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THE JOURNAL OF FEMALE
URINARY INCONTINENCE


Review Articles
 
 

Sub Urethral Readjustable Bands (REMEEX ®) in the treatment of urinary incontinence

Vila, F.C.A., Gomes, M.J., Versos, R.S., Marcelo, F.
Unit Urogynecology, Urodynamics and Neurourology
Urology Department
Hospital Geral de Santo António – Porto – Portugal.

 

Introduction

The pubovaginal sub urethral slings are used in the treatment of female urinary incontinence since the beginning of the last century. The introduction of synthetic grafts in clinical practice reduced the morbidity and surgical time associated with the procedure, with good clinical results. Since the development of the integral theory by Ulmsten and Petros, in the past decade, the sub urethral slings are the procedure of choice for the treatment of most patients with urinary incontinence. Nowadays they also have a major role in the treatment of male incontinence. The degree of support provided by the sling to the urethra is a delicate surgical step1. The main goal is to achieve complete continence without significant obstruction to urine flow, wich is sometimes a complex task. Sub urethral slings are the most common cause, in females, of infravesical of obstruction in current urological practice, with development of “de novo” emptying and storage symptoms in 2 to 24 % of the patients2. This fact may imply a second surgical procedure to resolve the patient’s complaints. A mechanism that allows to increase or ease the pressure exerted by the sling on the urethra in the short and medium term may have a role in this setting. These kind of slings, originally from Spain, are available in the market since the ending of the last decade3.


Material and Methods

A review of the applicability of the Sub Urethral Readjustable Bands (SURB) in male and female stress urinary incontinence was done. (REMEEX ®) (EXternal MEchanical REgulation) (Figure 1) is a sub urethral monofilamentar polypropylene prosthesis coupled to a pressure adjusting device (Varitensor) trought two monofilamentar threads, allowing to adjust postoperatively the degree of obstruction exerted on the urethra by the sling. The varitensor mechanism is a permanent implant that is placed over the abdominal rectus muscles fascia that when connected to an external handler allows moving up or down the sling.
In women the surgical procedure is similar to the "Tension free vaginal tape” (TVT):

  • Monofilamentar threads are introduced via perineal and parauretral route into the suprapubic region.
  • Mandatory cystoscopy to rule out bladder injuries.
  • Sub urethral prosthesis is then connected trought the threads to the Varitensor, placed over the rectus abdominis fascia.
  • The abdominal incision is closed, leaving the handler outside the skin no more than three days.


In the first post operative day, the pressure of the sling is readjusted by using a "stress test" with full bladder and the patient in supine position. The goal is to achieve enough pressure to prevent urinary losses without increases in the post voiding residual volume. The handler is removed before hospital discharge. If subsequent adjustments of the sling are necessary they are done in an office setting, under local anaesthesia. The external handler is reconnected to the system and rotated clockwise in order to raise the sling level, increasing the degree of obstruction, while its rotation in the opposite direction, along with pressure exerted on the urethra with a rigid bladder catheter causes the opposite effect. These late readjustments are advised to be conducted, if necessary, with a two month time away from the surgery in order to prevent any infectious complications4.
The pathophysiology of urinary incontinence (UI) in males depends mainly on the severity neuromyovascular sphincteric injury. The Artificial Urinary Sphincter (AUS) is nowadays the treatment of choice in moderate to severe UI. Bulking system and balloons such as Pro-Act® have poor success rates in these kinds of patients. The sub urethral slings, bone attached or by transobturator route, begins to appear as valid options to these men, with satisfaction rates of up to 90%.
The male REEMEX® surgical procedure is carried out trough a perineal approach4, with dissection of the bulbar urethra. The monofilamentar threads are introduced from there, parallel to the urethra, near the inner side of each isquiopubic branch until they reach the suprapubic area, using two modified Stamey needles. Cystoscopy, such as in the female procedure, is mandatory. The prosthesis is fixed, with absorbable stitches, to the bulbar urethra, in one piece with the bulbocavernous muscle. The Varitensor mechanism is ultimately connected to the sub urethral prosthesis in a similar way as already described in females REEMEX®.

