Prostatic Diseases and Male Voiding Dysfunction AdVance/AdVance XP Transobturator Male Slings: Preoperative Degree of Incontinence as Predictor of Surgical Outcome L. Domınguez-Escrig, Argimiro Collado Serra, Luıs Resel Folkersma, Jose n Alvaro Gomez-Ferrer, Jose Rubio-Briones, and Eduardo Solsona Narbo OBJECTIVE MATERIALS AND METHODS
RESULTS
CONCLUSION
To evaluate the efficacy of the AdVance transobturator male sling in the treatment of male stress urinary incontinence and to identify the preoperative predictors of a successful outcome. All patients were considered for sling placement 1 year after radical prostatectomy or transurethral resection of the prostate. The degree of incontinence was assessed using the 24-hour pad weight test. A preoperative urodynamic assessment and cystoscopy were performed in all cases. Patients without sphincter contractions during the “repositioning test” were excluded. Since September 2010, we have implanted the AdVance XP transobturator sling. Cure was defined as no pad use. From February 2008 to June 2011, 61 patients underwent transobturator sling (34 AdVance and 27 AdVance XP) insertion. In 26 cases, the sling was anchored with bioabsorbable sutures, and in 35 cases, it was not fixed. Of the 61 patients, 7 had a history of anastomotic stricture and 3 of radiotherapy. Preoperatively, median 24-hour pad weight was 200 g (range 25-1848). Finally, 26 patients had detrusor overactivity or low bladder compliance. The median follow-up was 26 months (range 12-53). The overall cure rate was 80% (49 of 61). Deterioration of continence was observed during follow-up in 2 patients. The preoperative variables (age, body mass index, 24-hour pad weight, International Consultation on Incontinence Questionnaire-Short Form, adverse urodynamics, sling fixation, AdVance XP) and their association with the surgical outcome were analyzed. The preoperative 24-hour pad weight correlated inversely with the outcome (odds ratio 0.996), with a 0.4% decrease in cure rate for each 1-g increase in the preoperative 24-hour pad weight. The complications included perineal hematoma in 2, acute urinary retention in 9, perineal numbness in 5, and de novo storage symptoms (urgency) in 5 patients. The results of our study have shown that the AdVance and AdVance XP male slings are safe and efficient in patients with mild postprostatectomy stress incontinence. The severity of incontinence was the only predictor of a successful outcome. UROLOGY 81: 1034e1039, 2013. 2013 Elsevier Inc.
S
tress urinary incontinence is a possible complication of radical prostatectomy.1 Adequate sphincter function depends on a healthy urothelium and urethral wall, functional smooth and striated muscle, and the correct position and support of the membranous urethra and pelvic floor.2 After radical prostatectomy, readaptation of these mechanisms is necessary, contributing to a progressive improvement in continence.1,3 Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Fundacion Instituto Valenciano de Oncologıa, Valencia, Spain; and Department of Urology, Hospital Clınico San Carlos, Madrid, Spain Reprint requests: Argimiro Collado Serra, Ph.D., Department of Urology, Fundacion Instituto Valenciano de Oncologıa, C/ Professor Beltran Baguena 8, Valencia 46009, Spain. E-mail:
[email protected] Submitted: September 20, 2012, accepted (with revisions): January 4, 2013
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ª 2013 Elsevier Inc. All Rights Reserved
At present, the artificial urinary sphincter (AUS) remains the preferred therapeutic option.4,5 However, this technique is not free of complications.5 In an attempt to avoid such complications, novel surgical techniques have been reported. The initial results with the AdVance male transobturator sling were published by Rehder and Gozzi6 in 2007. According to their theory, its mechanism of action is based on the relocation of the external urethral sphincter within the pelvis.6 Suburethral slings have been associated with less frequent and potentially less severe complications.7,8 Nevertheless, the published available data to date have been from smaller series with generally shorter follow-up. The aim of the present study was to evaluate our experience with the AdVance and AdVance XP male 0090-4295/13/$36.00 http://dx.doi.org/10.1016/j.urology.2013.01.007
transobturator slings, with a particular emphasis on the preoperative predictors of a successful surgical outcome.
