V05-08: Intraoperative adjustible non obstructive bulbourethral suspension
The bulbourethral suspension with intraoperative urodynamic adjustment was proposed for patients with post-radical prostatectomy incontinence in 2004. This non obstructive sling technique has now been routinely used for years in our department in patients with severe stress incontinence and has become an alternative to artificial urinary sphincter implantation.
This video demonstrates the standardized technique step by step. Antegrade urethral opening pressure and functional urethral length are determined before skin incision in general anesthesia without relaxation. After a perineal vertical midline incision just below the scrotum the bulbocavernous muscle is exposed and splitted. In a next step, an angled guide needle is introduced paraurethrally through the perineal access and is brought up strictly retropubically, lateral to the bladder neck, to the suprapubic skin. Cystoscopy is performed to exclude bladder perforation. A 4 x 2 cm non resorbable porcine dermal skin implant for bulbar urethal protection is sutured onto the 2.5 cm wide partial resorbable polypropylene/ polyglycolic-acid-caprolacton sling. Through the curved - perforated guide needle, the sling is drawn suprapubic with a wire. The suspension elevates the pelvic floor and improves functional urethral coaptation. A transverse suprapubic incision about 6 cm long is made down onto rectus fascia. Gentle pressure of the fist is applied onto the bladder with parallel increase of the sling tension to determine optimal antegrade urethral opening pressure. We aim an increase of the antegrade urethral pressure of 20-25 H20, as well as a prolonged functional urethral length. Repetitive antegrade pressure measurements confirm reliable introperative dynamic adjustement. Once the final pressure is accepted, the polypropylene ends are knotted.
In 2004, initial series showed feasability in 16 patients with social urinary continence rate of 69 %. Midterm term follow-up results after 36 months in 57 patients confirmed stable 60 % social continence and 14% significant improvement. Pressure-flow studies excluded infravesical obstruction. Only 12% of the patients underwent artificial urinary sphincter implantation in the long-term course.
The presented bulbourethral suspension technique is a standardized, intraperative adjustable and non obstructive urethral sling technique with high social continence rate and patient statisfaction.