Mechanism of Action of the Transobturator Sling for Post-Radical Prostatectomy Incontinence: A Multi-institutional Prospective Study Using Dynamic Magnetic Resonance Imaging.

OBJECTIVE: To compare the length of the membranous (functional) urethra in male patients who underwent the male transobturator sling (TOS) for postradical prostatectomy urinary incontinence (PPI). The TOS is in established use for treatment of PPI; however, the precise mechanism of action is unknown. MATERIALS AND METHODS: This is a prospective case-controlled study on men undergoing male TOS surgery from 2008 to 2014. The comparison arm included patients without incontinence after radical prostatectomy. All participants underwent dynamic magnetic resonance imaging (MRI) at baseline and this was repeated after TOS placement for those who underwent the procedure. Three standardized points were measured using MRI and compared in both groups in addition to clinical measures. RESULTS: Thirty-nine patients were enrolled and 31 patients completed the protocols. The controls (N = 14) had a longer vesicourethral anastomosis to urethra measured at the penile bulb (functional urethral length) distance compared to the pre-TOS group at rest (1.92 cm controls vs 1.27 cm pre-TOS, P = .0018) and at Valsalva (2.13 cm controls vs 1.72 cm pre-TOS, P = .0371). Placement of the sling (N = 17) increased the functional urethral length distance at rest (1.92 cm control vs 1.53 cm post-TOS, P = .09) and at Valsalva (1.94 cm post-TOS vs 2.13 cm control, P = .61), so that the difference was no longer statistically significant. CONCLUSION: We identified that one possible mechanism in improvement in stress urinary incontinence post-TOS placement is the lengthening of the vesicourethral anastomosis to bulbar-urethra distance. This is the first such study utilizing dynamics MRI in post prostatectomy controls, incontinent pre-TOS, and post-TOS to assess and show these findings.

Characteristics of genitourinary injuries associated with pelvic fractures during operation Iraqi Freedom and operation Enduring Freedom.

OBJECTIVES: Pelvic fractures are markers of severe injury and are often associated with lower genitourinary injuries. The purpose of this study was to investigate the incidence of lower genitourinary injuries and complaints associated with pelvic fractures sustained in combat among nonsurvivors and survivors. METHODS: The Armed Forces Medical Examiner System and The Joint Theater Trauma Registry databases were searched to identify survivors and nonsurvivors who sustained a pelvic fracture in combat in 2008. Survivor and autopsy data consisted of injury mode and mechanism and associated organ and extremity injuries. Pelvic fractures were classified using the Tile system. RESULTS: The database search yielded 91 nonsurvivors and 10 survivors with pelvic fractures. Forty-one patients (40%) sustained 61 genitourinary injuries. The majority of genitourinary injuries in nonsurvivors were associated with Tile C pelvic fractures (70%). Twenty percent of survivors had genitourinary injuries, all of which were associated with Tile A fractures. CONCLUSIONS: A higher incidence of genitourinary injuries in patients with combat-related pelvic fractures (60%) was found than that of their civilian counterparts. Of the survivors, 100% of those with genitourinary injuries were being treated for erectile dysfunction at their last follow-up. Continued collaboration between orthopaedic surgeons and urologist is needed to address these concurrent injuries.