Operative Therapie der männlichen Belastungsinkontinenz – Von der Schlinge bis zum artifiziellen Sphinkter

Zusammenfassung

Die häufigste Ursache der männlichen Belastungsinkontinenz ist die operative Therapie des Prostatakarzinoms. 12 Monate postoperativ sind 3–23 % der Patienten bei diesem Eingriff inkontinent. Versagen konservative Therapieansätze, so stehen mehrere operative Behandlungsoptionen zur Verfügung. Das ProACT™-System und männliche Harnröhrenschlingen können primär bei Inkontinenz milder bis mittlerer Ausprägung eingesetzt werden. Hiermit können im mittleren Follow-up, Kontinenzraten von 50–80 % erzielt werden; bei vorbestrahlten Patienten sind die Kontinenzraten jedoch deutlich niedriger. Prospektiv randomisierte Studien mit größeren Kollektiven und Langzeitdaten sind notwendig, um die Effektivität und das Komplikationsspektrum auch im Langzeitverlauf beurteilen zu können. Aufgrund der vielversprechenden Kontinenzraten bei gleichzeitig minimaler Invasivität können insbesondere das ProACT™-System sowie justierbare Schlingen empfohlen werden. In Anbetracht der guten Langzeitergebnissen auch nach sekundärer Implantation, muss der artifizielle Sphinkter weiterhin als Goldstandard in der operativen Therapie der männlichen Inkontinenz bei manuell und kognitiv unbeeinträchtigten Patienten angesehen werden. Nach Sphinkter-Implantation können im Langzeitverlauf Kontinenzraten von 73–92 % erzielt werden. Bietet selbst der artifizielle Sphinkter keine ausreichende Kontinenz, sollte eine Harnableitung in Erwägung gezogen werden. 

Abstract

Radical prostatectomy is the most common cause of male urinary incontinence. Up to 90 % of the patients are incontinent in the early postoperative phase. This rate reduces to 3–23 % approximately 12 months after prostatectomy. Male slings and the ProACT™-Ballon system are preferred minimal invasive therapeutic options for mild to moderate incontinence. Mid-term continence rates of 50–80 % can be achieved with bone anchored and adjustable slings or the adjustable ProACT™-Ballon system. The results after radiation therapy are significantly poorer. Randomised controlled trials with longer follow-ups are necessary in order to evaluate the effectiveness of these options for continence therapy. Considering the high continence rates of 73–92 % in long-term follow-ups, the artificial urinary sphincter (AUS) still remains the gold standard in the therapy for incontinence in men with normal dexterity and mental status. In cases where continence cannot be achieved by implantation of an AUS, a urinary diversion can be taken into consideration. 

