it has a significant impact on the patient s quality of life ( 1 ) . post - prostatectomy urinary incontinence ( ppi ) is a potential complication of prostate surgery and although it is more frequently seen after radical prostatectomy it can also occur after endoscopic or open surgery for benign prostate hyperplasia ( bph ) ( 2 ) . initial management is usually conservative and includes the use of diapers or pads , penile clamps , or various collecting systems ( such as a condom catheter ) . mild degrees of ppi in the early postoperative period may be improved by pelvic muscle exercises , physiotherapy , and pharmacotherapy ( 3 ) . however , for most patients who have moderate to severe ppi , conservative methods are not sufficient to return to their normal lives . the present study reports our intermediate experience in men who underwent implantation of adjustable perineal male sling using a tissue expander for ppi . this prospective study was approved by the local ethics committee and a comprehensive informed consent was obtained from all the patients before the surgery . between september 2007 and may 2013 , a total of 21 men with ppi underwent implantation of adjustable perineal male sling using a tissue expander . the underlying etiologies of ppi in patients were : radical prostatectomy for prostate cancer in 13 patients ( open radical retropubic prostatectomy=12 , transperitoneal laparoscopic radical prostatectomy=1 ) , open prostatectomy in 5 patients and transurethral prostate resection for bph in 3 patients . patient evaluation consisted of medical history , physical examination , blood and urine laboratory tests . all the patients underwent a standard urodynamic study including both cystometry and pressure - flow study to evaluate bladder storage and voiding capabilities , and to exclude overactive bladder . also , an urethrocystoscopy was conducted in all the patients to exclude urethral stricture and/or bladder neck contracture . the patients who had a history of previous surgery for ppi were not included in the study . incontinence in the patients was defined according to the use of incontinence pads over a 24 hours period : mild ( using 1 to 2 pads ) , moderate ( 3 to 5 pads ) and severe ( more than 5 pads ) ( 4 ) . the post - operative follow - up was carried out in the second week and every 6 months thereafter consisting of daily pad use , physical examination , maximum urine flow rate ( qmax ) and post - voiding residual urine volume ( pvr ) measurement . all patients received prophylactic antibiotics ( 3rd generation cephalosporin ) before the induction of anesthesia . under general or regional anesthesia after the insertion of a urethral catheter , a midline perineal incision of 40 to 50 mm was made . the critical point is not to remove periurethral fat tissues from urethra . both sides of urethra a eurosilicone ( laboratoires eurosilicone , france ) tissue expander device was used with an adjustable male sling in our patients . the device contains a silicone balloon expander , a connecting tube and an inflation component ( injection port ) that allows the expander to gradually fill up to a volume of 25 ml saline solution ( figure-1b ) . figure 1a ) both sides of urethra are dissected ; b ) a balloon expander ; c ) a balloon expander between two layers of the mesh ; d ) the mesh is stapled to the pubic bone using autosuture stat tacktm ; e ) prepared scrotal pouch for placing the inflation component . 
