Use of a pedicled rectus abdominis muscle flap sling in the treatment of complicated stress urinary incontinence

OBJECTIVE: A pedicled rectus muscle flap sling in the treatment of complicated stress urinary incontinence was evaluated. STUDY DESIGN: Thirty-two women underwent a combined vaginal and abdominal sling operation for stress incontinence with a pedicled muscle flap developed from the rectus abdominis muscle. All operations were performed jointly by the same two surgeons. The procedure involved transecting one rectus abdominis muscle just above its first tendinous intersection and isolating the muscle as a flap on its inferior vascular pedicle. The muscle flap was then swung beneath the urethra and bladder neck, pulled into the retropubic space on the contralateral side, and sewn to the obturator internus fascia or to Cooper's ligament. All patients undergoing the procedure had demonstrable stress incontinence on physical examination and underwent preoperative fluoroscopic video urodynamics. The diagnosis of complicated stress incontinence was based on the presence of one or more of the following factors: previous failed antiincontinence surgery (33 operations in 22 patients, average 1.5 operations), open vesical neck on fluoroscopy (14 patients), urethral closure pressure ≤30 cm H₂O by the Brown-Wickham technique (16 patients), or massive vaginal prolapse and demonstrable stress incontinence with the prolapse reduced and the urethra supported in a normal position (16 patients). Follow-up ranged from 2 to 13 months (average 6 months). Surgical outcome was assessed by physical examination and a detailed telephone interview conducted by a physician who was not involved in the operations. RESULTS: Twenty-eight patients (87.5%) were satisfied with the results of the operation. There were four surgical failures (12.5%). Stress incontinence persisted in three patients after surgery, and one patient who had mixed incontinence before surgery was cured of stress incontinence but continued to have significant urinary leakage as a result of detrusor overactivity. There appears to be less voiding dysfunction with this technique than with other sling procedures for stress incontinence. CONCLUSIONS: The sling procedure with a rectus abdominis muscle flap appears to be a viable surgical technique in the treatment of complicated stress incontinence. Further study is needed to assess the long-term results of this operation and to evaluate its proper place in reconstructive pelvic surgery. (Am J Obstet Gynecol 1996;175:1460-6.)     

Urodynamic and clinical assessment of the Lyodura sling operation for urinary stress incontinence

A Lyodura sling operation for urinary stress incontinence was performed on 36 patients. The success rate was 89%, when success was defined as absence of objective urine loss at coughing or straining, with full bladder in the upright position and during a Urilos test, at least 6 months after surgery. Full urodynamic assessment, including urethral rest and stress profiles, were performed before, and 6 months after, surgery. Success of the operation depended mainly on enhancement of urethral pressure transmission. Functional length of the urethra and maximal urethral pressure did not influence the success rate. The procedure is especially suitable in patients with some degree of uterine or vaginal prolapse.     

Urodynamic and clinical assessment of the Lyodura sling operation for urinary stress incontinence

Summary. A Lyodura sling operation for urinary stress incontinence was performed on 36 patients. The success rate was 89%, when success was defined as absence of objective urine loss at coughing or straining. with full bladder in the upright position and during a Urilos test. at least 6 months after surgery. Full urodynamic assessment, including urethral rest and stress profiles, were performed before, and 6 months after, surgery. Success of the operation depended mainly on enhancement of urethral pressure transmission. Functional length of the urethra and maximal urethral pressure did not influence the success rate. The procedure is especially suitable in patients with some degree of uterine or vaginal prolapse.     

The sloughed urethra syndrome

Sloughing of the urethra following obstetric trauma or pelvic surgery usually results in total urinary incontinence. Nine patients in a series of 2,000 investigated for incontinence presented with this syndrome. A technique of urethral reconstruction from the vaginal wall using a supporting bulbocavernosus graft and a Marlex sling is presented and results are discussed.     

