Background:Recently a new bulbourethral sling procedure in patients with severe post-prostatectomy incontinence was proposed (J.Urol.171,1866-70,2004). This study reports the the ongoing experience in this technique.
Methods:
Bulbourethral composite suspension was performed in 33 consecutive stress incontinent patients aged 66 (42-83) years. They had undergone radical prostatectomy (N=30) or transurethral resection (N=3) 30(8-248) months before. 7/33(21%) of the patients were severe stress incontinent and depended on diapers or condom catheter. Urinary stress incontinence and quality of life were assessed preoperatively by a validated questionnaire and a modified pad-test. Urethrocystoscopy excluded urethral stricture. The procedure was performed with a longitudinal perineal and a transverse suprapubic incision in regional or general anesthesia placing a 4x2cm collagen implant (Pelvicol®, Bard) for urethral protection and a polypropylene retropubic sling (Uretex®, Bard) that was tied suprapubically. Tension was adjusted under patient’s coughing and with retrograde urethral closure pressure monitoring at 60cm H20. In the last 10 cases, tension was regulated with intraoperative Valsalva leak point pressure of 60cm H20. Statistical analyses included the chi-square test and the Mann-Whitney test, with p<0.05 being the accepted significance level.
Results:
Bladder perforation occurred in 10/33(30%) patients. The Foley catheters were removed after 3 days. All patients had primary wound healing. Patients reported only minimal postoperative pain. Three patients had urinary retention and underwent sling tension release. No urethral or vesical erosion occurred. Clinical follow-up was performed at median 14(range 1-42) months postoperatively. 24/33(73%) of the patients were completely dry or weared one protection per day. 9/33(27%) of the patients had no benefit, whereof 5 underwent artificial sphincter procedure with good functional outcome. The number of pads decreased from 5(2-12) preoperatively to 0(0-10) postoperatively, p<0.001. Quality of life improved from 5(4-6) to 1(0-6), p<0.001. Cumulative material costs for all patients were 26‘400 USD, while saved pad-costs within the follow-up period amounted to 49‘800 USD.
Conclusions:
The bulbourethral composite suspension is a new efficient and cost effective operative treatment option in patients with severe post-prostatectomy urinary incontinence. This technique may become an alternative to the artificial urinary sphincter. Although encourraging early functional postoperative results, long term durability, urethral tolerability and detrusor function have to be carefully

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