confirmed and amplified by the experience of Furlow, w who reported a 60 per cent cure and improvement rate among 66 patients. Furlow and we have acknowledged that passive compression of the urethra is at best a "poor man's sphincter" and that it works best in patients not engaged in occupations requiring great exertion. In the latter case and in patients who have chronic pulmonary disease with cough the spikes of intravesical pressure may overcome the resistance imposed by passive urethral compression. We abandoned the crural approximation in 1972 in favor of using an inert implantable silicone gel prosthesis because we Accepted for publication July 7, 1978. Read at annual meeting of American Urological Association, Washington, D. C., May 21-25, 1978.
thought that this would allow adjustment by injection after edema subsided and scar tissue contracted. About the silicone capsule a velour of polyurethane was placed to encourage fixation by the ingrowth of fibrous tissue. The cushion was fixed by dacron straps placed about the crura until it was held in position by fibrous tissue ingrowth. As with other implants we witnessed urethral erosion in several cases fairly early in our experience. 11 Therefore, we changed the original model from one that was completely coated with velour to one that was coated and reinforced only on the base and sides, leaving the dome of the prosthesis with the silicone exposed to incite minimal reaction against the urethra and, hopefully, to avoid urethral erosion. Reinforcement of the base and sides of the prosthesis allows the device to expand upward against the urethra when it is injected percutaneously, rather than enlarging in all directions as a result of the postoperative injections. Several other minor modifications have been incorporated but the essential design remains unchanged. METHODS AND MATERIALS
No patient should be considered for operative correction of postoperative incontinence until 9 months have elapsed. Important in the preoperative evaluation is the urethral pressure profile to determine whether 1) there is any residual passive sphincteric activity, 2) active continence can be demonstrated by voluntarily contracting the pelvic muscles and 3) the closing pressure of the urethra can be raised significantly by manual pressure on the perineum during the performance of the pressure profile. Also relevant is how much intravesical pressure is generated by the patient with coughing, since if the patient has inordinately high intravesical pressures it is unlikely that he will obtain a good result from passive perineal compression. The best candidates for the operation are patients who have post-prostatectomy incontinence and, particularly those uncomplicated by a previous anti-incontinence operation, urethral stricture, radiation to the pelvis and perineum or a history of chronic obstructive pulmonary disease. In our series we had 16 patients with neurogenic bladder disorders who had bladder dysfunction with urinary retention associated with urinary incontinence. The anti-incontinence device increased retention to a complete degree and the patient was then trained to void by Crede's maneuver or to empty the bladder
605
606
KAUFMAN AND RAZ
by intermittent self-catheterization. In our series of 184 patients operated upon from 1972 to 1977, 168 were post-prostatectomy cases. Of these 104 (62 per cent) were incontinent after transurethral resection of the prostate for benign or malignant disease and, among this group, there were 10 patients who had radiation therapy in addition to transurethral resection. Radical prostatectomy for carcinoma accounted for the incontinence in 43 patients (26 per cent). Of these 31 patients had undergone radical retropubic prostatectomy and 12 had undergone a radical perinea! operation on the prostate. Twenty-one patients had had simple retropubic or suprapubic adenectomy leading to incontinence. Previous operations for incontinence had been done on 59 patients, of whom 35 had undergone previous silicone gel procedures. Of these 35 patients 28 had 1 silicone gel prosthesis removed and replaced, and 7 patients had had 2 previous silicone gel prostheses implanted. Six patients had undergone bladder neck reconstruction unsuccessfully and 14 patients were failures after crural cross-over or approximation procedures. Four patients had undergone the Berry prosthesis implant. The patient is given a broad-spectrum antibiotic usually of the aminoglycoside group on the evening before operation. This is repeated on the morning of the operation and continued every 8 hours during hospitalization. An enema is given the night before operation and the perineum is washed carefully with hexachlorophene the night before and the morning of operation. The patient is placed in a standard lithotomy position, the scrotum is elevated onto the pubis and a midline perinea! incision is made. The incision is carried precisely through the midline to the bulbocavernosus muscles. The bulbocavernosus muscle is exposed and on either side the crura are exposed but not dissected. The superficial neurovascular bundles on either side of the midline are retracted to either side and care is taken during the operation and wound closure to avoid incorporating nerves, an event that may produce annoying hypesthesia and paresthesia of the scrotum and penis. The central perinea! tendon is divided and the dissection continues behind the bulb to mobilize it from the central perinea! tendon and to allow its compression upward against the urogenital diaphragm by the prosthesis (fig. 1). We believe that this step provides the best compression of the urethra by approximating it to the urogenital diaphragm. Serrated bone staples are driven into the pubis above the origin of the ischiocavernosus muscles (fig. 2). The staple is inserted on the medial side of the pubic bone near the ischium and hammered into the bone on each side in a lateral direction (fig. 3). When the straps of the prosthesis are laced under the staples it results in a pulling upward of the prosthesis and a compression of the bulb against the urogenital diaphragm. The distal 2 straps of the
~-,
prosthesis are placed about or through the crura with the modified ligature carrier or with a sharp-pointed right angle clamp. If this appears to give inadequate fixation 2 additional bone staples can be used and these are driven into the pubic arch on either side of the ischiocavernosus muscles. The extra large silicone gel prosthesis is used most commonly. The medium-sized prosthesis is used on the small bulbous urethra. The prosthesis is washed and autoclaved for use before immersion in an antibiotic solution of 1 per cent neomycin or kanamycin for at least 5 minutes before being used. The wound is irrigated frequently with this solution during the operation. After the straps have been laced through the crura or through the staples the position of the dome of the prosthesis against the bulbous urethra is ascertained, the straps are pulled up and then the staples are impacted. The staples are left slightly disimpacted to allow some adjustability of the tension on the straps. The straps are then tied over the base of the prosthesis and, usually, the anterior and posterior straps are attached loosely to each other to prevent slipping over the end of the prosthesis. The wound is irrigated again and closed with absorbable interrupted sutures and the subcutaneous tissue is approximated with 3-zero absorbable sutures, after which the skin edges are closed with a subcuticular suture.
