CA2659325A1

CA2659325A1 - Suburethral hammock

Info

Publication number: CA2659325A1
Application number: CA002659325A
Authority: CA
Inventors: Pierre Dubernard
Original assignee: Individual
Current assignee: Compagnie de Recherche en Composants Implants et Materiels pour lApplication Clinique SAS
Priority date: 2006-08-02
Filing date: 2007-07-31
Publication date: 2008-02-07
Also published as: EP2068756A2; WO2008015338A2; JP2009545352A; AU2007280329A1; EP2068756B1; US20100130814A1; ES2528664T3; WO2008015338A3; US9861460B2

Abstract

The invention concerns an implantable prosthesis (1) for the treatment of incontinence, comprising a retaining means (2) having a support element (3) designed to be placed under the urethra (U) and to prevent any uncontrolled intraurethral flow, said prosthesis being characterized in that it comprises an atraumatic suspension means (4) provided with at least one bearing element (5) arranged so as to overlap part of the pubic bone (OP) and to rest on the latter, and at least one sling (6, 7) connecting said bearing element (5) to the retaining means (2), said sling (6, 7) being designed to hold the support element (3) at a substantially constant distance from the public bone (OP), called the retaining distance (do), a means (20) for reversibly adjusting the retaining distance (do), thus making it possible to reversibly vary said retaining distance (do). The prosthesis is used to treat incontinence.

Description

2

3 TECHNICAL FIELD

4 This invention relates to the general field of medical devices used for the treatment of incontinence, notably urinary incontinence.
6 This invention relates in particular to an implantable prosthesis for the treatment of 7 incontinence, comprising a retaining means having a support element designed to be placed 8 under the urethra in order to prevent the latter moving away in the direction of the lower pelvis, 9 and to prevent any uncontrolled intra-urethral flow.
This invention also relates to a surgical instrument used to implant a prosthesis to treat 11 incontinence.
12 This invention also relates to a surgical method to treat incontinence.

It is common to use surgically implanted medical devices in order to treat incontinence, 16 notably urinary incontinence.
17 Incontinence of this nature can result from an alteration of the natural sphincterian 18 functions of the patient; for example, with males as a result of a prostatectomy. With females, 19 another form of incontinence, known as "stress" incontinence can also result from a looseness of the pelvic tissues leading to a hyper-mobility of the urethra.
21 The type of medical device implanted depends on the nature and severity of the 22 incontinence, as well as on the patient's sex.
23 Thus, in the case of mild to moderate incontinence for females, such as stress 24 incontinence, it is common to implant a tension-free vaginal tape (TVT) positioned transversely under the urethra, in the tissues, without any significant tension.
26 In the case of males suffering from mild to moderate incontinence, it is common to 27 implant a textile plate underneath the urethra, stretched by fixing each of its extremities to one 28 of the branches of the ischiopubic ramus.
29 In the case of more severe incontinence, it is generally necessary to use an artificial sphincter, which usually contains a sleeve design to surround the urethra, containing, on its 31 inside face, an inflatable annular pocket which, when inflated, leads to the occlusion of the 32 urethra via constriction.
33 Although delivering satisfactory results from a therapeutic point of view, such devices 34 from the prior art have a number of non-negligible drawbacks.
Specifically, it is sometimes noticed, following implantation of a tape such as TVT, that it 36 is insufficiently efficient to resolve the incontinence problem.

21849677.1 1 1 In this case, it is necessary to carry out a second surgical intervention to replace the 2 aforementioned tape with an artificial sphincter, which exposes the patient to a new traumatism 3 and new complications.
4 Moreover, currently used artificial sphincters are relatively expensive, and implanting such artificial sphincters is a relatively complex surgical intervention.
6 As regards textiles plates, they are frequently attached to the pubic bone by means of 7 anchoring elements, such as screws, which increases the traumatism suffered by the patient, 8 and can be a source of complications.

STATEMENT OF INVENTION
11 It is therefore the object of the invention to propose a new implantable prosthesis to 12 treat incontinence without the drawbacks detailed above, and which can be used to efficiently 13 treat various degrees of incontinence, whilst being particularly easy to implant.
14 It is another object of the invention to propose a new prosthesis which would be particularly atraumatic and would substantially reduce the discomfort caused to the patient, as well 16 as the risk of post-operation complications.
17 It is another object of the invention to propose a new prosthesis of particularly simple 18 design and relatively inexpensive.
19 It is another object of the invention to propose a new prosthesis with a good level of mechanical stability and highly resistant in time.
21 It is another object of the invention to propose a new prosthesis particularly suited to 22 treat male urinary incontinence .
23 It is another object of the invention to propose a new prosthesis whose implementation 24 can be adapted to the patient's anatomy.
It is also an object of the invention to propose a new prosthesis for the combined 26 treatment of female urinary incontinence and cervico-cystoptosis.
27 It is also an object of the invention to propose a new ancillary enabling a quick, easy, 28 and particularly safe implantation of a prosthesis to treat incontinence according to the 29 invention.
It is also an object of the invention to propose a new method for the surgical treatment of 31 incontinence, said method particularly safe and efficient.
32 It is also an object of the invention to propose a new method for the surgical treatment of 33 incontinence, said method being insignificantly traumatizing for the patient 34 It is another object of the invention to propose a new method for the surgical treatment of incontinence, said method polyvalent and adaptable to each patient, regardless of sex, age or 36 corpulence.

21849677.1 2 1 It is also an object of the invention to propose a new surgical method particularly suited to 2 treating male urinary incontinence.
3 Lastly, It is also an object of the invention to propose a new surgical method particularly suited 4 to treating female urinary incontinence.
The objects of the invention are reached using an implantable prosthesis comprising a retaining 6 means having a support element designed to be placed under the urethra in order to prevent the latter 7 from moving away in the direction of the lower pelvis, and to prevent any uncontrolled intra-urethral flow, 8 said prosthesis characterized in that it comprises:
9 - An atraumatic suspension means provided with at least one bearing element, arranged so as to overlap part of the pubic bone, and to rest on the latter, and at least one sling, 11 connecting said bearing element to the retaining means, said sling being designed to hold the 12 support element at a substantially constant distance from the pubic bone, called the retaining 13 distance, 14 - A means for reversibly adjusting the retaining distance, thus making it possible to reversibly vary said retaining distance.
16 The objects of the invention are also reached by means of a surgical instrument used 17 to implant a prosthesis to treat incontinence, comprising a retaining means having a support 18 element, an atraumatic suspension means, provided with at least one bearing element arranged so as 19 to overlap part of the pubic bone and to rest on the latter, and at least one sling connecting the bearing element to the retaining means in order to hold the support element at a substantially constant retaining 21 distance from the pubic bone, said surgical instrument fitted with a introduction element designed to be 22 inserted in the tissues situated in the retropubic space in order to therein open a passageway intended 23 for one or the other of the slings, said introduction element comprising at least a proximal portion 24 arranged to penetrate the tissues, a distal portion connected to a gripping means, and an intermediate section connecting the proximal portion to the distal portion, and having an exterior lateral surface in 26 contact with the tissues traversed, said surgical instrument characterized in that the intermediate 27 section comprises at least a lateral orifice connecting its exterior lateral surface to a collecting duct so 28 as to be able to collect the liquid contained in the bladder when the introduction element accidentally 29 perforates the latter.
Lastly, the objects of the invention are also reached by means of a surgical method to treat 31 incontinence, comprising an engagement step (a) during which is implanted, under the urethra, a 32 retaining means having a support element, designed to prevent the urethra moving away in the direction 33 of the lower pelvis, and to prevent any uncontrolled intra-urethral flow, said surgical method 34 characterized in that it comprises a atraumatic bone suspension step (b) during which the retaining means is suspended to the pubic bone by means of an atraumatic suspension means in such a way that 36 the support element is maintained at a substantially constant distance from the pubic bone, and more 21849677.1 3 1 particularly from the symphysis pubica, called the retaining distance (do) as well as a suspension tension 2 adjustment step (c) during which the medical practitioner adjusts the retaining distance in vivo in order to 3 regulate the suspension stress exerted by the support element on the urethra.