MATERIAL AND METHODS From February 2008 to June 2011, 61 consecutive male patients with stress urinary incontinence were included in the present study. All patients had already been treated, unsuccessfully, with pelvic floor rehabilitation and pharmacologic therapy (duloxetine).3 The patients were considered for the present study only if they had undergone radical prostatectomy (established stress urinary incontinence) >1 year previously, thus, avoiding interference with the natural recovery period. Continence was assessed using the 24-hour pad weight (24h-PW) test, with 2 different measurements 2 weeks apart, and the International Consultation on Incontinence QuestionnaireShort Form (ICIQ-UI SF). The ICIQ-UI SF measures the frequency and volume of leakage and its effect on the quality of life. It is a very robust test, it has been validated in the Spanish language, and it has published evidence of its validity, reliability, and sensitivity to change.9 All included patients were continent at night and at rest. Except in isolated cases, patients with a 24hPW >400 g were considered for an AUS. Urinary culture was negative in all cases. A preoperative urodynamic assessment and flexible cystoscopy were performed in all cases. Urodynamic study (Medical Measurement Systems Solar, Enschede, The Netherlands) was performed according to the International Continence Society criteria.10 Detrusor overactivity, poor bladder compliance, the abdominal leak point pressure, outflow obstruction, and bladder contractility were recorded. Flexible cystoscopy allowed direct visualization of the vesicourethral anastomosis (stricture, rigidity), ruling out intravesical pathologic features (radiation cystitis), and evaluation of the sphincteric function, using the “repositioning test.” In the repositioning test, the midperineal area is digitally elevated, in a direction parallel to the membranous urethra, to check for possible circumferential closure of the sphincter. Repositioning of the urethra induces an autonomous concentric sphincter closure and is considered positive when the closed segment is superior to 1-1.5 cm in length.2,11 Patients without a sphincter contraction during the “repositioning test” were excluded. Poor sphincter function and pelvic radiotherapy (6 months minimum interval) were considered only relative contraindications. In contrast to other investigators, we did not consider the presence of urodynamic detrusor overactivity or previous surgery as contraindications.7,12 When flexible cystoscopy preoperatively diagnosed an anastomotic stricture, we performed a cold knife deep stricture incision, followed by clean intermittent catheterization to stabilize the stricture for a minimum of 6 months. Stabilization of the anastomosis was determined by cystoscopy before AdVance/AdVance XP surgery.8 From September 2010, we implanted the AdVance XP sling, which incorporates certain improvements. These include polypropylene mesh optimized for significant tension and a broad center, allowing fixation to the corpus spongiosum; 2 longlasting absorbable sutures with multiple knots and strengthened heat-sealed mesh edges; a chevron tissue-anchoring mechanism; a Tyvek liner incorporated inside plastic sheath; longer mesh arms to improve the ease of use in larger patients; and a helix diameter and needle tip angle, optimized for the male pelvis. UROLOGY 81 (5), 2013
All patients provided written informed consent. With antibiotic prophylaxis (tobramicin and co-amoxiclav), surgery was performed by 2 surgeons (A.C.S. and L.R.F.). The patient was placed in the dorsal lithotomy position, and the perineal skin was cleansed with a surgical betadine scrub for 10 minutes. The bulbospongiosus muscle was incised in its longitudinal axis. Once having identified the central tendon and marking its origin, its fibrous portion was severed proximally, allowing correct mobilization of the bulb. A helical rounded tip needle was introduced along the lateral edge of the pubic ramus, pointing toward and coming out at the uppermost corner between the urethral bulb and inferior pubic ramus.2 The edge of the proximal flap of the sling should be located at the origin of the previously marked central tendon. In 26 cases, it was anchored with bioabsorbable sutures (L.R.F), and in 35 cases, the sling was not fixed (A.C.S.). Next, the sling was put under tension while observing the proximal mobilization of the bulb. Finally, the sling was tunneled to avoid migration.2 In 1 case, we performed a synchronous insertion of an AMS-700 penile inflatable prosthesis. After insertion of the suburethral sling, we implanted the penile prosthesis using a penoscrotal incision.13,14 Postoperatively, a 16F Foley urinary catheter was left in place for 48 hours to avoid acute urinary retention (AUR), defined as a postvoid residual urine volume >150 mL.12 Steroids (prednisone in decreasing doses, 30 mg/d orally for 3 days, 20 mg/d orally for 3 days, and 10 mg/d orally for 3 days) were given to prevent perineal edema