The triangular vaginal patch sling for stress urinary incontinence and hypermobile urethra

OBJECTIVE: We describe an alternative sling procedure that permits concomitant correction of urethral hypermobility and urinary incontinence through a single surgical exposure. STUDY DESIGN: Fifteen women with severe urinary stress incontinence and urethral hypermobility underwent a sling procedure by creation of a simple triangular patch from the anterior vaginal wall. RESULTS: The mean operative time for the vaginal sling procedure was 38 minutes (range 29 to 65 minutes) in addition to other operations. The mean postoperative hospital stay was 7.7 days (range 5 to 13 days) and all patients were routinely discharged with an indwelling Foley catheter. Spontaneous micturition occurred in 12 patients after a mean period of 25 days (range 13 to 36 days). In three cases long-term catheterization was necessary. By subjective and objective evaluations, all the patients were cured of their stress incontinence. CONCLUSION: The triangular vaginal patch with the single sutures on each side provides an alternative approach for bladder neck stabilization that may permit a more anatomic suspension of a hypermobile urethra.(Am J Obstet Gynecol 1997;177:31)     

Prazosin: a neglected cause of genuine stress incontinence.

Prazosin, a common antihypertensive drug, lowers peripheral vascular resistance by selectively blocking alpha-1 adrenergic receptors on arteriolar smooth muscle. Alpha-1 adrenoceptor inhibition also has a relaxant effect on smooth muscle present in the urethra. Between 1985-1990, 58 of 1335 women (4.3%) seen in our urodynamic clinic with urinary incontinence and other urinary symptoms were taking prazosin. The incidence of genuine stress incontinence was significantly higher in women taking prazosin (86.2%) than in the non-prazosin group (65.7%) (P less than .01). Twenty-five of the 45 women contacted had their urinary incontinence improved or cured by prazosin withdrawal. All of these 25 women with prazosin-related urinary incontinence had stress incontinence. The incidence of previous bladder neck surgery in this group was over 50%, with 11 previous vaginal repairs, one Burch colposuspension, and one Aldridge sling procedure. Seven women who were continent after prazosin withdrawal had their urodynamic studies repeated. There was a significant increase in functional urethral length, maximum urethral closure pressure, and abdominal pressure transmission to the urethra following prazosin withdrawal, although no significant change was found in other cystometric measurements including peak flow rate and residual urine volume. In this study, prazosin was a frequently unrecognized cause of stress incontinence in women, many of whom had unsuccessful and possibly unnecessary surgery.     

A new classification of female stress urinary incontinence--based on transrectal sonographic cystourethrography.

A new classification of female stress urinary incontinence was made according to the results of transrectal ultrasonography of the urinary bladder and urethra (cystourethrography) studied in 67 women with genuine stress urinary incontinence (SUI). This classification is based on the following changes of the bladder and urethra on abdominal straining: hypermobility of the urethra, bladder neck incompetence, urethral sphincter incompetence and presence of a cystocele. Five types of SUI has been classified. We believe that this new classification can provide a better understanding of the anatomical changes as well as the pathophysiology of SUI. In addition, it can serve as a guideline of proper surgical management for SUI.     

Severe and Recurrent Stress Incontinence of Urine Treated by the Mersilene Gauze Hammock Operation

Summary: Severe and recurrent stress incontinence of urine in women presents many problems in management, especially in the elderly and the obese. The use of Mersilene gauze mesh as a modified Aldridge sling is presented as an alternative means of treatment in difficult cases where there are poor tissues to work with.
A series of 30 patients is presented with an 86% cure rate; the use of Mersilene as a broad sling beneath the bladder neck and urethra overcomes one of the main problems in the use of synthetic materials.     

Comparison of pubovaginal sling and burch colposuspension procedures in type I/II genuine stress incontinence

We compared morbidity and success rate of pubovaginal sling with Burch colposuspension operations in Type I/type II genuine stress urinary incontinence (GSI). The study included patients who had no preoperative detrusor instability (DI), no recurrent GSI, no severe pelvic prolapsus and whose Valsalva leak point pressure (VLPP) values were higher than 90 cm water. Twenty three of free-rectus fascial sling and 23 of Burch colposuspension operations were performed randomly on the patients by a single surgeon. There was no statistical difference between patients in terms of age, BMI, parity, number of daily pads used and preoperative bladder neck mobility. Operation time, change in hematocrit, spontaneous voiding time, length of hospitalization and urinary infection were not different in 2 procedures. 17 patients from both groups could be compared after one year. The bladder neck mobility of both groups were similar. One surgical failure, 1 DI, 1 severe cystocele and 1 enterocele were found in the Burch group while only 1 DI was found in the pubovaginal sling group. When pubovaginal sling operation was performed as the primary surgery on the patients with type I/II GSI, the morbidity, complications and 1 year success rate are the same as Burch procedure. Received: 24 July 2000 / Accepted: 6 December 2000     