  a standard polypropylene mesh of 100 x 100 mm was used as the sling material . first , the mesh was folded and a balloon expander was placed between the two layers of the modification . secondly , the balloon was completely filled with the saline solution , and the two layers of the mesh were sutured using 2/0 polypropylene suture to create a pocket between the two layers of the mesh ( figure-1c ) . during this procedure third , the mesh was stapled on both sides of the lower border of the pubic bone using an autosuture stat tacktm ( tyco healthcare , uk ) stapler ( figure-1d ) . the original surgical method defined by inci , et al . ( 5 ) used a polypropylene mesh that was fixed on the pubic bone with non - absorbable sutures . in our case , this method was modified and staples were used to prevent the sutures and the mesh from loosening and moving . after the sling tension was properly adjusted , the sling was placed as tightly as possible in all patients since urinary leakage had been observed in our patients postoperatively . the inflation component has two sides ( figure-1e ) . finally , the wound was closed with careful hemostasis . after the surgery , all the patients were asked to take an oral antibiotic ( 2th generation cephalosporin ) for 7 days . post - operative success was assessed by the number of pads used per 24 hours as follows ; zero to 1 safety pad - dry , 1 to 2 pads - mild , and 3 to 5 pads - moderate . at a minimum of 1 week after surgery , patients were questioned regarding their daily pad use . if incontinence persisted 7 to 10 days after surgery , tension over the urethra was increased by saline injection to expand the tissue expander via the injection port using an insulin needle . injection was started with 3 cc and increased by 2 cc at each injection . in this way the patients were asked to return 2 days after each adjustment to confirm the status of continence . the mean values of the parameters were calculated using the statistical package for social sciences version 13.0 for windows ( spss inc . , chicago , il , usa ) . the mean values of the parameters were calculated using the statistical package for social sciences version 13.0 for windows ( spss inc . , chicago , il , usa ) . the mean age of the patients was 66.27.3 ( 50 - 79 ) years and the mean pad usage was 6.40.6 ( 6 - 8 ) per day . the mean volume of the postoperatively inflated balloon was 11.65.7 ( 5 - 25 ) ml . after the follow - up period , 16 of the 21 patients ( 76.2% ) were dry ( 11 patients , 0 pads ; 5 patients using safety pads ) , 3 patients ( 14% ) had mild degree ppi and 2 patients ( 9.8% ) had moderate degree ppi . in the last assessment of the patients , qmax and estimated pvr were found to be 15.64.7 ( 10 - 31 ) ml / s and 10 ml , respectively . in these two patients , the polypropylene mesh with balloon , connecting tube and inflation component were removed and they did not undergo any additional intervention . local scrotal infection developed around the inflation component in three patients . in these patients , only the inflation component was removed , the connecting tube was clipped and the polypropylene mesh with inflated balloon was kept in place . in these patients , polypropylene mesh with inflated balloon provided suitable pressure on the urethra . in the follow - up period , they were completely dry . no complications occurred in relation to mesh erosion , voiding dysfunction , voiding difficulty or mechanical failure . six patients reported mild perineal pain in the early postoperative period but this was resolved using non - steroidal anti - inflammatory drugs . the rising elderly population and the increasing number of surgical interventions for prostate cancer mean that the incidence of ppi will rise . since its introduction in 1973 , the artificial urinary sphincter ( aus ) has been considered the gold standard treatment for stress urinary incontinence after prostatectomy , offering the patient the greatest chance of a cure ( 6 ) . the success rates of aus range from 59 to 90% ( 7 - 9 ) . although , aus is an effective and durable treatment , many patients are hesitant about implantation or refuse the procedure . most patients could not manipulate the scrotal pump ( 10 ) . furthermore , aus is expensive and requires a complex surgical procedure that is associated with significant rates of complications . a recent systematic review about aus reported that infection or erosion occurred in 8.5% of cases ( 3.327.8% ) , mechanical failure in 6.2% ( 213.8% ) , and urethral atrophy in 7.9% ( 1.928.6% ) . re - operation rate was reported to range from 14.8% to 44.8% ( 11 ) . the proact ( uromedica , us ) system was first described in 2005 by hubner et al . ( 12 ) . in theietlr study , there were 117 patients with ppi followed for a mean period of 13 months , after which 67% of the patients were found to be dry . ( 13 ) reported the results of the proact intervention in 62 