The other frequent prostate operation consists in removing an adenoma (or benign prostate hyperplasia): "We leave the outer aspect of the prostate and we remove the inner “nucleus”, it is like an orange from which we remove the quarters leaving only the peel. Because the sphincters are less altered, there is less incontinence (1% after adenomectomy)". We can also use the TOM-Sling device to treat this type of incontinence but they are mainly intended for the treatment of post-radical prostatectomy incontinence.
Good results
![TOM-Sling Kit]( "TOM-Sling Kit .")
The TOM-Sling has already been implanted in 350 patients at the University Hospital of Liège. The TOM-Sling procedure is minimally invasive and associated with a high success rate (85%). Even though Professor de Leval recognizes that it is difficult to appreciate the results because the situation varies greatly from one individual to another and with that, the interpretation of the results: “What constitutes severe or mild incontinence? Some patients are totally incontinent: everything passes into urine collectors or diapers. Others suffer from mild incontinence: a small pad is applied which is barely wet while others have to use two small or large protections per day".
It is considered that mild incontinence requires maximum two pads per day, moderate incontinence between two and five protections per day and more than five protections per day are required for severe incontinence.
For the TOM-Sling, the first results were published in 2008 in European Urology(1). Prof. de Leval also operated on a series of patients (30) in Geneva, with good results that are due to be published soon.
"In our results, we included all patients treated from the beginning and we did not exclude anyone: We have a 50% total cure rate for patients (0 pad per day) and 30% showing a large improvement, that is to say less than 2 or 1 protection per day. Patients who were losing all their urine and now only 10ml per day are delighted with the results. For patients who have undergone pelvic radiation therapy or with a history of stenosis at the level of the anastomosis between the urethra and the bladder, results are less favorable. If we exclude this two categories of patients, we get a 90% success rate", explains Jean de Leval.
During the studies, the indications got better defined: it is currently advised to treat any stenosis before proceeding with a surgical cure for incontinence. After radiation therapy, tissues are modified; they lose their flexibility and become hardened. It is then necessary to exert a lot of pressure on the prosthesis in order to achieve tension which often lessens afterwards. In this case it is preferable to implant an artificial sphincter which generates better results; but even in these patients, results are lower after radiation therapy.
Safe and precise
Today, the team from Liège has treated a series of patients with very good results and a low rate of complications. "There are two reasons for this”, explains Jean de Leval: “on one hand, we use a safe anatomical route because we know that by passing through the obturator foramens there is a very small risk of damaging neighbouring neurovascular structures, and on the other hand, a significant tension needs to be applied to the mesh to have sufficient support in order to cure stress urinary leakages".
Compression of the bulbar urethra should not prevent micturition; therefore tension must be appropriately applied. The team carried out pressure measurements during the operation. "This is very original”, he says, “We are almost the only ones to do this. In order to adapt the tension to each patient, we must make what we call ‘a urodynamic investigation’ during the operation. We measure the pressure at which leakage occurs and we measure a pressure profile at the level of the urethra. For example, if you cough a little, you may experience leakage. If you apply a little pressure on the abdomen, urine can also leak out: if you have leakage for a pressure of 30cm of water, we will apply a level of tension so that when straining, a pressure of more than 100cm of water would be required for leakage to occur".
