Treatment of incontinence after prostatectomy using a new minimally invasive device: adjustable continence therapy

Transrectal Ultrasound Guided Implantation of the ProACT Adjustable Continence Therapy System in Patients With Post-Radical Prostatectomy Stress Urinary Incontinence: A Pilot Study

PURPOSE

We evaluate the feasibility and potential advantages of ProACT system implantation using transrectal ultrasound rather than fluoroscopy for guidance.

MATERIALS AND METHODS

The transrectal ultrasound guided procedure was done between June and October 2005 in 7 patients with a mean age of 68.4 years (range 53 to 76) with mild to severe stress urinary incontinence after laparoscopic transperitoneal radical prostatectomy.

RESULTS

The ProACT system was successfully implanted in all cases without perioperative complications. Time needed to complete the overall procedure was 15 to 30 minutes. All transrectal ultrasound studies performed during the mean followup of 4.2 months (range 2 to 6) confirmed the exact location of the devices.

CONCLUSIONS

ProACT system implantation is feasible using transrectal ultrasound for guidance. Transrectal ultrasound enables excellent imaging of all anatomical landmarks during the entire procedure and it seems to provide considerable advantages over fluoroscopy in terms of safety and accuracy.

[Urinary incontinence and urodynamics]

Incontinence can be the result of impaired functioning of the detrusor muscle and/or the sphincter mechanism. For this reason, the pathomorphology and the pathophysiology should be documented before surgery, so that if it is not successful it is possible to deduce what alterations have been caused by an operation and the reason why the treatment has not been successful. Vaginal reconstruction of the pelvic floor following vaginal prolapse is a safe, effective surgical procedure, particularly for older women. Abdominal fixation of the vaginal stump through open or laparoscopic sacrocolpopexy gives long-lasting and anatomically favourable results especially for younger women who are sexually active, but is associated with a higher mortality rate. Incontinence treatment in men is itself gradually becoming accepted as a subspecialty. Pharmacological treatment that is used for urge incontinence takes the form of substances that relax or desensitize the detrusor (antimuscarinics, oestrogens, alpha-blockers, beta-mimetics, botulinum toxin A, resiniferatoxin, vinpocetin), while stress incontinence requires stimulation of the sphincter and pelvic floor (alpha-mimetics, oestrogens, duloxetin). Bladder function disturbances in children can be classified by noninvasive methods, but the therapy remains a difficult endurance test for the children, their parents and the doctor, often extending over years.

Rektumperforation als Spätkomplikation einer ProACT-Implantation

Operative approaches to solve severe urinary incontinence following radical prostatectomy include artificial urinary sphincters, bulking agents, urethral sling procedures, and the ProACT device (Uromedica Inc.). Previously reported complications of the ProACT procedure comprise ruptures and dislocations of balloons as well as erosions and perforations of the bladder or urethra. We report the case of a rectal perforation as a late complication of the ProACT procedure after prostatectomy and adjuvant radiotherapy. To the best of our knowledge this complication has not been described before.

Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention

OBJECTIVES

To update the complications of transurethral resection of the prostate (TURP), including management and prevention based on technological evolution.

METHODS

Based on a MEDLINE search from 1989 to 2005, the 2003 results of quality management of Baden-Württemberg, and long-term personal experience at three German centers, the incidence of complications after TURP was analyzed for three subsequent periods: early (1979-1994); intermediate (1994-1999); and recent (2000-2005) with recommendations for management and prevention.

RESULTS

Technological improvements such as microprocessor-controlled units, better armamentarium such as video TUR, and training helped to reduce perioperative complications (recent vs. early) such as transfusion rate (0.4% vs. 7.1%), TUR syndrome (0.0% vs. 1.1%), clot retention (2% vs. 5%), and urinary tract infection (1.7% vs. 8.2%). Urinary retention (3% vs. 9%) is generally attributed to primary detrusor failure rather than to incomplete resection. Early urge incontinence occurs in up to 30-40% of patients; however, late iatrogenic stress incontinence is rare (<0.5%). Despite an increasing age (55% of patients are older than 70), the associated morbidity of TURP maintained at a low level (<1%) with a mortality rate of 0-0.25%. The major late complications are urethral strictures (2.2-9.8%) and bladder neck contractures (0.3-9.2%). The retreatment rate range is 3-14.5% after five years.

CONCLUSIONS

TURP still represents the gold standard for managing benign prostatic hyperplasia with decreasing complication rates. Technological alternatives such as bipolar and laser treatments may further minimize the risks of this technically difficult procedure.