Pelvic Pain Syndromes / Sexual Dysfunction
Adjustable slings represent a valid treatment option for male stress urinary incontinence. Autologous fascia can be used instead of polypropylene tape in order to avoid synthetic mesh-related complications. Ileal neobladder, one of the most commonly employed types of orthotopic urinary diversion following radical cystectomy, carries a substantial risk of urinary incontinence. Anti-incontinence measures may be employed at the time of definitive oncological surgery, especially for patients with preexisting urinary leakage. Herein, we report a male patient with urgency urinary incontinence (UUI) and high risk non-muscle invasive bladder cancer who underwent retropubic placement of adjustable sling with autologous fascia at the same session with robotic radical cystectomy and creation of ileal neobladder.
A 49-year-old African-American male patient with a history of high-risk non-muscle invasive bladder cancer was scheduled for robotic radical cystectomy and creation of ileal neobladder owing to the facts that he was unable to tolerate intravesical BCG treatment and radiological signs of progression were evident. He also reported bothersome UUI refractory to anticholinergic medications. We elected to place an adjustable sling at the time of cystectomy to avoid a second surgical procedure in the technically challenging and complication-prone setting of a neobladder.
The patient was positioned in steep Trendelenburg for the robotic procedure and dorsal lithotomy to accommodate the sling placement. The procedures began concurrently. A 7 cm midline perineal skin incision was made and carried down to the level of the bulbospongiosus muscle. Dissection was extended superolaterally, on each side of the bulbar urethra, to the level of the pubic bone. A 1 x 3 cm segment of rectus fascia was harvested. The fascial graft was penetrated with PDS stay sutures at the bench to substitute for the Remeex polypropylene mesh. Following completion of the cystoprostatectomy, trocars were passed retropubically under direct robotic visual guidance for accurate placement in the presence of pneumoperitoneum. The PDS sutures were loaded to the trocars and then passed to suprapubic incision to be integrated into the varitensor. The varitensor adjuster was removed in anticipation of delayed tensioning after complete recovery from neobladder reconstruction.
Adjustable male sling with the autologous fascia can be safely placed at the time of orthotopic neobladder reconstruction to obviate the need for future anti-incontinence surgery and to mitigate the risk of synthetic mesh-related complications. This approach is particularly appropriate for patients with baseline urinary incontinence.