Retropubic TFS Minisling for Postprostatectomy Male Incontinence: First Report

Abstract

Hypothesis: A structurally sound puboprostatic ligament (PPL), like the pubourethral ligament in the female, is the core structure for control of stress urinary incontinence (SUI) in males.

Methods: The hypothesis was tested at several levels. Twelve transperineal ultrasound examinations were performed to confirm reflex directional closure vectors around the PPL, with digital support for the PPL rectally and cadaveric testing with a tissue fixation system (TFS) minisling, and finally, 22 cases of postprostatectomy incontinence were addressed only with retropubic insertion of a 7-mm TFS sling between the bladder neck and perineal membrane to reinforce the PPL.

Results: On ultrasound testing, 3 urethral closure muscles were confirmed to act reflexively around the PPL to close the urethra distally and at the bladder neck. A finger was inserted rectally, pressed against the symphysis only on one side of the urethra at the origin of the PPL that controlled urine loss on coughing. The mean pre-op pad loss was 3.8 pads at 9 months; the mean post-op loss was 0.7 pads; 13/22 (59%) patients were 100% improved; 7/22 (31%) improved >50% but <100%; 2/22 (9.1%) improved <50%.

Conclusions: The 7-mm-wide TFS minisling is the first retropubic minisling for postprostatectomy urinary incontinence. It differs significantly from transobturator male operations surgically and in modus operandi. As in the female, reconstruction of the PPL alone was sufficient to cure/improve SUI, suggesting that preservation of the PPL is of critical importance during retropubic radical prostatectomy.

Keywords: Male closure mechanism; Postprostatectomy incontinence; Puboprostatic ligament; Tissue fixation system minisling.

Fig. 1

The detailed anatomy of urethral closure in the female as described in 1990 [1]. The PUL inserts into the midurethra and vagina. The PVL has the same origin as the PUL; it inserts into a thickening of the anterior bladder wall called the “arc”. On effort, the PCM contracts forward against the PUL to stiffen the posterior wall of the distal vagina; the LP pulls back against the PUL to stiffen the PVL and proximal urethra; the conjoint longitudinal muscle of the anus (LMA) pulls down against the uterosacral ligament (not shown here) to rotate the bladder around the arc (broken lines) to close (kink) the urethra at the bladder neck. The vagina between the PUL and bladder base “ZCE” is elastic, so it can stretch bilaterally to allow the distal (PCM) and proximal (LP/LMA) closure mechanisms to operate separately. PVL, pubovesical ligament; arc, precervical arc of Gil-Vernet; PCM, pubococcygeus muscle; LP, levator plate; ZCE, zone of critical elasticity.

Fig. 2

Three reflex muscle forces, backward, downward, and forward close the male urethra as in the female. Left at rest. The lower level of ES is at G4. MU runs between G4 and H7. Right during straining. The lower level of ES is now between H and I and 2.5. PPL has stretched considerably backward, from E6.5 to G4.5, almost double, indicating weakness; MU has moved slightly forward. ES, external sphincter; PS, pubic symphysis; B, bladder; MU, membranous urethra.

Fig. 3

Position of the TFS anchor in the PPL. When the TFS was inserted into the male cadaver using the exact technique used in the female, the anchor exited in the position of the PPL.

Fig. 4

Incision of the perineal membrane. Tunneling with scissors.

Fig. 5

Site of the TFS sling. The tape is in the analogous position of PPL insertion in the removed prostate. The AdVance sling is somewhat lower, a mesh hammock placed at the anterior part of the bulb.

Fig. 6

Anatomy of a fetal male, parasagittal section. Caudal portion of the external urethral sphincter (arrowheads) wrapping the BG (by permission Gil-Vernet et al. [7]). arc, precervical arc of Gil-Vernet; PV, pubovesical ligament; SV, seminal vesicle; ST, transverse superficial perineal muscle; BG, bulbourethral gland; LA, levator ani; CS, penile bulb; EAS, external anal sphincter; IAS, internal anal sphincter; ST, superficial transverse perinei; BS, bulbospongiosus muscle.