Schlüsselwörter

Prostatektomie - Inkontinenz - künstlicher Sphinkter - Harnröhrenschlinge

Key words

prostatectomy - incontinence - sphincter - male sling

Literatur

• 1 Teunissen T AM, van Weel C, Lagro-Janssen A LM. Prevalence of urinary-, fecal and double incontinence in the elderly living at home.  Int Urogynecol J. 2004;  15 10-13
• 2 Andersson G, Johansson J E, Garpenholt O et al. Urinary incontinence – prevalence, impact on daily living and desire for treatment: a population-based study.  Scand J Urol Nephrol. 2004;  38 125-130
• 3 Kundu S D, Roehl K A, Eggener S E et al. Potency, continence and complications in 3477 consecutive radical retropubic prostatectomies.  J Urol. 2004;  172 2227
• 4 Lourenco T, Pickard R, Vale L et al. Minimally invasive treatments for ­benign prostatic enlargement: systematic review of randomised controlled trials.  BMJ. 2008;  337 a1662
• 5 Bianco Jr F J, Scardino P T, Eastham J A. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (“trifecta”).  Urology. 2005;  66 83-94
• 6 Poon M, Ruckle H, Bamshad B R et al. Radical retropubic prostatectomy: bladder neck preservation versus reconstruction.  J Urol. 2000;  163 194-198
• 7 Patel V R, Coelho R F, Palmer K J et al. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes.  Eur Urol. 2009;  56 472-478
• 8 Porena M, Mearini E, Mearini L. Voiding dysfunction after radical retropubic prostatectomy: more than external urethral sphincter deficiency.  Eur Urol. 2007;  52 38-45
• 9 Teunissen D, Van Den Bosch W, Van Weel C et al. “It can always happen”: the impact of urinary incontinence on elderly men and women.  Scand J Prim Health Care. 2006;  24 166-173
• 10 Madjar S, Raz S, Gousse A E. Fixed and dynamic urethral compression for the treatment of post-prostatectomy urinary incontinence: is history repeating itself?.  J Urol. 2001;  166 411-415
• 11 Comiter C V. The male sling for stress urinary incontinence: a prospective study.  J Urol. 2002;  167 597-601
• 12 Fassi-Fehri H, Badet L, Cherass A et al. Efficacy of the InVance male sling in men with stress urinary incontinence.  Eur Urol. 2007;  51 498-503
• 13 Ballert K N, Nitti V W. Association between detrusor overactivity and postoperative outcomes in patients undergoing male bone anchored perineal sling.  J Urol. 2010;  183 641-645
• 14 Giberti C, Gallo F, Schenone M et al. The bone-anchor sub-urethral sling for the treatment of iatrogenic male incontinence: subjective and objective assessment after 41 months of mean follow-up.  World J Urol. 2008;  26 173-178
• 15 Giberti C, Gallo F, Schenone M et al. The bone anchor suburethral synthetic sling for iatrogenic male incontinence: critical evaluation at a mean 3-year follow-up.  J Urol. 2009;  181 2204-2208
• 16 Samli M, Singla A K. Absorbable versus nonabsorbable graft: outcome of bone anchored male sling for post-radical prostatectomy incontinence.  J Urol. 2005;  173 499-502
• 17 Comiter C V. The male perineal sling: intermediate-term results.  Neurourol Urodyn. 2005;  24 648
• 18 Castle E P, Andrews P E, Itano N et al. The male sling for post-prostatec­tomy incontinence: mean followup of 18 months.  J Urol. 2005;  173 1657-1660
• 19 Fisher M B, Aggarwal N, Vuruskan H et al. Efficacy of artificial urinary sphincter implantation after failed bone-anchored male sling for postprostatectomy incontinence.  Urology. 2007;  70 942-944
• 20 Guimarães M, Oliveira R, Pinto R et al. Intermediate-term results, up to 4 years, of a bone-anchored male perineal sling for treating male stress urinary incontinence after prostate surgery.  BJU Int. 2009;  103 500-504
• 21 Romano S V, Metrebian S E, Vaz F et al. An adjustable male sling for treating urinary incontinence after prostatectomy: a phase III multicentre trial.  BJU Int. 2006;  97 533-539
• 22 Romano S V, Metrebian S E, Vaz F et al. [Long-term results of a phase III multicentre trial of the adjustable male sling for treating urinary incontinence after prostatectomy: minimum 3 years].  Actas Urol Esp. 2009;  33 309-314
• 23 http://http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Incontinence.pdf
• 24 Sousa-Escandón A, Cabrera J, Mantovani F et al. Adjustable suburethral sling (male remeex system) in the treatment of male stress urinary incontinence: a multicentric European study.  Eur Urol. 2007;  52 1473-1479
• 25 Sousa-Escandon A, Rodriguez Gomez J I, Uribarri Gonzalez C et al. Externally readjustable sling for treatment of male stress urinary incontinence: Points of technique and preliminary results.  J Endourol. 2004;  18 113-118
• 26 Schaeffer A J, Clemens J Q, Ferrari M et al. The male bulbourethral sling procedure for post-radical prostatectomy incontinence.  J Urol. 1998;  159 1510-1515
• 27 Davies T O, Bepple J L, McCammon K A. Urodynamic changes and initial results of the AdVance male sling.  Urology. 2009;  74 354-357
• 28 John H, Blick N. Mid-term outcome after bulbourethral composite suspension for postprostatectomy incontinence.  Urology. 2008;  71 1191-1195
