Presentation Authors: Gregory Dean*, Nathan Peffer, Ziho Lee, Martin Herman, Voorhees, NJ
Introduction: Treatment of urinary incontinence from inadequate coaptation of the bladder neck or sphincter can be challenging. Techniques for reconstruction include bladder neck reconstruction, bladder neck bulking and compressive slings. We believe that the more anterior the sling placement, the better its compressive effects because of the better backing of the pubis. To develop a more anterior approach, we have devised a compressive sling placed through a novel peno-scrotal approach. This increases ease of placement with the potential for improved compressive efficacy
Methods: A 9 year old boy with lumbar sacral myelomeningocele and an open bladder neck diagnosed by video urodynamics, presented to our clinic. Adequate bladder capacity was confirmed. He had previously undergone a Mitrofanoff and MACE procedure. Options were reviewed, and the family requested a compressive bulbar sling. The patient was brought to the operating room where a circumferential sub-coronal penile incision was made and a second longitudinal mid-line incision made and carried down to the penoscrotal junction. The phallus was degloved, elevating the skin from the phallus as a single dorsal sheet. The intact penoscrotal junction was retracted toward the anus exposing mid-line scrotal fat. This was divided for a short distance providing space to further retract the scrotum posteriorly. With the bulbar urethra well exposed, the ischium was exposed with blunt dissection on either side. Pilot holes were then drilled into the ischium bilaterally at a point between the margin of the corpora and the cord structures. Bone anchors were then secured and then used to attach a compressive collagen sling which was then tensioned.
Results: The procedure lasted 150 minutes and was well tolerated by the patient who was discharged that day and resumed catheterization via his Mitrofanoff. The patient was initially completely dry from below. Six months out, there has been some gradual drop-off in efficacy.
Conclusions: This novel penile sling access is easier to perform than the perineal bulbar approach. The patient is positioned supine rather than in hyper-lithotomy. The anterior position appears to be an anatomically favorable position to achieve ideal bulbar urethral compression. We believe that the drop-off in efficacy in this patient is related to choice of sling material with potential stress relaxation of the sling. This penile approach is suitable for several sling materials including fascia as well as a tendon sling which have the benefit of being resistant to stress relaxation.Because of of increased urethral compression, practitioners should be aware of the potential for urethral erosion.