BRIEF DESCRIPTION OF THE FIGURES
6 Other advantages and objects of the invention will appear in greater detail on reading 7 of the description which follows, and with the help of the appended drawings which are 8 supplied purely for explanation and are not limitative, in which:
9 - Figure 1 illustrates, from an anterior front view, the implementation of an embodiment of the implantable prosthesis according to the invention.
11 - Figure 2 illustrates, from a schematic side view, the implementation, in a male, of an 12 embodiment of the prosthesis according to the invention.
13 - Figure 3 illustrates, from a partial schematic perspective view, the implementation of an 14 embodiment of the prosthesis corresponding to that of figure 2.
- Figure 4 illustrates, from a partial sectional front view, the operating principle, in a male, of an 16 embodiment of the prosthesis according to the invention.
17 - Figure 5 illustrates, from a bottom view, an embodiment of the prosthesis according to 18 the invention particularly suited to the treatment of male incontinence.
19 - Figures 6A and 6B illustrate, respectively, from a partial perspective view and a sectional view, a first embodiment of the means for adjusting the retaining distance, liable to be used 21 with an implantable prosthesis according to the invention.
22 - Figure 7 illustrates, from a partial perspective view, a second embodiment of the means 23 for adjusting the retaining distance, liable to be used with an implantable prosthesis 24 according to the invention.
- Figures 8A and 8B illustrate, from a partial perspective view and a longitudinal sectional 26 view, a third embodiment of the means for adjusting the retaining distance, liable to be used 27 with an implantable prosthesis according to the invention.
28 - Figure 9 illustrates, from a schematic top view, an embodiment of the prosthesis, 29 according to the invention, particularly suited to the combined treatment of female incontinence and cervico-cystoptosis.
31 - Figure 10 illustrates, from a simplified side sectional view, the implementation, in a 32 female, of an embodiment of the prosthesis according to the invention.
33 - Figure 11 illustrates, from a simplified side sectional view, the implementation, in a 34 female, of the prosthesis shown in figure 9.
- Figure 12 illustrates, from a partial perspective view, a fourth embodiment of the 36 means for adjusting the retaining distance, liable to be used with an implantable prosthesis 21849677.1 4 1 according to the invention.
2 - Figure 13 illustrates, from a general perspective view, an embodiment of the surgical 3 instrument of the invention.
4 - Figure 14 illustrates, from a partial longitudinal sectional view, a part of the surgical instrument of figure 13.

8 This invention relates to an implantable prosthesis 1 used to treat incontinence, and more 9 preferably, urinary incontinence. Advantageously, the prosthesis 1 of the invention can be adapted to treat various types and degrees of urinary incontinence, both male and female.
11 Thus, the said prosthesis 1 can be adapted to treat light, moderate or severe incontinence in 12 males, caused by sphincterian insufficiency, by replacing the natural sphincterian function.
13 The prosthesis 1 can also be adapted to treat effort incontinence in females caused by a hyper-14 mobility of the urethra and the urinary bladder neck. In particular, the said prosthesis 1 can be advantageously used in females when other operating techniques have failed.
16 The prosthesis 1 of the invention comprises a retaining means designed to be placed under the 17 urethra U in order to prevent the latter moving away in the direction of the lower pelvis, and to prevent 18 any uncontrolled intra-urethral flow.
19 According to the invention, the support element 3 can either be in direct contact with the bottom part of the urethra; i.e. with that part of the urethra substantially oriented towards the 21 patient's lower members, or said support element 3 can be in indirect contact with the underlying 22 tissues joining said urethra.
23 The configuration of the contact can depend on the patient's sex; for females, the support 24 element 3 will be preferably applied directly against the urethra, whereas for males, the said support element 3 will be preferably placed against the bulbospongious muscle MBC.
26 Naturally, the surface condition and the surface area of the support element 3 intended to be 27 actually positioned against the tissues (urethra or bulbospongious muscle) should also be chosen to give 28 the said support element 3 a substantially atraumatic nature.
29 According to an important characteristic of the invention, the prosthesis 1 comprises an atraumatic suspension means 4 with at least one bearing element 5, said bearing element arranged so as to overlap 31 part of the pubic bone OP and to rest on the latter, and at least one sling 6, 7 connecting said bearing 32 element 5 to the suspension means 2, said sling 6, 7 being designed to hold the support element 3 at a 33 substantially constant distance from the pubic bone OP, and particularly from the symphysis pubica SP, 34 called the retaining distance do.
In other terms, the atraumatic suspension means 4 is arranged to mechanically link the retaining 36 means 2, and more specifically its' support element 3 to the pubic bone OP
so that said support element 21849677.1 5J