men with ppi and found that 71% of the patients wore no pads or used 1 pad per day after 6 months ( following the adjustment ) . however , in 19 men the device was removed due to infection and erosion ( n=5 ) , migration ( n=1 ) , and iatrogenic traumatism ( n=2 ) . moreover , , the authors evaluated the results of proact in 114 men with ppi at a mean follow - up time of 58 months and reported an overall dry rate of 50% . in that study , complications included balloon leakage ( 11% ) , migration ( 5% ) and wound erosion ( 4% ) . the authors reported that there was a total re - operation rate of 27% , and 12% of the patients underwent aus or a urethral sling procedures due to proact not being effective . the argus ( promedon sa , argentina ) sub - urethral sling with an adjustable system is another treatment option in men with ppi that was first described by romano et al . the authors reported a cure rate of 73% and the improvement rate was 10% in 48 men with ppi after a mean follow - up of 7.5 months . ( 16 ) reported mid - term complications after the placement of the argus sling in 29 men with ppi at a mean follow - up of 35 months . overall , 24 patients ( 83% ) experienced complications , consisting of acute urinary retention ( 35% ) and removal of the sling ( 35% ) owing to urethral erosion , infection , system dislocation , urinary retention , and persistent pain . furthermore , 27% of the patients complained of significant perineal pain . the authors concluded that the argustm sub - urethral sling was associated with serious mechanical and infectious complications , and sparse functional results with negative impact on the patient s quality of life . a bone anchored sling ( bas ) compresses the bulbar urethra with a silicone - coated polypropylene mesh by attaching the sling to the inferior pubic ramus with bone screws . following initial reports of degradation of organic materials , synthetic mesh ( invance , american medical systems , us ) has become the most commonly utilized material with the bas ( 17 ) . ( 4 ) reported their results in 46 patients with ppi who undergo bas implantation . in their study , the total cure rate was 37% . furthermore , 37% of the patients significantly improved , and the treatment of 26% patients failed after an average of 24 months follow - up . they concluded that the male sling procedure is an effective and safe procedure for the management of stress urinary incontinence . guimaraes et al . ( 18 ) reported their intermediate results of up to 4 years with the invance sling . their cure rate was 65% and the improvement rate was 23% in 54 men with ppi after a mean follow - up of 28 months . the authors claimed that the invance sling offers a good intermediate cure and improvement rates with acceptably low rate of complications in patients suffering from ppi . another study investigated the use of the invance sling in 40 patients with ppi ( 19 ) . the authors observed perineal pain in 73% of the patients , detrusor overactivity in 5% and sling infection in 15% . the traditional bas procedure does not provide for the adjustment of the tension of the sling material in the post - operative period and this can result in progressive failure over time . in a study by castle et al . social continence was achieved in 67% 50% and 0% of mild , moderate and severe cases , respectively . comiter ( 20 ) speculated that the surgeons left the fatty tissue over the bulbospongious intact , and additionally used a piece of porcine dermis between the urethra and the sling a combination of fat necrosis and absorption of the dermis over time likely contributes to diminution of the compression provided by the sling over the bulbar urethra . ( 21 ) reported a median time to recurrent incontinence as 3 months after bas procedure . similarly , cespedes and jacoby reported an early failure ( within 6 months ) in 5% of their patients ( 22 ) . in another study ( 23 ) , the authors retrospectively reported objective and subjective outcomes in 40 male patients who underwent bas positioning for stress urinary incontinence due to intrinsic sphincter deficiency . patients with stress urinary incontinence due to radical retropubic prostatectomy ( n=32 ) , robot assisted laparoscopic prostatectomy ( n=3 ) and transurethral prostate resection ( n=5 ) underwent the bas procedure over a 5 years period . previous anti - incontinence procedures , radiotherapy and transurethral procedures due to urethral stricture were performed in 5 , 11 and 5 patients , respectively . at a mean follow - up of 35.2 months , 22 patients ( 55% ) were cured , the condition of 5 patients ( 12.5% ) improved and the treatment of 13 patients ( 32.5% ) failed . the authors concluded that bas is a simple and effective procedure that can produce immediate good results with low morbidity , especially when strictly selected patients are treated . an adjustable perineal male sling technique was used for the treatment of