Discussion

SURB are currently used in the treatment of female and male urinary incontinence. For females there is growing experience, particularly in patients with intrinsic sphincter insufficiency5, failed previous surgical treatment and those with associated genital prolapses that warrants surgical correction. There are also clinical groups using this kind of system in patients with urethral hyper mobility ad initium. Currently there are no prospective randomized studies available comparing REMEEX® with the other commercially available surgical techniques. The Spanish groups are those with more experience worldwide. In one of the greatest multicentric available series6, a total of 683 women from 15 Spanish hospitals were evaluated, including patients with intrinsic sphincter insufficiency, mixed incontinence, surgical retreatment, and patients with pelvic floor surgical associated with the urinary incontinence surgical correction. Along with the sling tension adjustment on the first few days after surgery, it was required to readjust the sling tension 6 months latter, under local anaesthesia, in 32 patients, in order to improve continence, and for relief of storage and emptying symptoms (release sling pressure on the urethra) respectively on 3 and in 2 cases with good clinical outcome; the global cure rate was 92%.
Male series are more recent, with very limited numbers. In moderate to severe iatrogenic urinary incontinence, the readjustable meshes have an overall effectiveness of about 65% (patients completely dry) with satisfactions rates around 85%. Bladder perforation is the most frequently reported complication, along with a few reports of erosion of the bulbar urethra and suprapubic persistent seroma (resolved by removing the Varitensor).

Conclusions

The SURB are a valid therapeutic option with low morbidity, good reproducibility and effectiveness in the treatment of urinary incontinence. Available experience, especially in females, is mainly available on clinical settings where other techniques have higher rates of failure and where the readjustment possibility of the sling tension is an important asset. The SURB (type REMEEX®) also present themselves as a recent and valid technique in the treatment of male urinary incontinence7, mainly iatrogenic, with satisfaction rates of 85% and low complication rates. In women their main application is on recurrent SUI or in association with detrusor hipoactivity and urogenital prolapses. The real added clinical value of these systems needs to be further evaluated in new randomized clinical trials.


 
 
 
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Figure1–REMEEX® system:1- Polypropilene mesh; 2- Monofilamental threads;
3– Varitensor; 4- Handler

 
 
 
 
 
 
References
  1. Martínez A.M., Ramos N.M, Requena J.F., Hernández J.A.G.; Analysis of retropubic colpourethrosuspension results by suburethral sling with REMEEX prosthesis.; Eur J Obstet Reprod Biol 106 (2003) 179-183
  2. Bujons T.A., Errando S.C., Prados S.M., Báez C.A.P., Gutiérrez R.C., Villavicencio M.H.; Obstrucción infravesical trás cabestrillo tipo Remeex; Actas Urol Esp. 2006; 31 (1): 43-48
  3. Martínez A.M, Labao L., Nieto M.A., Padilla M., Cerezuela J.F., Buitrón E.L. et al. Cabestrillo suburetral regulable con prótesis REMEEX. Resultados 1999-2004. Prog Obstet Ginecol. 2006; 49 (4): 182-7.
  4. Escandón A.S., Cabrera J, Mantovani F., Moretti M., Ioanidis E., Kondelidis N. et al Adjustable suburethral sling (male remeex system) in the treatment of male stress urinary incontinence: a multicentric European study. Eur Urol. 2007 Nov; 52(5): 1473-9
  5. Dati S., Luzio F., Stefano, M., Palma D. Sling eterologa regolabile nella ISD e nella IUS recidiva. Follow-up a medio termine. Pelvi-Perin. RICP, 25, 39-40, 2006
  6. Sierra J.M., Queimadelos A.M., Beltran P.A., Pérez P.F., Requena J.F.C., Otero E.C. et al. Registro Español del sistema TRT REMEEX em mujeres con incontinencia urinaria de esfuerzo. Arch. Esp. Urol.., 59,2 (169-174), 2006
  7. Escadón A.S., Rodríguez J.I.G., Uribarri G.C., Queimadelos A.M. Externally readjustable sling for treatment of male urinary incontinence: points of technique and preliminary results. J Endourol, 2004 Feb; 18 (1) ; 113-8.