1 3 prevents possible displacement of the urethra in moving away from the pubic bone, and more 2 particularly from the symphysis pubica SP. The support element 3 thus forms an "anti-fall" stop 3 which substantially retains the urethra at a predetermined "maximum"
retaining distance do from the 4 said symphysis pubica by substantially resisting the effects of gravity.
Thus, the support element 3 is liable to exert a holding force or "suspension stress" F
6 which prevents the urethra U from moving away from the symphysis pubica and, more precisely, 7 from sinking down towards the bottom of the pelvis.
8 Depending on the patient's age and corpulence, the retaining distance do will be preferably 9 between approximately 5 cm and 20 cm, and preferably between 8 cm and 15 cm.
By "atraumatic suspension" is meant that the suspension means 4, and more particularly, 11 the bearing element 5 is designed so as not to damage the tissues on which it is resting and in 12 particular to respect the integrity of the pubic bone.
13 More particularty, the suspension means 5 according to the invention will not have any 14 anchoring elements that are prominent, cutting, perforating or abrasive such as tips, lugs or screws, liable to perforate, lacerate or crack the pubic bone, at the surface or inside said pubic 16 bone, and/or nearby tissues.
17 According to another characteristic of the invention, the prostheses 1 comprises a means 18 20 for reversibly adjusting the retaining distance do thus making it possible to vary said retaining 19 distance do.
By "reversibly" is meant that the means of adjustment allows for increasing as well as 21 decreasing the retaining distance do, said means being however "fixed" in the sense that the 22 retaining distance do is durably maintained once the prosthesis is implanted. Thus, the means 23 20 of adjustment is designed to substantially maintain said retaining distance constant, in 24 normal operation, in such a way that the latter is not, for example, spontaneously changeable in a dynamic manner when subjected to forces from the patient's various organs.
26 However, the said retaining distance can be advantageously once again modified 27 without any difficulty in the course of a voluntary therapeutic action undertaken by the doctor, for 28 example, in the course of a minor subsequent surgical intervention whereby the surgeon 29 accesses the means of adjustment by a simple and short suprapubic incision, without having to undertake a major dissection to completely reveal the urethra.
31 The said means of adjustment 20 advantageously permits the medical practitioner to 32 freely choose, notably when implanting the prosthesis 1, the distance at which he positions the 33 end stop comprising the support element 3, and to adjust the retaining distance according to the 34 patient's specific anatomy. In this way, the same standard prosthesis 1 model can be used to treat several patients.
36 Moreover, and in a particularly advantageous manner, the means of adjustment 20 can 21849677.1 6 1 be used, depending on the tightening effect obtained by the distance, more or less near, 2 between the retaining means 2 and the symphysis pubica SP, to adjust the intensity of the 3 suspension stress F.
4 More precisely, the more we try to reduce the distance do, the more traction is generated in the slings 6, 7, and the more we tend to compress the urethra U against the overhanging 6 tissues, by exerting on the said urethra, a force from bottom to top, and substantially oriented in 7 the direction of an imaginary straight line between the base of the urethra U in contact with the 8 support element 3 and the symphysis pubica SP.
9 Thus, it is possible to opt for an "active" suspension whereby the prosthesis 1 permanently exerts a non-null suspension stress F on the urethra. In particular, such a solution 11 could be used to treat urinary incontinence in males.
12 By contrast, it is possible to obtain, with the same means of adjustment 20, a "passive"
13 suspension; i.e., a loose holding, of the urethra by adjusting the retaining distance do so that it 14 substantially corresponds to the natural anatomical distance when resting, and so that the suspension stress F exerted by the prosthesis 1 be substantially null by default.
16 In other terms, it is possible to use the means of adjustment 20 to position the 17 support element 3 substantially in contact against the urethra, without stresses, or "without 18 tension", as illustrated in figure 10, so that said support element 3 form a sort of barrier, and 19 that a stress emerges only when the urethra tries to "flee" the symphysis pubica by pulling on the slings. Such a solution is particularly appropriate for treating stress incontinence in 21 females, notably because of the risk of eroding the highly delicate tissues of the urethra.
22 Thus, the support element 3 according to the invention can be more or less 23 compressive and its implementation adapted depending on whether the purpose is to simply 24 maintain, without residual compression, the urethral roof in a functional configuration (as is the case with females) or whether the purpose is to exert and maintain a permanent residual 26 compression of the urethra (as is the case with males).
27 According to an embodiment (not shown), the suspension means 4 can be arranged 28 to permit the suspension "in the manner of a transobturator" of the retaining means 2; i.e., 29 the bearing element 5 is designed to be urged to be supported on an ischiopubic branch or on an iliopubic branch , and more particularly on the top side of one of the said branches.
31 With this embodiment, one or the other of the slings 6, 7 is preferably arranged to 32 connect the retaining means 2 to the bearing element 5 by passing through the obturator 33 foramen.
34 However, in a particularly preferential manner, the suspension means 4 comprises a peri-symphyseal suspension means designed to suspend the retaining means 2 to the 36 symphysis pubica SP.