The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine

The fascia lata sling procedure has been used over the past 22 years in our unit for treating recurrent urinary stress incontinence when irreparably poor local support tissues were suspected. Sixty-nine patients had undergone one previous operation to correct urinary stress incontinence. One hundred one patients had two or more previous operations. The cure rate for the condition of genuine stress incontinence has been 100% in the last 148 cases and 98.2% overall. However, the cure rate for the symptom of urinary stress incontinence was 92.4%. There were only three sling failures in the entire series, occurring in the first 22 cases. Ten other patients had urinary incontinence with stress because of motor urge incontinence. The most troublesome postoperative problem has been delayed voiding.     

Fascia lata urethrovesical suspension for recurrent stress urinary incontinence

Although the physiologic mechanisms of normal micturition in the female subject are not fully understood, it is generally believed that urinary continence is maintained by a competent urethrovesical neck. Unfortunately, the patient who has had multiple operations for recurrent stress urinary incontinence often has a urethra that is shortened and fixed in scar tissue. In such patients, anterior colporrhaphy with operative release of the periurethral fibrosis and plication of the endopelvic fascia to create a functionally more normal urethrovesical junction will increase the chances for good results. A fascia lata support of the proximal 1 to 2 cm of the urethra ensures continued elevation of the urethra and with stress the sling provides a pulling-up effect. Fifty patients with a suburethral sling procedure are presented in detail. Forty-seven of these patients had a total of 121 prior operative procedures for stress urinary incontinence. Urologic studies are outlined. Forty-two patients (84%) were continent postoperatively, five were improved, and three had failures. Operative technique and complications are discussed.     

Marlex gauze hammock sling operation with Cooper's ligament attachment in the management of recurrent urinary stress incontinence.

In 1970 Morgan described an operation designed to meet the problem created by scarring and fibrosis resulting from previous operative procedures to the urethra and bladder neck. In the method, a 2 cm wide polypropylene (Marlex) mesh is placed as a broad hammock to elevate and support the urethrovesical junction with lateral attachment at Cooper's ligament. Sixty-nine women operated upon by Morgan's technique have been followed up for 6 months to 8 years. In those with unmixed stress incontinence, 90% were dry at follow-up, whereas in those with a mixture of stress incontinence and symptoms of detrusor disturbance, only 50% were benefited.     

Treatment of stress incontinence by a fibrin bioplast.

A new simple method of treating urinary stress incontinence is to fix a fibrin implant vaginally to the bladder neck and upper urethra. The support provided by the implant is maintained after its resorption by the fibrous tissue which replaces it. The two-year cure rate in 85 patients was 93 per cent.     

Ultrasonographic and urodynamic evaluation after tension free vagina tape procedure (TVT)

BACKGROUND: This study was carried out to evaluate the urodynamic and ultrasonographic findings after tension-free vagina tape (TVT) procedure on stress urinary incontinent women. METHODS: Ninety women suffering from genuine stress incontinence without pelvic relaxation syndrome underwent surgery. Urodynamic measurement, one-hour pad test and introital ultrasonographic evaluation were performed preoperatively and one year after surgery. Additional ultrasonographic surveillance of the urethra was performed immediately after the operation. The position and mobility of the bladder neck was compared pre- and post-operatively in relation to the inferior edge of the pubic symphysis. RESULT: Eight women were excluded for various reasons. Among the 82 women who completed the study, 76 (93%) were cured, four were improved and two failed. No major intra- or post-operative complications occurred. The position and mobility of the bladder neck showed no significant difference before and after surgery. A urethral knee angle was noted ultrasonographically on cured and improved patients during maximum straining. Nine patients with immediate postoperative voiding difficulty were found to have a pronounced mid-urethra angulation. The symptom and sign were resolved by time after urethra depressing. Urodynamic assessment of the urethral pressure profile and other parameter showed no significant difference before and after the surgery except that a positive pressure transmission in the middle portion of the urethra was noted among 70 (87.5%) of cured and improved subjects. CONCLUSION: Tension-free vagina tape operation is an effective surgical procedure for the treatment of female urinary stress incontinence. The procedure seems neither to change hypermobility nor to elevate the position of bladder neck. Urinary continence after surgery is most probably achieved by creating a dynamic mid-urethral knee angulation by which the urethra is closed i.e. kinked at stress. Lifting of the mid-urethra resulted in postoperative voiding difficulty. It is the important that the tape is placed tension free under the urethra. Introital ultrasonographic surveillance is a suitable technique to visualize the result of the operation.     