and facilitate voiding. Initially, the flow rate and postvoid residual urine volume were routinely measured. Currently, these tests are only performed if clinical suspicion is present.8 Postoperative complications were evaluated according to the Clavien classification of surgical complications.15 Follow-up examinations were performed every 3 months for the first year and every 6 months thereafter, in parallel with the oncologic follow-up protocol (prostate-specific antigen measurement, 24h-PW, and ICIQ-UI SF). Cure was defined as no pad use. Improvement was defined as a 24h-PW reduction of 50%. All other outcomes were defined as failures. Statistical analysis of the quantitative variables was assessed using a 2-tailed Student’s t test and of the qualitative variable using the chi-square test. A logistic univariate regression model was used to assess the potential predictors of a successful surgical outcome. Statistical significance was defined as P 30 Cystometry Normal Low bladder compliance Detrusor overactivity Pressure-flow* Normal Detrusor underactivity Acontractile detrusor 24-h Pad weight test (g) 400 Pads/d 1 2 3 ICIQ-UI SF 12 13-17 18 Radiotherapy No Yes Anastomotic stricture treated No Yes Repositioning test Complete coaptation Weak coaptationy
15 (25) 32 (52) 14 (23) 35 (57) 5 (8) 21 (35) 49 (80) 9 (15) 3 (5) 26 (43) 30 (49) 5 (8) 20 (33) 17 (28) 24 (39) 14 (23) 18 (30) 29 (47) 58 (95) 3 (5) 54 (88) 7 (12) 47 (77) 14 (23)
BMI, body mass index; ICIQ-UI SF, International Consultation on Incontinence Questionnaire-Short Form Data presented as n (%). * Bladder outflow obstruction ruled out in all cases. y Poor sphincter function.
radiotherapy (70 Gy) for recurrent prostate cancer after radical prostatectomy (prostate-specific antigen level >0.4 ng/mL and prostate-specific antigen doubling time >9 months). The preoperative evaluation revealed anastomotic stricture in 7 patients. The strictures were treated cold knife deep stricture incision and followed up with dilations and cystoscopy at 6 months. In 1 case, we performed a synchronous insertion of an AMS-700 penile prosthesis. Preoperatively, flexible cystoscopy confirmed a positive “repositioning test” in all 61 patients; however, in 14 patients (23%), the closure was incomplete. The preoperative median ICIQ-SF score was 16 (range 5-21), and the median 24h-PW was 200 g (range 25-1848), including 5 patients with a 24h-PW >400 g, who refused AUS placement. At the first follow-up appointment (3 months postoperatively), 49 patients (80%) were considered to be cured, with 12 (20%) remaining incontinent. However, 5 of these 12 patients recorded a 50% improvement of their incontinence (8%). The success rate in patients with a 24h-PW 400 g/d (n ¼ 5). Overall, surgery resulted in a reduction of the median ICIQ-SF score from 16 (range 5-21) to 3 (range 0-21), before and after surgery, respectively. Among those patients considered to be cured, the median ICIQ-UI SF score decreased from 15 (range 5-21) to 0 (range 0-7). In those patients considered to have treatment failure, a modest reduction in the median ICIQ-SF score from 18 (range 11-21) to 15 (range 0-21) was observed. The postoperative complications are summarized in Table 2. We observed 9 cases of AUR. All AUR occurred within the first 3 days after catheter removal and had resolved with urethral catheterization and a subsequent successful trial without the catheter within 5 days. Of these 9 cases of AUR, 6 (66.6%) occurred before the introduction of steroid therapy. During follow-up, only 1 of those 9 patients continued to complain of symptoms and urodynamic features suggestive of outflow obstruction. Perineal discomfort was recorded in 5 patients (8%), of whom, only 1 required occasional analgesia and was completely continent. Urgency was reported by 5 patients (8%) after surgery, with preoperative urodynamic evidence of detrusor overactivity in only 1 of them. However, all 5 responded to anticholinergic treatment. The potential predictors of a successful surgical outcome are listed in Table 3. Because of the limited number of patients, previous incontinence surgery with ProACT (2 of 2 cured), and previous transurethral resection of the prostate (3 of 3 cured) were not included in the statistical analysis. In the case of previous ProAct insertion, we removed it during the AdVance surgery and increased fibrosis or decreased urethral mobility was not observed. Although, the “repositioning test” was positive in all cases, the analysis accounted for differences between those with complete or weak coaptation. Also, the use of fixation or no fixation of the sling and the type of implant (AdVance vs AdVance XP) were included in the analysis. During the follow-up period, we observed 2 cases of some deterioration of continence in those cured by surgery (5 and 30 months postoperatively). Furthermore, at the last follow-up date, no recurrent anastomotic stricture, urethral sling erosion, or any other recognized late complication has been reported.