21849677.1 7 1 Such a suspension mode offers several advantages in terms of stability, functional 2 efficacy and simplicity of suspension.
3 To simplify the description, it will therefore be considered for the remainder of this 4 text that the prosthesis 1 is intended to be suspended to the symphysis pubica, without however this constituting a limitation to the invention.
6 Preferably, the suspension means 4 comprises at least one anterior sling 6 and one 7 posterior sling arranged to connect the bearing element 5 to the retaining means 2 by 8 passing, respectively, in front of, and behind, the symphysis pubica SP.
9 The bearing element 5 can therefore advantageously position itself around the pubic bone, so as to marry, at least partially, the contour of the latter, and more particularly, the top side of 11 said contour.
12 In the sense of the invention, the bearing element 5 of the invention constitutes a mechanical 13 support point, i.e., has a contact surface with the underlying tissues; a surface along which a force can be 14 transmitted, said force used, in this case, to provide the suspension.
In this respect, it is remarkable that the pubic bone OP, and more particularly the symphysis 16 pubica SP, offers a particularly rigid, resistant and stable point of suspension, which confers a good level 17 of seating to the prosthesis 1.
18 Moreover, the suspension of the invention is advantageously a "free"
suspension, i.e., 19 the bearing element 5 is simply put down on the symphysis pubica, without having to be thereto anchored, for example by stitching, stapling or knotting.
21 Moreover, even though it is conceivable to engage the bearing element 5 above the symphysis 22 pubica at a distance from the latter, thus compressing the tissues trapped between said bearing element 23 5 and the top surface of the symphysis pubica SP (such as muscular aponeurosis), it is nevertheless 24 preferable that the bearing element 5 be in contact against the pubic bone, and rest directly on the top edge of the symphysis pubica which it overlaps.
26 Advantageously, such a system guarantees the lateral holding of the prosthesis 1, and 27 more precisely the bearing element 5, by the pubic spine which acts as an end stop.
28 According to an embodiment not shown, the bearing element 5 can take the form of a sort of U-29 shaped saddle used to enclose the symphysis pubica.
It is remarkable that the peri-symphyseal suspension means of the invention provides 31 the retaining means 2 with a mechanical fixing point substantially vertically in line the urethra U, 32 thereby allowing for a"direcP' suspension; i.e., one which, unlike the tapes or plates of the prior 33 art, causes the direction of the suspension stress F to substantially coincide with the stressing 34 direction of the elements comprising the suspension means 4.
Indeed, tapes or plates of the prior art are intended to be put down transversely under 36 the pubis, and under the urethra in such a way that, to generate a resulting suspension stress, 21849677.1 8 1 even a weak one, said tapes or plates need a significant transversal stressing which can 2 traumatize the soft tissues or bone tissues into which their extremities are fixed.
3 This is why the preferential suspension means 4 according to the invention can be used 4 advantageously to minimize the forces exerted on the said fixing tissues, since said means 4 converts almost all the stresses exerted on said fixing tissues into a useful suspension stress F.
6 Moreover, as will be detailed below, such a mode of symphyseal fixing advantageously 7 makes for a holding that is more stable, encloses more of the urethra, improves the urinary 8 continence of prosthesis 1, and is easier to implant than an artificial sphincter.
9 Preferably, as shown in figures 1 and 3, the suspension means 4 comprises at least 2 suspension harnesses 10, 11 each of which has an anterior sling 6, a bearing element 5 and a 11 posterior sling 7.
12 Naturally, the above-mentioned elements can be initially separate and then assembled 13 using any nature of a mechanical joining means, or, on the contrary, the one and/or the other sling 14 6, 7 can form a single piece with the bearing element 5 and/or the retaining means 2.
By convention, the adjective "anterior" refers to an element in the area between the 16 symphysis pubica and the anterior teguments of the patient, whereas the adjective "posterior"
17 refers to a retropubic element located between the symphysis pubica and the pelvic cavity.
18 Thus, as shown in figures 1 to 3 and 7, each suspension harness 10, 11 forms 19 substantially an arch whose slings form the feet, and whose curved portion, which envelops, or "mounts" the top side of the symphysis pubica, forms the bearing element 5.
21 As shown in figures in figures 2, 3 or 10, each harness thus advantageously forms, in 22 cooperation with a part of the retaining means 2, a loop, preferably single, through which the 23 symphysis pubica passes.
24 Preferably, the support element 3 and more globally, the suspension means 2, is divided into a left area 3G and a right area 3D located on along both sides of an imaginary center line (L) 26 substantially parallel to the main extension direction (XX') of the urethra U when the prosthesis is 27 implanted, and the suspension means 4 has a left harness 10 and a right harness 11, said left 28 and right harnesses 10 and 11 respectively attached to the retaining means in the left area 3G
29 and in the right area 3D.
Such an arrangement permits advantageously to balance and stabilize the suspension by 31 enabling the medical practitioner to pass the left harness to the left of the urethra and the right 32 harness to the right of the urethra.
33 Moreover, the retaining means 2 preferably comprises, as shown in figures 3 and 4, 34 lateral holding elements 12, 13, and in this specific case, at least one left lateral holding element 12 and one right lateral holding element 13, designed to be placed on each side of 36 the urethra U and prevent the lateral displacement of the latter.