Clinical and urodynamic assessment of the porcine dermis bladder sling in the treatment of genuine stress incontinence

Fifty women, aged between 37 and 76 years, underwent a bladder sling operation for urinary incontinence using porcine dermis. All patients had undergone previous unsuccessful vaginal surgery for genuine stress incontinence and had stable bladders. Thirty-nine patients (78%) were made continent of urine, both subjectively and on urodynamic testing.     

Transvaginal sonography in the postoperative evaluation of colposuspension

Thirty-two patients with cystocele and rectocele with complaints of genuine urinary stress incontinence were subjected to complete urodynamic study, including intravaginal endosonography, before the operation and 6 weeks and 1 year after the operation. Intravaginal endosonography demonstrated the anatomic correlation of the bladder base, neck, and proximal urethra in relation to the inferior border of the symphysis pubis. In 28 patients, satisfactory correction of the bladder anatomy was achieved with operative treatment of genuine stress incontinence (GSI). Four patients presented persistent and recurrent GSI (2 in each group) after several weeks postoperatively. In addition, 2 patients had frequency-urgency syndrome, and 3 had voiding difficulties after the operation, but with no symptomatology of GSI. The patients with the symptoms described had various anatomic configurations after colposuspension. Vaginal endosonography is a simple technique with many advantages and satisfactory results in preoperative postoperative study, without radiation exposure and with minimal inconvenience to the patient.     

Colposuspension and transvaginal bladder neck suspension in the treatment of stress incontinence

The present work was performed to evaluate the clinical usefulness of colposuspension in stress urinary incontinence without uterovaginal descent and bladder neck suspension in cases with uterovaginal descent. Modified Burch colposuspension was performed in 29 patients and modified Raz bladder neck suspension in 19 patients. The patients were examined clinically and urodynamically before and 8-12 months after operation. All patients in the colposuspension group regarded themselves as being totally continent postoperatively. In the bladder neck suspension group the respective figure was 58%, plus 21% showing improvement and 21% failures. Urodynamically, the cure rates (positive urethral closure pressure at stress) were 100% for colposuspension and 79% for bladder neck suspension. After colposuspension the urethral closure pressure at stress and the pressure transmission ratio were significantly increased whereas successful bladder neck suspension increased only urethral closure pressure at stress. The failed bladder neck suspensions did not induce any urodynamic changes. The present data confirms that Burch colposuspension is effective in stress urinary incontinence in women without simultaneous uterovaginal descent, whereas bladder neck suspension by the modified Raz technique did not appear to be optimal for the treatment of stress incontinence in patients with uterovaginal descent.     

A clinical and urodynamic study comparing the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence

Twenty women with urodynamically proven genuine stress incontinence were randomly allocated to treatment by suburethral sling or Stamey endoscopic bladder neck suspension. Urodynamic assessment was performed before and 3 months after surgery; clinical follow-up is reported up to 2 years. Blood loss was greater, and there were significantly more postoperative complications associated with the sling procedures. The subjective and objective cure rates at 3 months and 2 years were not significantly different between the two procedures. No significant changes in the resting urethral pressure profile were evident, although with both procedures, cure was associated with an enhancement in pressure transmission ratios in the proximal urethra. Detrusor instability occurring for the first time after operation was associated with both procedures; the sling, in addition, induced a significant degree of outflow obstruction, although this was not evident after the Stamey procedure.     

A clinical and urodynamic study comparing the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence

Summary. Twenty women with urodynamically proven genuine stress incontinence were randomly allocated to treatment by suburethral sling or Stamey endoscopic bladder neck suspension. Urodynamic assessment was performed before and 3 months after surgery; clinical follow-up is reported up to 2 years. Blood loss was greater, and there were significantly more postoperative complications associated with the sling procedures. The subjective and objective cure rates at 3 months and 2 years were not significantly different between the two procedures. No significant changes in the resting urethral pressure profile were evident, although with both procedures, cure was associated with an enhancement in pressure transmission ratios in the proximal urethra. Detrusor instability occurring for the first time after operation was associated with both procedures; the sling, in addition, induced a significant degree of outflow obstruction, although this was not evident after the Stamey procedure.