Correction of incontinence and erectile dysfunction after radical prostatectomy

Redondo C, Castroviejo F, D`Angelo G, Sierrasesumaga N, Calvo R, Calleja J, Bedate M

Introduction: The surgical management of prostate cancer has evolved remarkably. Despite advances in robotic surgery, the EAU reports erectile dysfunction (ED) rates ranging from 25% to 75% and urinary incontinence (UI) rates between 0% and 11% at 12 months postoperatively.

<br/>UI is classified according to urinary loss as follows: mild: &lt;100 g/24 h; moderate: 100–400 g/24 h; and severe: &gt;400 g/24 h.<br/><br/>Implantation of the AdVance™ XP Male Sling is

indicated in patients with a maximum urine loss of 100–200 g/24 h, without significant bladder dysfunction or prior pelvic radiation. When urine loss exceeds 400 g/24 h or in cases of severe

sphincter insufficiency, implantation of an artificial urinary sphincter should be considered. Reported cure rates range from 63% to 83% at 5 years for mild-to-moderate incontinence.<br/>This video

demonstrates the simultaneous surgical management of post-prostatectomy incontinence and erectile dysfunction.

Objectives: This video demonstrates the simultaneous surgical management of post-prostatectomy incontinence and erectile dysfunction.

Methods: The patient is placed in the dorsal lithotomy position, with the thighs aligned with the

shoulders, flexed less than 90&#176;, and slightly abducted.<br/><br/>A perineal incision is made,

followed by opening of Colles’ fascia. The conjoint tendon is identified and divided to allow mobilization of the proximal bulbar urethra, ensuring adequate displacement.<br/><br/>The sling

arms are introduced through the obturator foramen, approximately one fingerbreadth below the tendon of the adductor longus muscle and lateral to the ischiopubic ramus. The target point is

identified using a fine needle to palpate the bony ridge.<br/><br/>Two small skin incisions are made for passage of the introducer needle. Initially, the needle is advanced at a 45&#176; angle, with the

index finger of the contralateral hand placed lateral to the bulbar urethra to protect it and to receive

the tip of the needle. The needle is then rotated medially to facilitate its passage and rotation behind the ischiopubic ramus.<br/><br/>The mesh is attached to the passer needle and extracted by

rotating the needle in the opposite direction. The same procedure is then repeated on the contralateral side.<br/><br/>The sling is tensioned until it is centered beneath the bulbar urethra,

ensuring correct positioning and absence of torsion. It is secured with four cardinal sutures.<br/> <br/>Gentle symmetric traction is applied to the sling arms to reposition the bulbar urethra, typically

achieving an elevation of approximately 4 cm.<br/><br/>The philosophy of the AdVance system is to reposition the urethra to optimize sphincteric coaptation, not to compress the urethra to achieve

occlusion.<br/>It is recommended to secure the sling arms with a clamp when removing the plastic sheath to avoid excessive tensioning.<br/><br/>Finally, the bulbospongiosus muscle, Colles’ fascia,

and perineal incision are closed in layers.<br/><br/><br/><br/>We began the second part of the procedure with a penoscrotal incision. Both corpora cavernosa were exposed and secured with four reference sutures, which will later be used to close the corporal bodies after implantation of the cylinders, thus preventing accidental perforation. The urethra must be continuously identified and protected throughout the procedure to avoid injury.<br/><br/>A longitudinal corporotomy was performed using a cold scalpel until the cavernous tissue was reached.<br/>The corpora cavernosa

were dilated distally and proximally, initially using scissors with the tips directed laterally to prevent

crossover or urethral injury.<br/><br/>The length of each corpus cavernosum was measured distally 1 of 2 and proximally. We verified that the distal cylinder tips were symmetrical and that the proximal portions were equidistant, <br/><br/><br/><br/>The Furlow introducer was used to facilitate

placement of the cylinders, beginning with the proximal segments. Once the distal ends of the cylinders could be palpated at the glans, on either side of the urethra, the corporal bodies were

closed.<br/><br/>Next, the reservoir was positioned in the space of Retzius, <br/><br/>Finally, all connections were completed, and the pump was implanted in the medial hemiscrotum to allow easy

manipulation.

Results: Operative time: 120 minutes.<br/>Blood loss: negligible.<br/>Hospital stay: 48 hours.

<br/>Patient remained continent and satisfied with prosthesis function

Conclusion: The combined use of a male sling and inflatable penile prosthesisrepresents an effective

and safe option for the simultaneous treatment of post-prostatectomy urinary incontinence and erectile dysfunction.<br/><br/>It is crucial to implant the sling before the penile prosthesis to avoid

accidental cylinder perforation during passage of the introducer needles between the ischiopubic ramus and the proximal corpora cavernosa.

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