~ p;
Fm. 2. Anatomical relationship of corpus spongiosum to crura. Bottom figure left shows silicone gel prosthesis compressing urethra and straps laced through staples, which are inserted above origin of crura to lift prosthesis against urogenital diaphragm.
(
\~
~
Supf. transverse perinea! m.
Fm. 1. A, division of central perineal tendon. B, placement of silicone gel prosthesis with posterior bone staples and anterior lacing through or around crura.
.'!'l'~~~.cc.::'f"!""''?~' ,~"'~.r"'t>~-£1:.~·:ic~ 607
URETHRAL COMPRESSION TREATMENT OF MALE URINARY INCONTINENCE
112 cases that could be classified as excellent (completely dry, 33 per cent) or good (uses protection for stress incontinence, up to 4 pads per day, 28 per cent) and 39 per cent of cases were considered failures (see table). These figures include those patients followed between 1 and 5 years who may have had an excellent result at 1 or 2 years but who had regression and required injections subsequently. Postoperative injections, usually monitored by urethral pressure profile, are done with a 23 or 24 gauge needle and using radiographic contrast medium, customarily injecting 5 to 10 ml. at each time. It is easy to palpate the prosthesis in the perineum and to gauge when the needle has punctured the thick base of the prosthesis. The needle should not be advanced deeply into the prosthesis to prevent puncturing the unveloured dome (fig. 4). COMPLICATIONS
Fm. 3. Postoperative x-ray of pelvis shows posterior staples directed laterally and prosthesis partially injected with radiopaque medium. Urethral pressure profile in this case indicates maximum closing pressure of 60 cm. water.
The wound is sprayed and a urethral pressure profile is repeated. Almost invariably moderate tension with the straps will result in a closing pressure of 70 to 90 cm. water. If a closing pressure 120 cm. water be found and the surgeon should consider opening the wound and relaxing tension in the straps if this should occur. A 12 or 14F Foley catheter is left in the bladder for 48 hours. Occasionally, a suprapubic cystostomy with a cystocath is done if a urethral catheter cannot be passed easily. The patient usually voids well on removal of the catheter but 30 per cent or so will require replacement of the catheter because of transient retention. In such cases the catheter is left in place for another 48 hours. Sitz baths 3 times daily are begun 1 day postoperatively and continued for 10 days or so. Antibiotics are used postoperatively: aminoglycosides until the patient is discharged from the hospital and then cephalosporins. Perineal pain generally is not severe and by the time of discharge from the hospital 4 or 5 days postoperatively, the patient is quite comfortable.
In this series there were 20 major complications, including 12 urethral or perineal skin erosions, 2 of which were associated with osteomyelitis requiring prolonged hospitalization for parenteral aminoglycoside therapy. In 2 cases erosions of the Small-Carrion prostheses and the silicone gel prosthesis occurred. Of the patients with urethral erosion 3 required supravesical diversion: 1 had a ureterosigmoidostomy and 2 had ureteroileal cutaneous diversion. Eight patients had infection with draining sinuses ultimately requiring removal of the prostheses. Minor complications occurred in 45 patients and were primarily in the form of urinary retention requiring replacement of the catheter for several days. DISCUSSION
Since 1974 we generally have used staples to fix the posterior straps because we witnessed a fair number of cases in which insufficient compression of the urethra was obtained by placing the straps about the attenuated proximal crura. SerResults of urethral compression procedure for the treatment of male urinary incontinence in 184 cases Early No. Excellent or good* Fair or poort
169
15
Intermediate -Before InJ·ec- Late-After Injection tion No.(%) No. 71 113
112 (61) 72 (39)
* Patient is happy, uses no pads or 4 pads a day for stress incontinence. t Patient is unimproved or uses >4 pads a day.