• 29 Clemens J Q, Bushman W, Schaeffer A J. Questionnaire based results of the bulbourethral sling procedure.  J Urol. 1999;  162 1972-1976
• 30 De Leval J, Waltregny D. The inside-out trans-obturator sling: a novel surgical technique for the treatment of male urinary incontinence.  Eur Urol. 2008;  54 1051-1065
• 31 Cornu J N, Sèbe P, Ciofu C et al. The AdVance Transobturator Male Sling for Postprostatectomy Incontinence: Clinical Results of a Prospective Evaluation after a Minimum Follow-up of 6 Months.  Eur Urol. 2009;  56 923-927
• 32 Hübner W A, Schlarp O M. Adjustable continence therapy (ProACT): evolution of the surgical technique and comparison of the original 50 patients with the most recent 50 patients at a single centre.  Eur Urol. 2007;  52 680-686
• 33 Hübner W A, Schlarp O M. Treatment of incontinence after prostatec­tomy using a new minimally invasive device: adjustable continence therapy.  BJU Int. 2005;  96 587-594
• 34 Gilling P J, Bell D F, Wilson L C et al. An adjustable continence therapy device for treating incontinence after prostatectomy: a minimum 2-year follow-up.  BJU Int. 2008;  102 1426
• 35 Crivellaro S, Singla A, Aggarwal N et al. Adjustable continence therapy (ProACT) and bone anchored male sling: Comparison of two new treatments of post prostatectomy incontinence.  Int J Urol. 2008;  15 910-914
• 36 Lebret T, Cour F, Benchetrit J et al. Treatment of postprostatectomy stress urinary incontinence using a minimally invasive adjustable continence balloon device, ProACT: results of a preliminary, multicenter, pilot study.  Urology. 2008;  71 256-260
• 37 Foley F EB. An artificial sphincter: A new device and operation for control of enuresis and urinary incontinence. General conside rations.  J Urol. 1947;  58 250-259
• 38 Scott F B, Bradley W E, Timm G W. Treatment of urinary incontinence by implantable prosthetic sphincter.  Urology. 1973;  1 252-259
• 39 Stoffel J T, Barrett D M. The artificial genitourinary sphincter.  BJU Int. 2008;  102 644-658
• 40 Venn S N, Greenwell T J, Mundy A R. The long-term outcome of artificial urinary sphincters.  J Urol. 2000;  164 (3 Pt 1) 702-706
• 41 Elliott D S, Barrett D M. Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: a review of 323 cases.  J Urol. 1998;  159 1206-1208
• 42 Raj G V, Peterson A C, Toh K L et al. Outcomes following revisions and secondary implantation of the artificial urinary sphincter.  J Urol. 2005;  173 1242-1245
• 43 Kim S P, Sarmast Z, Daignault S et al. Long-term durability and functional outcomes among patients with artificial urinary sphincters: a 10-year retrospective review from the University of Michigan.  J Urol. 2008;  179 1912-1916
• 44 Hajivassiliou C A. A review of the complications and results of implantation of the AMS artificial urinary sphincter.  Eur Urol. 1999;  35 36-44
• 45 Hussain M, Greenwell T J, Venn S N et al. The current role of the artificial urinary sphincter for the treatment of urinary incontinence.  J Urol. 2005;  174 418-424
• 46 O'Connor R C, Lyon M B, Guralnick M L et al. Long-term follow-up of single versus double cuff artificial urinary sphincter insertion for the treatment of severe postprostatectomy stress urinary incontinence.  Urology. 2008;  71 90-93
• 47 O’Connor R C, Gerber G S, Avila D et al. Comparison of outcomes after single or double cuff artificial urinary sphincter insertion.  Urology. 2003;  62 723-726
• 48 García Montes F, Knight S L, Greenwell T et al. [“Flowsecure” artificial urinary sphincter: a new adjustable artificial urinary sphincter concept with conditional occlusion for stress urinary incontinence].  Actas Urol Esp. 2007;  31 752-758
• 49 Aaronson D S, Elliott S P, McAninch J W. Transcorporal artificial urinary sphincter placement for incontinence in high-risk patients after treatment of prostate cancer.  Urology. 2008;  72 825-827
• 50 Henry G D, Graham S M, Cornell R J et al. A multicenter study on the perineal versus penoscrotal approach for implantation of an artificial uri­nary sphincter: cuff size and control of male stress urinary incontinence.  J Urol. 2009;  182 2404-2409
• 51 Murless B C. The injection treatment of stress incontinence.  Br J Obstet Gynaecol. 1938;  45 67
• 52 Hurtado E A, McCrery R J, Appell R A. Complications of ethylene vinyl alcohol copolymer as an intraurethral bulking agent in men with stress urinary incontinence.  Urology. 2008;  71 662-665
• 53 Westney O L, Bevan-Thomas R, Palmer J L et al. Transurethral collagen injections for male intrinsic sphincter deficiency: the University of Texas-Houston experience.  J Urol. 2005;  174 994-997
• 54 Klutke J J, Subir C, Andriole G et al. Long-term results after antegrade collagen injection for stress urinary incontinence following radical retropubic prostatectomy.  Urology. 1999;  53 974
• 55 Faerber G J, Richardson T D. Long-term results of transurethral collagen injection in men with intrinsic sphincter deficiency.  J Endourol. 1997;  11 273
• 56 Smith D N, Appell R A, Rackley R R et al. Collagen injection therapy for post-prostatectomy incontinence.  J Urol. 1998;  160 364