21849677.1 9 1 In a particularly preferential manner, the lateral holding elements 12, 13 and the support 2 element 3 consists of a single piece.
3 Such an embodiment permits advantageously firstly to substantially envelop the urethra 4 inside a bearing structure forming a sort of hammock, or retention harness, intrinsically limiting the displacement of the urethra in the left-lateral, right-lateral, and lower-vertical directions, and 6 secondly, to stabilize the retaining means 2 using two triangular structures formed by the slings 7 of each of the harnesses 10, 11.
8 More globally, it is remarkable that the prosthesis 1 of the invention has preferably a 9 globally symmetrical structure ; i.e., that its' left portion correspond substantially to the image of its' right portion through a symmetrical plane which corresponds substantially to the sagittal plane of 11 the patient.
12 A person skilled in the art will be naturally in a position to determine the suitable length 13 of the harnesses 10, 11 according to the patient's age and corpulence.
14 For example, the total length of each of the said harnesses 10, 11 will preferably be between 10 cm and 50 cm approximately, and even more preferably between the 15 cm and 25 16 cm approximately.
17 Preferably, the harnesses, and more generally the suspension means 4, are designed to 18 be sufficiently flexible to enable their implantation, and notably their inflexion above the 19 symphysis, whilst having low extendability so as to substantially support, without longitudinal deformation, the traction stress providing the suspension of the retaining means 2 to the said 21 symphysis.
22 Moreover, the said harnesses will be preferably non-adhesive.
23 Thus, one and/or the other of the harnesses 10, 11 could be formed on the basis of a band 24 made from a polymer material, for example, polytetrafluoroethylene (PTFE) One and/or the other of the harnesses 10, 11 could also be formed on the basis of a band 26 made from a composite material comprising an implantable textile insert, such as polypropylene 27 or polyester, and an elastomer coating or matrix, such as silicon.
28 It is also conceivable to carry out a surface treatment in order to make the textile anti-29 adhesive, for example by applying a fluoride gas plasma procedure, such as C2H2F4.
Preferably, the width of the said band will be substantially between 0.5 cm and 3 cm, and 31 particularly preferably substantially equal to 1 cm, whilst its thickness will be preferably between 32 0.2 mm and 1 mm.
33 Advantageously, using bands enables the harness flats to position themselves 34 substantially around the pubic bone, by taking on the form of the latter so as to distribute the suspension stresses over a relatively large surface.
36 According to another embodiment (not shown), in particular when the suspension is done 21849677.1 10 1 practically without tension, for example with females, the harnesses can be formed by thin 2 cords, of a diameter, for example, between 1 mm and 3 mm.
3 Moreover, in order to facilitate the implantation of the prosthesis 1, one and/or the other 4 of the harnesses is, before implantation, divided into a first strand 10A, 11A and a second strand 10B, 11 B each of which has a captive extremity, attached to the retaining means 4, and a 6 free extremity.
7 Thus, advantageously, each harness 10, 11 can be re-created in vivo by joining the free 8 extremity of its first strand 10A, 1 1A with the free extremity of its second strand 10B, 11 B, said 9 first and second strands having being first put into the tissues on both sides of the symphysis pubica.
11 In particular, the first and second strands can substantially correspond to the anterior 12 and posterior slings respectively.
13 Moreover, according to an embodiment not shown, it is entirely conceivable that one or 14 both of the harnesses be formed by a single strand attached by one of its extremities to the retaining means 2, and whose free extremity can be bent back onto the said retaining means 2 16 after having being first passed around the symphysis.
17 Moreover, according to a preferential arrangement variation (not shown), the means 20 18 for adjusting the retaining distance will be substantially located in the proximity of the retaining 19 means 2, at the base of the anterior sling 6, so as to be easily accessible and maneuverable by the surgeon.
21 Preferably, as is illustrated on figure 3, the means 20 for adjusting the retaining 22 distance has an element 21 to adjust the length of one or the other of the slings 6, 7 and more 23 precisely, one or the other of the harnesses 10, 11.
24 More particularly, the means of adjustment for reversibly adjusting the retaining distance do permits both the extension as well as the shortening of said harnesses 10, 11.
26 Naturally, any discrete or continuous means of adjustment of the length of the harnesses 27 is within the scope of the invention.
28 Thus, according to an embodiment, the means 20 for reversibly adjusting the retaining 29 distance is designed to allow a discrete modification of the retaining distance do.
More particularly, as shown in figures 5, 6A and 6B, the element 21 to adjust the length 31 can include several "male" fixing elements 22 distributed along the first strand 10A, 11A as well 32 as one or more matching "female" fixing elements 23 associated with the second strand 10B, 33 11 B in such a way that the effective length of the corresponding harness 10, 11 can be adjusted, 34 by a predetermined incremental step, according to the pair of fixing elements 22, 23 used.
As shown in figures 5, 6A and 6B, the male fixing elements can be formed using full or 36 hollow conic protuberance, or by anchors with one or more deformable branches, for example 21849677.1 11 1 arranged by cutting the strand making up the harness.
2 The female fixing element, or elements, 23 can be formed by pull-through orifices, such 3 as button hole orifices, whose lips may be deformable, and able to cooperate by clicking into the 4 male fixing elements 22.
To this end, the male fixing elements 22 associated with the first strand , 11A comprising 6 preferably a sloping introduction face 24 and an retaining face 25, with the passage of the first 7 strand through the second strand 10B, 11 B taking place by forcing the deformation of the 8 protuberances and/or the orifice.
9 According to an embodiment shown in figure 12, it is possible to use a stop element 70 with one or several orifices 71, 72 drilled through the width of said element 70 to allow the 11 passing of strands (shown as dotted lines in figure 12), and having a central protuberance 73 on 12 its top side, said protuberance forming an anchoring button with which the button hole openings 13 74 drilled in the strands cooperate, when said strands are pushed back against the stop 14 element 70 in the direction shown by the arrows. In particular, the button hole openings can have the form of clefted circular recesses.
16 An arrangement of this nature has the advantage of being simple, inexpensive and 17 compact.
18 If necessary, the stop element 70 can comprise a flexible and/or curving base 75 intended 19 to rest on the top side of the symphysis pubica, and form a part of the bearing element 5.
Preferably, the means 20 for adjusting the retaining distance will be designed to enable 21 continuous modification of the retaining distance do; i.e., will permit without restriction the free 22 selection of said retaining distance from amongst all intermediate values in a predetermined range.
23 To this effect, the element 21 to adjust the length comprises, preferably, as shown in 24 figures 3, 7, 8A and 8B, a tightening loop 26 wrapped around a sling 6, 7, and arranged to allow a continuous adjustment of the length of said sling.
26 The said tightening loop which may be somewhat comparable with loops used on 27 handbag straps or rucksack straps will comprise, for example, a frame 27, preferably rigid or 28 semi-rigid, with fixed orifices 28 drilled into its width, or provided with sliding crossbars 29, the 29 purpose of said frame being to hold the strands when folded on themselves, and to stop the latter by crushing.
31 Thus, the tightening loop 26 will act as a clasp permitting to join together, in pairs, the 32 anterior strands 10A and posterior strands 10B of a given harness 10 in order to reconstitute 33 the latter by giving it the desired length.
34 Preferably, the adjustment range given by the element 21 to adjust the length according to the invention, notably in the case of discrete adjustment means, is substantially included 36 between 0.5 cm and 5 cm.

