Sling pain management and salvage techniques for male sphincter in frail urethra
Addressing painful midurethral slings and rescue approaches for male urinary sphincter in frail urethra were some of the focal topics of the Plenary Session “Implants in functional and reconstructive urology” led by Chairs Dr. Benoit Peyronnet (FR) and Dr. Javier Romero-Otero (ES).
In her state-of-the-art lecture “Managing painful midurethral slings”, Dr. Eva Fong (NZ) discussed the link between pain and the mesh sling. This included immediate symptom onset (i.e., occurrence of pain as soon as the sling was placed). Despite continuous symptoms, the delay in removal is an average of seven years. She also discussed early post-operative problems such as urinary retention which has triple the rate of subsequent complications.
“Ideally, treatment should involve a multidisciplinary team and implementation of a trauma-informed approach. The first point of contact for the patients should be a non-clinical health navigator who documents the patients’ stories and then shares them with the rest of the team; then, a consumer adviser and a clinical nurse specialist to support the treatment journey; and a psychologist, pain specialist, and clinician for the medical assessment process,” stated Dr. Fong.
She underscored the adage that prevention is better than cure. “We are focusing on better patient selection and are currently, designing a urodynamics teaching model. We also aim to encourage better surgery, training, and clinical governance. In New Zealand, we have undertaken credentialing for pelvic floor procedures.”
Dr. Fong also stressed the importance of investigating improved follow-up, early detection of complications, and a peer-reviewed registry. She said, “Presently, we are engaged in research to design novel functional PROMS (patient-reported outcome measures) for pelvic floor surgery.”
In the state-of-the-art lecture “Salvage techniques for male urinary sphincter in frail urethra,” Dr. Lin Zhao (US) stated, “We can divide the concept of frail urethra into two scenarios. One is prostate in situ where the principal diagnoses are spinal cord injury, spina bifida, and pelvic fracture. In this scenario, the major risk factor is intermittent catheterisation or prior urethroplasty. In situations where the prostate is missing, one of the most common causes for the frail urethra is prior radiation, although a history of the artificial urinary sphincter (AUS) and urethroplasty may apply in this situation as well.”
Dr. Zhao discussed bladder neck AUS, which he stated is “better for spina bifida or incontinence from injury (e.g. spinal cord, pelvic fracture).” He added, “If the prostate is there, then [opt for] bulbar AUS as this potentially has something to do with the catheterisation required.”
Dr. Zhao additionally discussed transcorporal AUS, where the incision is placed around the corpora cavernosum. He said, “Potentially, there is less erosion in the fragile urethra. However, there is a risk of erectile dysfunction and difficulty if there is a prior prosthesis. There is controversial evidence that there is less coaptation and more urinary retention due to the reduced flexibility.” He also touched on the Gullwing modification, “It is a transcorporal AUS modification wherein some of the corporal tissue is placed around the ventral urethra to buttress that.”
“Certain modifications have been made in my practice,” said Dr. Zhao, who showed the processes of the Gracilis Wrap AUS and the Rectus Muscle Wrap AUS.
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