RESULTS
Of 184 cases done between July 1972 and January 1977 there were 125 primary cases and 59 cases that had had previous unsuccessful operations for incontinence. All patients had either grade II or III incontinence, that is incontinence of nonresistance with or without ability to stop and start the stream but with continual loss of urine between voiding. 12 There were no cases of simple stress incontinence in this group. Of these 184 cases 168 were incontinent after prostatectomy and 16 cases had a neurogenic bladder. The results in the prostatectomy group essentially were the same irrespective of the type of antecedent operation causing the incontinence, transurethral resection or radical prostatectomy comprising the vast majority of cases. Up to 6 weeks postoperatively 169 of the 184 cases had an excellent or very good result, while 15 patients failed to be improved. Followup from 6 weeks to 6 months showed a significant loss of continence in the early improved group with only 72 patients (about 40 per cent) improved, while 113 patients had regressed to the point of requiring >4 changes of pads or an appliance. However, with 1 or more injections of the prosthesis and at 1 year or longer there were
Fm. 4. Same patient shown in figure 3 after injection of contrast medium to raise urethral closing pressure from 60 to 105 cm. water.
~
f
I
(i
608
KAUFMAN AND RAZ
rated 1 x 5 /s-inch bone staples are placed above the origin of the crura into the pubic bone near where it joins with the ischium (fig. 3). The purpose of this placement is to allow the posterior straps to elevate the prosthesis and to obtain better compression of the urethra against the urogenital diaphragm. We believe that it is desirable to divide the bulbocavernosus muscle from the central perineal tendon. It is important to appreciate the anatomical relation of the urethra to the crura and pubic bones to conceptualize optimal compression of the urethra against the urogenital diaphragm by a perineal prosthesis. To obtain satisfactory continence with urethral compression it is necessary that the urethra be supple but still capable of distension when urine is flowing through it. Periurethral fibrosis secondary to a previous operation or radiation therapy, and urethral strictures adversely affect the compressibility of the bulbous urethra. Likewise, factors producing inordinate intravesical pressure tend to impair the continence balance. Patients with chronic pulmonary disease, uninhibited bladder contractions, chronic constipation and stressful occupations are subject to unduly increased intravesical pressure. Moreover, obese patients have high intra-abdominal and intravesical pressures and, for these reasons, such patients are not good candidates for urethral compression anti-incontinence procedures. REFERENCES 1. Heister, D. L.: Institutiones Chirurgicae. Amstelaedami: Jans-
sonio Waesbergios, p. 112, 1750.
2. Young, H. H.: Suture of urethral and vesical sphincters for cure of incontinence of urine, with report of a case. Trans. South Surg. Ass., 20: 210, 1907. 3. Lowsley, 0. S.: New operations for the relief of incontinence in both male and female. J. Urol., 36: 400, 1936. 4. Berry, J. L.: A new procedure for correction of urinary incontinence: preliminary report. J. Urol., 85: 771, 1961. 5. Girgis, A. S. and Veenema, R. J.: Perinea! urethroplasty: a new operation for correction of urinary incontinence in the male patient. J. Urol., 93: 703, 1965. 6. Hinman, F., Jr., Schmaelzle, J. F. and Cass, A. S.: Autogenous perinea! bone graft for post-prostatectomy incontinence. II. Technique and results of prosthetic fixation of urogenital diaphragm in man. J. Urol., 104: 888, 1970. 7. Puigvert, A.: Surgical treatment of urinary incontinence in the male. Urol. Int., 26: 261, 1971. 8. Kaufman, J. J.: A new operation for male incontinence. Surg., Gynec. & Obst., 131: 295, 1970. 9. Kaufman, J. J.: Surgical treatment ofpost-prostatectomy incontinence: use of the penile crura to compress the bulbous urethra. J. Urol., 107: 293, 1972. 10. Furlow, W.: Second Urodynamic Workshop, Mayo Clinic, Rochester, Minnesota, January 1976. 11. Kaufman, J. J. and Richie, J. P.: Urethral erosion. Complications of Kaufman anti-incontinence operation. Urology, 3: 218, 1974. 12. Kaufman, J. J. and Raz, S.: Passive urethral compression with a silicone gel prosthesis for the treatment of male urinary incontinence. Mayo Clin. Proc., 51: 373, 1976.