21849677.1 12 1 It is remarkable that the means 20 for adjusting the retaining distance can 2 comprise both discrete adjustment elements used to make approximate adjustments to 3 the overall length of the harnesses according to the patient's anatomy, and continuous 4 adjustment elements used to make fine adjustments to the suspension stress F.
Moreover, according to a preferential embodiment, the retaining means 2 contains a 6 framing element 30 connected to the slings 6, 7, as shown in figure 5.
7 Advantageously, such a framing element 30 can be used to reinforce the sub-urethral 8 support and to determine one or several specific points of compression.
9 More specifically, the framing element 30 is preferably formed by a cross piece 31, whose center is substantially in register with the center line (L) which divides the support 11 element 3 into its left area and its right area, and whose branches 32, 33, 34, 35 are each 12 connected to the extremity of a harness 10, 11.
13 In a particularly preferential manner, the framing element and one and/or the other of 14 the harnesses 10, 11 consist of a single piece.
Thus, as shown in figure 5, the branches 32, 33, 34, 35 of the cross piece can 16 advantageously form the captive extremities of the strands 10A, 10B, 11A, 11 B; i.e., the cross 17 piece 31 is formed by the sub-urethral crossing of the left and right strands 10, 11.
18 Preferably, the support element 3 is formed, at least partially and preferably 19 totally, by a flexible plate 40.
The said flexible plate 40 can, for example, consists in a fabric, notably knitted, or 21 non-woven, based on a colonizable material such as polypropylene, in order to guarantee 22 integration of the said flexible plate with the supported organ, in this case the urethra U and/or 23 the bulbospongious muscle, and to avoid any risk of relative sliding of said organ with respect to 24 said flexible plate 40.
The said flexible plate 40 is also preferably able to substantially change shape into a 26 "U" form, as shown in figures 3 and 4, in order to partially envelop the urethra U and/or, as 27 appropriate, the whole formed by the urethra U, the cavernous body CC and the 28 bulbospongious muscle MBC.
29 The flexible plate 40 forms therefore preferably both the support element 3 and the lateral holding elements 12, 13.
31 Thus, the retaining means 2 can advantageously marry the inferior and lateral portions of 32 the urethra U and/or the bulbospongious muscle, so as to firstly, spread the suspension stress F
33 over a significant tissue surface area and secondly, limit the displacement of the urethra U with 34 respect to the prosthesis 1 and the symphysis pubica SP.
Thus, a particularly stable and atraumatic suspension is advantageously obtained.
36 Preferably, the framing element 30 is flexible and connected to the flexible plate 40.
21849677.1 13 1 Thus, the retaining means can have a multi-layer structure, in which the framing elements 2 30 are opposite the support element 3.
3 In particular, the cross piece 31 can be subjected to the flexible plate 40 by gluing or 4 stitching.
Moreover, the said cross piece 31 will be preferably arranged so that the harnesses 6 emerge substantially at the corners of the retaining means 2 and more precisely of the flexible plate 7 40.
8 It is remarkable that the presence of framing means 30 makes it possible to 9 advantageously first, define in space, a relatively rigid preferential compression point, under the support element 3, substantially at the crossing of harnesses, and secondly, avoid the puckering 11 of the flexible plate 40, all of which facilitates the placing of the prosthesis and makes the 12 retaining means 2 resistant in time.
13 Naturally, the framing element 30 is not at all limited to a particular shape, and could 14 comprise a reinforcing edge along, for example, substantially the contours of the flexible plate 40.
Moreover, the flexible area 40 comprises preferably one or more stitching areas 41 intended 16 to be stitched to the bulbospongious muscle MBC in order to immobilize said bulbospongious 17 muscle within the retaining means 2. Preferably, as shown in figure 5, the stitching area 41 will 18 substantially extend to the edge of the flexible plate 40.
19 According to a preferential embodiment, the depth Dl of the support element 3, and more generally the flexible plate 40; i.e., its (overall) dimension considered along the main 21 extension direction XX' of the urethra U and "flat", i.e., when prosthesis 1 is resting opened out 22 on a flat surface, is greater than, or equal to its width D2, i.e., to its (overall) dimension 23 considered along a transversal lateral direction YY' to the said main extension direction XX' of 24 the urethra in the same conditions.
For example, the depth Dl can be substantially included between 40 mm and 60 mm, 26 and the width D2 between 30 mm and 50 mm.
27 Thus, the suspension means 2 advantageously has the form of the hammock, or a sort of 28 cradle marrying the anatomical form of the urethra and/or of the bulbospongious muscle, and 29 capable of distributing the suspension stress F over a significant length of the latter.
Moreover, in order to adapt as best as possible to the patient's anatomy, the support 31 element 3, and more generally the flexible plate 40 is preferably substantially quadrangular, 32 and particularly preferably substantially trapezoidal; i.e., the width of its anterior edge 3A is 33 substantially less than or equal to the width of its posterior edge 3P.
34 Moreover, the prosthesis 1 of the invention can comprise an inflatable means of compression 50 which is put down at the level of the support phase 3, between the retaining 36 means 2 and the urethra U, and which is arranged in a manner to be able to, when inflated, 21849677.1 14 1 exert, as shown in figure 4, a compression of the urethra against the tissues above the latter , 2 for example the transversal ligament of the pelvis.
3 Thus, advantageously, the prosthesis 1 of the invention can combine a separate 4 suspension stress F and compression stress P, said compression stress P
being able to reduce the urethral lumen in order to perform a blocking function compensating a sphincterian 6 deficiency. The prosthesis 1 of the invention can therefore be considered an alternative, 7 advantageously simple and inexpensive, to artificial sphincters of the prior art.
8 More precisely, the inflatable means of compression 50 is advantageously supported 9 on the bottom part of the retaining means 2 to exert an additional pressure P on the urethra which tends to push the bottom wall of the latter towards the symphysis pubica.
11 Preferably, the inflatable means of compression 50 comprises a cushion 51 which is 12 arranged substantially in register with the center line dividing the support element surface 3 13 substantially parallel to the main extension direction XX' of the urethra U, as illustrated in figure 14 4.
The said cushion can notably be lodged in a "kangaroo" pouch, arranged under the 16 surface of the support element 3 by a fold in the flexible plate 40.
17 It is remarkable that this embodiment includes preferably a cross piece 31, as described 18 above, so as to give the cushion 51 a particularly solid point of support on the retaining means 19 2. Thus, the compression stress P will preferably act in a localized and differential manner with respect to the overall suspension stress F.
21 In a particularly preferential manner, the inflatable means of compression 50 is 22 connected to a fluid reservoir 54, such as an implantable site, by means of flexible tubing such 23 as a catheter 55.
24 Preferably, as shown in figure 3, the implantable site 54 is arranged to rest, in a stable and rigid manner, against the anterior side of the symphysis pubica SP.
26 Moreover, the prosthesis 1 can comprise fluid transfer means, such as a remote 27 controlled pump or a pear enabling the patient to control at will by inflating and deflating the 28 cushion 51, and thus permit miction or, on the contrary, guarantee continence.
29 Moreover, the prosthesis 1 of the invention can be advantageously designed to treat cervico-cystoptosis combined with incontinence in females.
31 To this effect, as shown in figures 9 and 11, the suspension means 2 can have a 32 subvesical extension 60 designed to bear up against the bladder V.
33 Moreover, it is remarkable that, with this embodiment, the posterior strands 10B, 11 B, 34 are preferably oriented obliquely with respect to the edges of the flexible plate, in order to enhance the ergonomic aspect of the prosthesis 1.
36 Advantageously, the subvesical extension 60 can also extend beyond the points of fixing 21849677.1 15 1 of the posterior strands to the retaining means, between said posterior strands and, for example, 2 form a flap with a rounded edge, as shown in dotted lines in figure 9.
3 As shown in figure 11, the subvesical extension is designed to support at least the base of 4 the latter, whilst the posterior slings 7 are arranged to go around both sides of the bladder V, and connect the said subvesical extension 62 to the bearing element 5.
6 Thus, the prostheses 1 can support the bladder V by suspending the latter, as well as 7 suspending the urethra, to the symphysis pubica.
8 Advantageously, a single intervention thus suffices to treat simultaneously a prolapse and 9 incontinence.
Naturally, this invention is not at all limited to a particular embodiment.
Thus, the invention 11 can concem solely, independently of the presence of a means for adjusting the retaining distance, an 12 implantable prosthesis intended to treat incontinence comprising a retaining means having a support 13 element designed to be placed under the urethra, in order to prevent the latter moving away in the 14 direction of the lower pelvis, and to prevent uncontrolled intraurethral flow, said prosthesis provided with a symphyseal suspension means designed to suspend the said retaining means to the 16 symphysis pubica, and to hold the support element at a substantially constant distance from the said 17 symphysis pubica, called the retaining distance.
18 Moreover, this invention relates to an ancillary designed to facilitate the placement of the 19 above-described prosthesis, and more particularly to facilitate the passage of posterior slings 7 into the retropubic space whilst ensuring that the integrity of the bladder is respected.
21 As shown in figures 13 and 14, the ancillary of the invention takes the form of a surgical 22 instrument 80 provided with an introduction element 81 designed to be pushed into the tissues 23 located in the retropubic space in order to create a passageway therein for one or the other of 24 the slings 6, 7.
The said introduction element 81 comprises at least a proximal portion 81A
arranged to penetrate 26 the tissues, a distal portion 81 B connected to a gripping means 81, such as a handle and an intermediate 27 section 81 C which connects the proximal portion 81A to the distal portion 81 B, and has an extemal lateral 28 surface 83 in contact with the tissues traversed.
29 An important characteristic of the invention is that the intermediate section 81 C
comprises at least a lateral orifice 84 connecting its external lateral surface 83 to a 31 collecting duct 85 so as to be able to collect the liquid contained in the bladder when the 32 introduction element accidentally perforates the latter.
33 Thus, a flow of urinary liquid or of colored liquid preliminary injected into the bladder 34 immediately informs the surgeon that the introduction element 81 is traversing the bladder draining its content; i.e., that the said bladder has been accidentally perforated and that it is therefore necessary to 36 intervene to restore its operation.

