Men and Mesh

June 12, 2013 ~ You may have recently seen the advertisements for male urinary incontinence products. The Guardian pad was just launched in April with promises of offering “discrete protection for men who suffer from light to moderate male incontinence.” See here.

According to the Mayo Clinic newsletter (here), male urinary incontinence is the most disruptive assault on a man’s quality of life and one of the greatest fears associated with prostate surgery. Mayo reports men fear that coughing, sneezing, laughing or lifting can cause incontinence forcing men to use pads not unlike what women must do. Some medications can cause incontinence such as high blood pressure drugs, antidepressants, diuretics and sleeping pills, reports WebMD (here).

After a radical prostatectomy, stress urinary incontinence is estimated to happen in about five percent of men. Since 1972 an artificial urinary sphincter (AUS) is the go-to treatment, the “gold standard” which has a success rate of about 75 percent.

Male urethral sling, Brazilian J of Urology

However, eventually the literature reports that first-time sphincters eventually fail 25 to 30 percent of the time. So for those patients, a suburethral sling is implanted to hold up the urethra decreasing leakage. Slings can be made of nonimmunogenic porcine material (pig). Mayo reports eight patients who have undergone the procedure since 2008 achieved just over 50 percent success after a follow-up of 16.5 months. Men with light leakage are considered candidates for a polypropylene mesh male sling, which was introduced about five years ago.

“The male sling continues to be refined,” says Mayo Clinic describing the 30-minute minimally invasive outpatient procedure. Again the sling is implanted beneath the bulbous urethra lifting it and preventing leakage.

With a success rate of 60 to 70 percent and 20 percent experiencing markedly improved symptoms, the Mayo Clinic notes those patients must be carefully selected. Generally those who smoke or who are obese are not considered good candidates. Men who have undergone radiation or transurethral resection of the prostate are also not considered to be good candidates.

“Thanks to high patient volumes and opportunities for long-term follow-up, Mayo Clinic urologists have an objective, evidence-based platform for continuous improvement and innovation to relieve patients’ incontinence.”

Polypropylene mesh tape for male sphincteric incontinence 2004, Department of Urology, Istanbul University, PubMed

http://www.ncbi.nlm.nih.gov/pubmed/15764251

In a study conducted in Turkey, polypropylene mesh tape (PMT) was used in 12 patients ages 17 to 75 with an average age of 61. Sphincteric incontinence resulted from a radical prostatectomy in three of the patients, a transurethral prostatectomy in four, open prostatectomy in two and neurologic problems in three. all of the patients had stress incontinence. The researchers called it a "new male sling technique." On average, the operation lasted 65 minutes and was followed-up on average at just over 31 months.

"Urinary incontinence was cured or improved in nine patients (75%) reports researchers, while there was no improvement in three (25%). None of the patients experienced urethral erotion but one patient had a bladder perforation that occurred during the surgery.

Researchers conclude more patients with a longer follow-up time is needed to come to any conclusions. There does not appear to be a quality of life standard, that is, are the patients living with ongoing pain and complications.

Another study published in the Indian Journal of Urology (here) , January to March 2007, Prolene (mesh) bulbourethral sling in male incontinence.

In this study conducted from May 2003 to June 2005, six patients with postprostatectomy urinary incontinence, received a prolene mesh bulbar urethral sling manufactured by Johnson & Johnson, of Aurangabad, India. After 6 to 22 months. After one year one patient had mild stress incontinence return, four of the six “were completely dry till their last follow-up.” The risk of infection is a major concern with synthetic grafts because of perineal bacteria, though no significant infection was reported here. None of the patients experienced mesh erosion.

Materials used for male slings beside polypropylene (PP) include, Dacron and PTTE mesh. The cost of the prolene bulbar urethral sling is reported to be about $350. “Since the pressure over the urethra is low and largely extended, the risk of urethral erosion is minimal,” say researchers.

In an accompanying editorial (here), Alan Shindel, MD, urologist at the UC Davis, says that urethral slings are used to treat female SUI, creating a hammock on which the urethra rests. But in men there is not a continence producing hammock that can be recreated due to the difference in their anatomy. That why slings have not been as successful as a treatment for men.

The male sling for stress urinary incontinence: a prospective study, (here) conducted at the University of Arizona Health Science Center in Tucson involved 21 men who had sling surgery. The researchers conclude that incontinence was cured in 76 % of the patients and failed in one patient.

Images International Brazilian J of Urology July August 2004