COMMENT Sphincteric dysfunction after radical prostatectomy can be the result of 1 of the following insults: direct injury to the sphincter or its inervation, shortening of the membranous urethra, and sphincter complex displacement.16 The latter is potentially explained by a postoperative incompetence of the posterior structures that support the urethra (Denonvillier’s fascia, the rectourethralis muscle, the perineal body, and the levator ani complex).17 UROLOGY 81 (5), 2013
Table 2. Postoperative complications (Clavien classification of surgical complications) Complication
Grade
Acute urinary retention Perineal-scrotal pain* Perineal hematoma De novo urgency
Patients (%)
I I I II
9 5 2 5
(15) (8) (3) (8)
Data in parentheses are percentages. * One patient required analgesia (grade II).
Table 3. Risk factors associated with surgical outcome Parameter Age BMI Interval from prostatectomy to sling placement ICIQ-UI SF score 24-h Pad weight test Radiotherapy Weak sphincter coaptation Adverse urodynamics Sling fixation AdVance vs AdVance XP
OR
95% CI
P Value
1.043 0.924-1.178 .497 0.978 0.808-1.184 .817 1.007 0.980-0.999 .610 0.861 0.996 0.104 1.622 0.690 0.952 1.141
0.723-1.025 0.992-0.999 0.009-1.263 0.311-8.460 0.194-2.448 0.265-3.424 0.318-4.096
.092 .018* .076 .566 .565 .940 .840
CI, confidence interval; OR, odds ratio; other abbreviations as in Table 1. * Statistically significant.
Rehder and Gozzi6 postulated that the AdVance implant corrects the weakness of the posterior support. After sling insertion, endoscopy demonstrated a forward displacement of the bulb of 3-4 cm toward the pelvis. According to their theory, this forward displacement improves sphincteric function by increasing coaptation at the membranous urethra.6 Hence, the importance of objectively recording sphincteric function before surgery.2 Nevertheless, incomplete coaptation is not a contraindication to surgery, as demonstrated in our series, in which 12 of 14 patients (86%) with only partial coaptation were cured. The Advance sling is not an obstructive device. Davies et al18 and Soljanik et al19 performed urodynamic assessments after surgery, demonstrating no changes in the pressure-flow parameters. However, an objectively demonstrated elevation of the abdominal leak point pressure occurs after surgery, a phenomenon already demonstrated with the earlier suburethral InVance device.20 Rehder and Gozzi6 have described fixation of the sling to the urethral bulb after severing the central tendon. In our series, it was not fixed in 35 cases to avoid a potential lesion to the bulb during traction. Despite reports associating early and late sling mobilization with treatment failure,7 at the last follow-up point, we had not observed any significant differences. The published cure rates have varied, depending on the definition criteria applied in each study. Soljanik et al,12 Cornu et al,21 Rehder et al,22 Rapoport et al,23 UROLOGY 81 (5), 2013
and Bauer et al,24 reported a cure rate of 47%, 62%, 73.7%, 86%, and 51.6%, respectively. In our series, we demonstrated a comparable cure rate of 80%. The degree of incontinence was the most important preoperative predictor of the outcome.2 This correlation had already been reported by Fischer et al25 for another type of sling, the bone-anchored male perineal sling (InVance). Bauer et al24 observed that, compared with the overall 51.6% cure rate, the cure rate was only 28.5% in patients with >200 g on the 24h-PW test. In our study, we found a significant correlation (P ¼ .018) between the preoperative degree of incontinence and the surgical outcome (odds ratio 0.996), demonstrating that for each 1-g increase on the 24h-PW test, the cure rate decreased by 0.4%. Thus, the chance of cure will be 80% lower for a patient with a 24h-PW of 400 g than for a patient with a 24h-PW of 200 g. Because the success rate decreases to 40% for patients with a 24h-PW >400 g, we believe an AUS is indicated for such cases. Other factors that have correlated with successful surgical outcomes include incomplete sphincteric coaptation and impaired urethral mobility secondary to fibrosis or rigidity (anastomotic stricture and pelvic radiotherapy).19,24,26 Pelvic radiotherapy, in particular, can produce stenosis, a loss of elasticity, and reduced mobility.27 In our limited experience, we observed fibrosis during bulbar dissection, and, in 2 of the 3 cases, surgery was unsuccessful. At present, although potentially a cause of