21849677.1 16 1 Naturally, the introduction element 81 is sufficiently rigid to create a passageway in the tissues, 2 and to route its way through the tissues when the surgeon exerts a pushing force on the gripping 3 element 82.
4 To this effect, the extremity of the proximal portion 81C can be provided with a penetration device, for example, a tip, which may be blunt and/or removable, and is preferably made from a polymer 6 material.
7 Moreover, the introduction element will be preferably curved to form a type of hook, thereby 8 facilitating the creation of a peri-symphyseal passageway, without taking the risk of perforating deeper 9 anatomical regions.
Moreover, the introduction element 81 will preferably be long enough that its' proximal portion 11 81A can reemerge outside of the tissues, under the pubis, whilst its distal portion 81 B with the gripping 12 means 82 is still emerging from suprapubic tissues.
13 With a preferred embodiment, the introduction element is formed from a curved, hollow 14 rod, metallic for example, having preferably a cylindrical geometry with a circular base, the collecting duct 85 running inside the said rod and emerging in free air, or in a pocket provided 16 for this purpose at the distal extremity 81 B
17 Preferably, the instrument 80 has several lateral orifices 84 drilled substantially radially in 18 the thickness of the rod's wall and arranged along the introduction element.
19 With a preferred embodiment, the lateral orifices 84 are arranged in several points along the circumference of the introduction element so as to be able to drain the bladder liquid regardless 21 of the orientation of the said introduction element 81.
22 The said introduction element 81 is therefore preferably multi-perforated, both along its 23 length and around its edge.
24 Even though the ancillary of the invention is particularly suited to the implementation of a prosthesis 1 as described above, its usage is in no way thereto limited.
Thus, it is 26 entirely conceivable to use, for other purposes, a surgical instrument with an introduction 27 element provided with one or more lateral orifices 84 connecting its external lateral surface 28 83 to a collecting duct 85 so as to be able to collect the liquid contained when said 29 introduction element accidentally perforates an organ.
Naturally, the invention also concerns a surgical kit containing a prosthesis to treat 31 incontinence 1 according to the invention, and a surgical instrument 80 as described above.
32 This invention also relates to a surgical method to treat incontinence per se.
33 Such a method will now be briefly described, with reference to the implantation of a 34 prosthesis 1 according to the invention using a surgical instrument 80 according to the invention.
More particularly, the described method refers to a peri-symphyseal suspension, whereby it 36 is understood that a substantially similar method can be applied to obtain a peri-osseous 21849677.1 17 1 suspension to the ischiopubic or iliopubic branches by trans-obturator route.
2 According to the invention, the said surgical method comprises an engagement step (a) 3 during which is engaged, under the urethra U a retaining means 2 with a support element 3 4 designed to prevent the urethra moving away in the direction of the lower pelvis, and to prevent any uncontrolled intra-urethral flow.
6 With males, the said retaining means 2 will preferably be placed under the bulbospongious 7 muscle MBC, in contact against the latter, whilst with females, the support element 3 of the 8 retaining means 2 will be preferably placed in contact against the urethra itself.
9 According to an important characteristic of the invention, the said surgical method also comprises an atraumatic bone suspension step (b) during which the retaining means is 11 suspended to the pubic bone OP, using an atraumatic suspension means 4 so that the 12 support element 3 be kept at a distance substantially constant from the pubic bone OP, and 13 more particularly from the symphysis pubica SP, called the retaining distance do.
14 Preferably, the suspension step (b) constitutes a suspension step to the symphysis pubica SP.
16 Thus, the urethra U is "imprisoned" or tightly fitted inside a space delimited by firstly, the 17 symphysis pubica SP, and secondly, the support element 3 located at a distance do.
18 In this respect, it is remarkable that a surgical method including the engagement step (a) and 19 then a symphyseal suspension step (b'), atraumatic or invasive, can constitute an invention per se.
21 In a particularly preferential manner, the atraumatic suspension step (b) comprises a peri-22 osseous penetration sub-step (bl), and more particularly, a peri-symphyseal penetration sub-step, 23 during which a bearing element 5 is placed astride a portion of the pubic bone, and more 24 particularly on the symphysis pubica SP, and the retaining means 2 is connected to said bearing element 5 using at least one anterior sling 6 passing in front of the pubic bone, respectively the 26 symphysis pubica SP, and at least a posterior sling 7 passing behind the said pubic bone, 27 respectively the said symphysis pubica SP in the retropubic space.
28 Access to the concerned anatomical region depends notably on the patient's sex.
29 With male patients, the surgeon preferably performs a transversal, horizontal peno-scrotal incision which permits, following longitudinal incision of the superficial planes (subcutaneous 31 cellular tissue and superficial fascia of urogenital diaphragm) to expose the inferior and lateral 32 faces of the urethra and of the bulbospongious muscle.
33 The surgeon then introduces his index finger in the angle located between the inside of the 34 bulbourethral muscle on the inside and the branch of the cavernous body on the outside, so as to locate the bottom edge of the ischiopubic branch and initiate the (ascending) passageway.
36 The surgeon then canies out a transversal suprapubic incision of 2 to 3 cm, at two finger 21849677.1 18 1 thicknesses from the middle line up to the sheath of the rectus abdominis muscle, which is also incised.
2 The surgeon then inserts his second index in the incision to create, from top to bottom, a passageway at 3 the level of the posterior face of the pubis up to the pelvic floor and operates the junction with the index 4 already introduced from bottom to top by the peno-scrotal incision.
A suitable ancillary passed from top to bottom through the passageway so formed is used to 6 take hold of the posterior strand, and to exteriorize said strand via the suprapubic incision.
7 Advantageously, the surgeon can use a surgical instrument 80 to create the passageway 8 ("tunnel driiling" operation) and then take hold of the posterior strand.
9 To this end, he introduces, using force, the introduction element 81 via the suprapubic incision, and pushes it in progressively wrapping its curved part around the symphysis pubica, until 11 the proximal extremity reemerges to free air.
12 Preferably, the drilling step using an instrument according to the invention is preceded by 13 a step wherein the bladder is filled with colored liquid in order to facilitate the detection of a 14 possible complication.
In the event of abnormal flow through the collecting duct 85 during this operation, the 16 surgeon carries out a fibroscopy check to diagnose the nature and scale of the bladder perforation 17 in order to undertake remedial action.
18 The same maneuver is repeated on the opposite side (on the right side if the first 19 maneuver took place on the left) to put the second posterior strand in place.
A gripping ancillary is then introduced via the same suprapubic incision, and then passed in front 21 of the pubis to reach the latero-urethral space and take hold of the anterior strand to lift up the latter and 22 exteriorize it via the said suprapubic incision.
23 With female patients, the exposure of the urethra is preferably obtained using a vertical incision 24 of the anterior vagina wall. The surgical gesture enabling the passage of the strands making up the harnesses is done in a substantially similar manner to that which has been described for male patients.
26 The surgical methods of the invention also comprises a suspension tension adjustment step (c) 27 during which the medical practitioner adjusts in vivo the retaining distance do in order to adjust the 28 suspension stress F exerted by the support element 3 on the urethra U.
29 More precisely, the said suspension tension adjustment step (c) can consist in a sub-step (c1) for adjusting the length of the slings during which the length of one or the other of the slings 6, 7, and 31 more precisely, of the hamesses, 10, 11 is adjusted.
32 To this end, the surgeon can join the anterior strand 10A and the corresponding 33 posterior strand 10B using a tightening loop 26 in order to re-create the corresponding harness 34 10, and then adjust the length of the said "sliding" harness by pulling on the free extremity of one of the strands 10A, 10B passed through the said tightening loop 26.
36 In particular, the surgeon can select an initial length of the harness, and then proceed in 21849677.1 19 1 an iterative manner, by a succession of lengthening and/or shortening operations, to select the 2 most appropriate length given the suspension stress to be obtained.
3 With males, the surgical method of the invention can also include a stabilization step (d) 4 during which the bulbospongious muscle MBC is stitched to the retaining means 2, and more precisely to the flexible plate 40. The said stabilization step (d) preferably takes place prior to 6 the suspension tension adjustment step (c) and more precisely, prior to creation of the 7 harnesses by assembling their respective strands.
8 With females, the surgical methods of the invention can include a vesical suspension 9 step (e) during which a subvesical extension 60 is introduced to the retaining means 2 under the bladder V in order to jointly support the urethra and the said bladder.
11 More particularly, the said subvesical suspension step (e) can include a sub-step 12 (el) during which the proximal extremity of the subvesical extension 60 is connected to the 13 bearing element 5 by means of a posterior sling 7, by passing the two posterior strands 10B, 14 11 B, one to either side, around each side of the bladder.
Naturally, the placement of such a subvesical extension requires a more sophisticated 16 subvesical dissection than that described above. The adjustment of the suspension tension F
17 remains advantageously identical to that described above.
18 Thus, the prosthesis of the invention can be used advantageously to efficiently treat 19 practically all cases of urinary incontinence for a moderate cost, and without causing significant traumatism for the patient.
21 Moreover, the differential action exerted firstly by the suspension means, and secondly by 22 the inflatable compression means make it possible to easily adapt said prosthesis to the severity of 23 the incontinence to treat.
24 Lastly, the stability and atraumatic character of the said prosthesis 1 considerably reduce the probability of having to repeat a medical intervention, by minimizing tissue erosion, both as regards 26 the urethra as well as regards the support points used to suspend the prosthesis.