ppi as described previously ( 5 ) . in that study an adjustable perineal male sling with a 10 ml tissue expander was implanted in 19 consecutive men with severe ppi . according to the results of that study , at a mean follow - up of 17.3 months 15 patients ( 78.9% ) were completely dry and 2 ( 10.5% ) improved significantly using only 1 to 2 pads per day . a total of 11 patients required volume adjustment injections . the average number of adjustments was 2 ( range 1 to 3 ) and the average injected volume was 6.3 cc ( range 5 to 10 ) . regarding the complications , 1 patient had a superficial wound infection , 1 patient required surgical revision due to infection and 8 patients reported mild to moderate perineal pain . the authors concluded that the short term results indicate that this minimally invasive technique seems to be safe and effective , and patient satisfaction appears to be high . the same group presented their long term results in the international continence society annual meeting 2013 . in a study by ergen and ozdemir the mean follow - up time was 52 months . the completely dry rate decreased from 78.9% to 58% in the long term period . the authors concluded that adjustable male sling using a 10 ml tissue expander is an effective method for severe ppi , in the early period , but the effectiveness gradually decreases in the long term . the review of our intermediate results at 40.1 months showed that 16 of the 21 patients ( 76.2% ) were completely dry , 3 patients ( 14% ) had mild incontinence and 2 patients ( 9.8% ) had moderate incontinence . the success rate of the current study is better than that of the other studies mentioned above ( 5 , 24 ) . a possible explanation for our high success rate may be associated with the high capacity of the silicone balloon . in our patients , we used a larger size of silicone balloon ( 25 ml ) than the other two studies . additionally , we used a stapler which allows the easier attachment of the polypropylene mesh on the lower border of the pubic bone in both sides . although previous pelvic radiotherapy history has also been claimed to be a negative predictor of success rate in ppi surgery ( 19 , 23 ) , 2 patients in current study whom had a previous history of pelvic radiotherapy were dry in the intermediate follow - up . a new device is a perineal sling with a tissue expander , composed of 2 silicone components , a balloon expander and an injection port , connected by a tube . in turkey , this device is relatively cheap compared with aus , proact , argustm ( $ 500 vs. $ 5.000 vs. $ 2330 vs. $ 2400 ) and easy to implant , even in difficult cases . although complications occurred in this study , including the removal of the device and the removal of inflation component due to local scrotal infection , our intermediate follow - up study suggests that an adjustable perineal male sling using a tissue expander appears to be an efficient and safe alternative surgical treatment option for patients suffering from ppi . the major limitations of our study were the small number of patients and the duration of the follow - up period . additional follow - up and larger series of patients are necessary to confirm our results .
purpose to report our intermediate experience in treating patients with severe incontinence using an adjustable perineal male sling with a tissue expander.materials and methods an adjustable male sling procedure was performed on 21 patients with severe incontinence . 
 the underlying etiology of urinary incontinence was radical prostatectomy in 13 patients , open prostatectomy in 5 patients and transurethral prostate resection in 3 patients . 
 the difference between the classical and the adjustable sling is that in the latter there is a 25 ml tissue expander between the two layers of polypropylene mesh with an injection port . 
 adjustment of the sling was performed with saline via an inflation port , in case of recurrence or persistence of incontinence.results the mean age of the patients was 66.27.3 ( 50 - 79 ) years and mean pad usage was 6.40.6 per day . 
 the mean follow - up time was 40.123.2 ( 6 - 74 ) months . 
 the balloon was postoperatively inflated on average with 11.65.7 ( 5 - 25 ) ml . 
 after the mean 40.1 months of follow - up , 16 of the 21 patients ( 76.2% ) were dry ( 11 patients , 0 pads ; 5 patients using safety pads ) , 3 patients ( 14% ) had mild and 2 ( 9.8% ) had moderate degree post - prostatectomy urinary incontinence ( ppi ) . 
 the average maximum urine flow rate of the patients was 15.64.7 ( 10 - 31 ) ml / s . 
 no residual urine was found . in 2 patients , all parts of the device 
 were removed due to infection and discomfort , and in 3 patients only the inflation component was removed due to local scrotal infection.conclusions our results show that using an adjustable perineal male sling with a tissue expander seems to be an efficient , and safe surgical treatment option in patients with ppi .