fibrosis, a history of surgical treatment is not yet considered a contraindication for surgery.22 The presence of underlying urodynamic abnormalities and its effect on the surgical outcome remains controversial. Although Bauer et al7 regarded them as exclusion criteria, Trigo et al4 and Soljanik et al12 failed to demonstrate any clear correlation between the urodynamic parameters and outcome. We could not identify any correlation between the urodynamic findings and surgical outcomes. Intraoperative complications are rare, with only a few isolated reported cases of urethral injury.7 To avoid these injuries, it is important to protect the pathway and the rotation of the needle. Postoperative complications are generally transient and of low severity.7 The reported AUR rates have ranged from 5% and 23%. It could be the result of postoperative transient urethral edema and/or detrusor muscle weakness that could occur after a period of incontinence.12,22,24 Soljanik et al12 reported that no obstruction was found in patients who experienced transient AUR in the early postoperative period. In our series, 9 patients experienced AUR. We now routinely administer steroids to decrease the urethral edema. The clinical benefits of perioperative treatment with steroids have been demonstrated, including minimizing surgical stress and reducing edema without increasing the risk of complications or infections of the prosthesis.28,29 Generally, perineal and scrotal pain, reported in 10%-19% of cases, tends to disappear within the first 3 months.22,24,26 Collado et al8 believe that 1037
complete transaction of the midline raphe, decreasing the perineal tension, will make this complication less likely than with the InVance sling. Only a few cases of obstruction requiring reoperation, with cutting of the sling, have been reported.7 In our study, although 12 patients demonstrated anomalies during the voiding phase, only 1 patient developed outflow obstruction. Equally, the reported incidence of de novo detrusor overactivity has been low (1.8% reported by Soljanik et al12 and 8% demonstrated in our series). Although limited by the short follow-up period, it appears that the late complication rates were low. The AUS has been associated with cuff erosion in 6.0%, urethral atrophy in 9.6%, mechanical failure in 6.0%, and surgical removal or revision in 27.1%.5 In the case of the AdVance sling, Bauer et al7 reported a 1.3% removal rate, and Harris et al30 reported 1 case. In our series, we have not yet observed any late sling complications. The AdVance sling is not a compressive device and the thickness of the urethral bulb is preserved, both of which could have a protective effect. In our series, we had 12 treatment failures. Of these 12 patients, 10 declined any additional treatment and 2 underwent additional surgery with placement of the AMS-800. Contemporary published series have also reported the possibility of implanting a second AdVance sling without removing the first sling.19
CONCLUSION AdVance male sling placement is a safe and efficient technique in patients with mild postprostatectomy stress incontinence. Although a detailed preoperative assessment is mandatory, the severity of the preoperative incontinence, as measured using the 24h-PW test, was the only predictor of a successful surgical outcome in our study. References 1. De Ridder D, Rehder P. The AdVance (r) male sling: anatomic features in relation to mode of action. Eur Urol Suppl. 2011;10: 383-389. 2. Rehder P, Webster GD. The AdVance (r) male sling: patient selection and workup. Eur Urol Suppl. 2011;10:390-394. 3. Collado A, Rubio-Briones J, Puyol M, et al. Postprostatectomy established stress urinary incontinence treated with duloxetine. Urology. 2011;78:261-266. 4. Trigo RF, Gomes CM, Mitre AI, et al. A prospective study evaluating the efficacy of the artificial sphincter AMS 800 for the treatment of postradical prostatectomy urinary incontinence and the correlation between preoperative urodynamic and surgical outcomes. Urology. 2008;71:85-89. 5. Lai HH, Hsu EI, Teh BS, et al. 13 Years of experience with artificial urinary sphincter implantation at Baylor College of Medicine. J Urol. 2007;177:1021-1025. 6. Rehder P, Gozzi C. Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol. 2007; 52:860-866. 7. Bauer RM, Mayer ME, May F, et al. Complications of the AdVance transobturator male sling in the treatment of male stress urinary incontinence. Urology. 2010;75:1494-1498.
