Urology Centers of Alabama conducting study with sling
For three years now, Australian urologists have made a point of stopping in Birmingham for training. The draw is a local urologist, Brian Christine, MD. He’s performed over 200 procedures implanting a relatively new sling to treat incontinence in men, and that number marks him as one of the most experienced in the world.
“Slings for women have been around for decades,” says Christine, Director of Erectile Restoration and Prosthetic Urology at Urology Centers of Alabama. “Slings for men have only been around for maybe ten years, and the current version that I do has just been available since 2006.”
The older version relied on urethral compression and anchors screwed into the pelvic bone. Christine recalls it being moderately effective at about 70 to 75 percent.
With the newest version, Christine’s cure rate for men with mild to medium leakage (one to four pads per day) jumped to 88 to 90 percent.
Made of a polypropylene mesh, the sling resembles a two-centimeter-wide ribbon. It cures incontinence by repositioning the urethra. No compression, and no screws. “It’s like a hammock that supports the proximal urethra. It’s sutured to the urethra and anchored into the fascia,” Christine says.
The outpatient procedure begins with a four to five centimeter perineal incision. The sling is passed through the obturator foramen of the pelvis and is sutured to the proximal urethra. Tension on the sling repositions the urethra.
“The cure is immediate,” Christine says. “You know in the first 24 hours if the patient is continent or not. It’s a durable fix. We don’t see any evidence of decreased efficacy over time.”
Christine posits that radiation plays a role in unsuccessful outcomes. “If they’ve had radiation after their prostatectomy, they have a lower cure rate,” he says. “Radiation change on the tissue compromises the mobility of the urethra.” In those conditions, his cure rate drops to 55 percent.
But Christine adds that with some unsuccessful outcomes, a second try may yield success. “I’ve had to go back once on my own procedure to redo the sling and had one or two who were referred to me. The repeat sling worked in them all.”
Though not built to correct severe incontinence (five or more pads per day), Christine still generates a successful outcome of 65 to 70 percent in those men. “Some of the severe patients realize the sling is not ideal for their circumstance. But they want something done, and they don’t want to put up with a mechanical device, like the sphincter, in their body. They want their voiding to be as normal as possible,” he says.
If for any reason the sling does not work, the option still remains for the patient to implant an artificial urinary sphincter instead. “You haven’t burned any bridges with the sling,” Christine says.
American Medical Systems, the maker of the male AdVance sling, is bringing over a second contingent of Australian urologists this year to train with Christine. This group asked to visit Urology Centers of Alabama so they could train and also study how a large practice of urologists runs.
The Australian visits last about two days with a full day in the OR with Christine. “We typically do about five or six cases on that day,” he says. “We mix it up with a combination of penile implants and sling and sphincter procedures. I also save up really complex cases for that day, like correcting prior implant malfunctions or a combined penile implant with a sling or sphincter procedure.”
On the final morning, the Australians view other procedures. “They want to observe my partners doing robotic prostatectomies. Those are not much done in Australia yet, so they’re very interested in the robotics,” Christine says.
Urology Centers of Alabama has also begun an Institutional Review Board-approved study using the sling. Christine and the robotic surgeons are looking at the impact on incontinence of implanting a sling concurrent with performing a robotic prostatectomy. “It’s the first randomized prospective study on this,” Christine says.
So far, they have enrolled 27 of the 40 patients they need. The patients, half of whom will have a sling implanted, will be studied for one year following their surgery. “The early data is tremendously encouraging for immediate return to continence,” Christine says. “This could be a game-changer.”