29 The invention finds its industrial application in the designing and manufacturing of prostheses to treat incontinence.

21849677.1 20

Claims

1 - Implantable prosthesis (1) for the treatment of incontinence, comprising a retaining means (2) having a support element (3) designed to be placed under the urethra (U) in order to prevent the latter moving away in the direction of the lower pelvis, and to prevent any uncontrolled intraurethral flow, said prosthesis being characterized in that it comprises:

- an atraumatic suspension means (4) provided with at least one bearing element (5) arranged so as to overlap part of the pubic bone (OP) and to rest on the latter, and at least one sling (6, 7) connecting said bearing element (5) to the retaining means (2), said sling (6, 7) being designed to hold the support element (3) at a substantially constant distance from the pubic bone (OP), called the retaining distance (d o) - a means (20) for reversibly adjusting the retaining distance (d o), thus making it possible to reversibly vary said retaining distance (d o).

2- Prosthesis of claim 1 characterized in that the means (20) for reversibly adjusting the retaining distance (d o) has an element (21) to adjust the length of one or the other of the slings (6, 7).

3- Prosthesis of claims 1 or 2 characterized in that the suspension means (4) comprises at least one anterior sling (6) and one posterior sling (7) arranged to connect the bearing element (5) to the retaining means (2) by respectively passing in front of, and behind, the pubic bone (OP).

4- Prosthesis of claim 3 characterized in that the suspension means (4) comprises at least two suspension harnesses (10, 11), each comprising an anterior sling (6), a bearing element (5) and a posterior sling (7).

5- Prosthesis of claim 4 characterized in that one and/or the other of the harnesses (10, 11) is, prior to implantation, divided into a first strand (10A, 11A) and a second strand (10B, 11B), having a captive extremity attached to the retaining means (2) and a free extremity.

6 - Prosthesis of claims 4 or 5 characterized in that one and/or the other of the harnesses is formed on the basis of a PTFE band, or on the basis of a composite material comprising an implantable textile insert, such as polypropylene or polyester, and an elastomer coating or matrix, such as silicon.

7 - Prosthesis of one of the claims 4 to 6 characterized in that the retaining means (2) has a left area (3G) and a right area (3D) situated to both sides of an imaginary center line (L) substantially parallel to the main extension direction (XX') of the urethra and in that the suspension means (4) has a left harness (10) and a right harness (11), said left and right harnesses being respectively attached to the retaining means (2) in its left area and in its right area.

8- Prosthesis of any one of the preceding claims characterized in that the retaining means (2) comprises a framing element (30) joined to the slings (6, 7).

9- Prosthesis of claims 7 and 8 characterized in that the framing element (30) is formed by a crosspiece (31) whose center is substantially in register with the center line (L) and whose branches (32, 33, 34, 35) are each connected to the extremity of a harness (10, 11).

- Prosthesis of claims 8 or 9 characterized in that the framing element (30) and one/or the other of the harnesses (10, 11) consists of a single piece.

11 - Prosthesis of any one of the preceding claims characterized in that the retaining means (2) comprises lateral holding elements (12, 13) designed to its be placed on each side of the urethra.

12 - Prosthesis of claim 11 characterized in that the lateral holding elements (12, 13) and the support element (3) consist of a single piece.

13 - Prosthesis of any one of the preceding claims characterized in that the support element (3) is formed, at least partially and preferably totally, by a flexible plate (40).

14 - Prosthesis of any one of the claims 8 to 10, and of claim 13 characterized in that the framing element (30), is flexible and connected to the flexible plate (40).

- Prosthesis of claims 13 are 14 characterized in that the depth (D1) of the flexible plate (40) considered along the main extension direction (XX') of the urethra is greater than, or equal to, its' width along a transversal lateral direction (YY') to the said main extension direction (XX') of the urethra.

16 - Prosthesis of any one of the claims 13 to 15 characterized in that the width of anterior edge of the flexible plate (40) is substantially less than, or equal to, the width of its posterior edge.

17 - Prosthesis of any one of the preceding claims characterized in that the means (20) for adjusting the retaining distance (d o) is designed to allow continuous modification of the retaining distance (d o).

18 - Prosthesis of claims 2 and 17 characterized in that the element (21) to adjust the length comprises a tightening loop (26) wrapped around a sling (6, 7) and arranged to enable continuous adjustment of the length of the said sling.

19 - Prosthesis of any one of the preceding claims characterized in that the means (20) for adjusting retaining distance (d o) is designed to permit a discrete modification of the retaining distance (d o).

20 - Prosthesis of claims 2, 5 and 19 characterized in that the element (21) to adjust the length comprises several male fixing elements (22) distributed along the first strand (10A, 11A) as well as one or more matching female fixing elements (23) associated with the second strand (10B, 11B) in such a way that the length of the corresponding strand can be adjusted according to fixing element pair (22, 23) chosen.

21 - Prosthesis of any one of the preceding claims characterized in that suspension means (4) comprises a peri-symphyseal suspension means designed to suspend the retaining means (2) to the symphysis pubica (SP).

22 - Prosthesis of any one of the preceding claims characterized in that it comprises an inflatable means of compression (50) positioned at the level of the support element (3) between the retaining means (2) and the urethra (U), and fitted in such a way that, when inflated, it exerts a compression on the urethra against the tissues above the latter.

23 - Prosthesis of any one of the preceding claims characterized in that retaining means (2) has a subvesical extension (60) designed to bear up against the bladder.

24 - Surgical instrument (8) to be used for implanting a prosthesis (1) for the treatment of incontinence comprising a retaining means (2) having a support element (3), an atraumatic suspension means (4) provided with a bearing element (5) arranged to overlap a part of the pubic bone (OP) and rest on the latter, as well as at least one sling (6, 7) connecting the bearing element (5) to the retaining means (2) in order to hold the support element (3) at a retaining distance (d o) substantially constant from the pubic bone (OP), said surgical instrument being provided with an introduction element (81) designed to be inserted in the tissues situated in the retropubic space in order to therein open a passageway intended for one or the other of the slings (6, 7) said introduction element (81) comprising at least a proximal portion (81A) arranged to penetrate the tissues, a distal portion (81B) connected to a gripping means (82) and an intermediate section (81C) connecting the proximal portion to the distal portion and having an external lateral surface (83) in contact with the tissues traversed, said surgical instrument (80) characterized in that the intermediate section (81C) comprises at least a lateral orifice (84) connecting its external lateral surface (83) to a collecting duct (85) so as to be able to collect liquid contained in the bladder when the introduction element accidentally perforates the latter.

25 - Surgical instrument of claim 24 characterized in that it comprises several lateral orifices (84) tiered along the introduction element (81).