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8. Collado A, Gomez-Ferrer A, Rubio-Briones J, et al. [Which patients with stress urinary incontinence after radical prostatectomy benefit from the indication of an InVance?]. Arch Esp Urol. 2009;62: 851-859. 9. Staskin D, Kelleher C, Avery K, et al. Patient-reported outcome assessment. In: Abrams PH, Cardozo L, Khoury S, Wein A, eds. Incontinence. 4th ed. Paris: Health Publications; 2009:363-412. 10. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167-178. 11. Bauer RM, Mayer ME, Gratzke C, et al. Prospective evaluation of the functional sling suspension for male postprostatectomy stress urinary incontinence: results after 1 year. Eur Urol. 2009;56: 928-933. 12. Soljanik I, Becker AJ, Stief CG, et al. Urodynamic parameters after retrourethral transobturator male sling and their influence on outcome. Urology. 2011;78:708-714. 13. Gorbatiy V, Westney OL, Romero C, et al. Outcomes of simultaneous placement of an inflatable penile prosthesis and a male urethral sling through a single perineal incision. J Sex Med. 2010;7: 832-838. 14. Christine B, Wilson SK, Shamloul R, et al. Simultaneous placement of an inflatable penile prosthesis and AdVance male sling for erectile dysfunction and incontinence: robust efficacy and safety data at 2 years follow up. J Urol. 2010;183(suppl 4): e490. 15. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-213. 16. Paparel P, Akin O, Sandhu JS, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol. 2009;55: 629-637. 17. Walz J, Burnett AL, Costello AJ, et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol. 2010;57:179-192. 18. Davies TO, Bepple JL, McCammon KA. Urodynamic changes and initial results of the AdVance male sling. Urology. 2009;74: 354-357. 19. Soljanik I, Becker AJ, Stief CG, et al. Repeat retrourethral transobturator sling in the management of recurrent postprostatectomy stress urinary incontinence after failed first male sling. Eur Urol. 2010;58:767-772. 20. 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 followup. J Urol. 2009;181: 2204-2208. 21. Cornu JN, Sebe 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. 22. Rehder P, Mitterberger MJ, Pichler R, et al. The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence. BJU Int. 2010;106: 1668-1672. 23. Rapoport D, Walter JR, Borawski KM, et al. The AdVance male sling: predictors of success. J Urol. 2009;181(suppl):619. 24. Bauer RM, Soljanik I, Fullhase C, et al. Mid-term results for the retroluminar transobturator sling suspension for stress urinary incontinence after prostatectomy. BJU Int. 2011;108:94-98. 25. Fischer MC, Huckabay C, Nitti VW. The male perineal sling: assessment and prediction of outcome. J Urol. 2007;177:1414-1418. 26. Cornu JN, Sebe P, Ciofu C, et al. Mid-term evaluation of the transobturator male sling for post-prostatectomy incontinence: focus on prognostic factors. BJU Int. 2011;108:236-240.
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27. Zelefsky MJ, Chan H, Hunt M, et al. Long-term outcome of high dose intensity modulated radiation therapy for patients with clinically localized prostate cancer. J Urol. 2006;176:1415-1419. 28. Hatef DA, Ellsworth WA, Allen JN, et al. Perioperative steroids for minimizing edema and ecchymosis after rhinoplasty: a meta-analysis. Aesthet Surg J. 2011;31:648-657.
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29. Niedermeier K, Braun S, Fauser C, et al. A safety evaluation of dexamethasone-releasing cochlear implants: comparative study on the risk of otogenic meningitis after implantation. Acta Otolaryngol. 2012;132:1252-1260. 30. Harris SE, Guralnick ML, O’Connor RC. Urethral erosion of transobturator male sling. Urology. 2009;73:443.
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