Suburethral sling procedure for genuine stress incontinence and low urethral closure pressure. A continued experience

Forty-eight patients with genuine stress incontinence and low urethral closure pressure have undergone a suburethral sling procedure using polytetrafluoroethylene. Forty-five of the 48 patients have been followed up beyond 3 months, allowing assessment of postoperative complications. Ten patients required intermittent self-catheterization, 6 continuing beyond 3 months secondary to obstructed voiding or vesical dysfunction. Six slings were removed due to graft infection and/or vaginal mucosa erosion. All patients who were continent prior to removal remained so afterwards. Two slings were loosened secondary to obstructed voiding (1 patient experienced improved voiding, the other continued intermittent catheterization). Sixty-two per cent (28/45) of the patients followed, developed at least one documented urinary tract infection. Thirty-four of the 45 patients followed, underwent postoperative multichannel urodynamic testing. Ten patients (29%) demonstrated postoperative detrusor instability (5 were new onset, 5 were persistent). Six improved with medication and bladder retraining drills. Twenty-eight of the 34 patients tested (82.4%) were objectively cured of genuine stress incontinence. In spite of the complications noted, this suburethral sling procedure offers a high success rate and is a viable alternative in treating patients with genuine stress incontinence and low urethral closure pressure. Modifications in surgical technique have been made to reduce postoperative complications in the future.     

Tension-free vaginal tape sling for recurrent stress incontinence after transobturator tape sling failure

The transobturator tape (TOT) sling is a new minimally invasive technique to treat stress urinary incontinence (SUI). Short-term follow-up studies show high success rates; however, as with any surgical treatment of SUI, failures are known to occur. The treatment of recurrent or persistent stress urinary incontinence after a TOT sling is therefore a new dilemma as well. In this paper, we describe the successful use of a retropubic tension-free vaginal tape (TVT) sling in five patients after failed TOT sling. We present case series of five patients who had TOT slings placed for stress incontinence that failed and subsequently had TVT slings placed for persistent SUI. The TVT slings were placed under local/regional anesthesia without removal of the TOT sling. Retrospective chart review of office and hospital charts was completed, and both objective and subjective data were collected. Five patients had TVT slings placed 6–30 weeks after early failure of TOT slings that were placed for stress urinary incontinence. Postoperatively, all patients with urodynamic testing showed evidence of intrinsic sphincter deficiency; however, all maintained urethral mobility of 30°. All five patients had successful treatment of their incontinence with the retropubic tension-free sling procedure with a mean follow-up of 17 months. Recurrent or persistent stress urinary incontinence after TOT sling may be treated with TVT sling without removal of the TOT sling. Further studies with larger numbers and longer-term follow-up is warranted.     

Clinical and urodynamic re-evaluation of combined abdominovaginal Marlex sling operations for recurrent stress urinary incontinence

Sixty-five women underwent combined abdominovaginal Marlex sling procedures for recurrent stress urinary incontinence. Urodynamic evaluation consisted of uroflowmetry and simultaneous pelvic electromyographic (EMG) studies, carbon dioxide cystometry, urethral pressure profilometry, and cystometry and urethroscopy. Cure rates were 75% for urgency incontinence and 95.3% for stress incontinence. The statistically significant improvements in pre- and postoperative urodynamic parameters involved a decrease in uroflow volumes and an increase in urethral functional length, but not in maximum urethral closure pressure. Bladder capacity remained unchanged.     

The surgical results of the pubovaginal sling procedure using Intravaginal Slingplasty (IVS) for stress urinary incontinence

Objective: We investigated the surgical results and complications of the Intravaginal Slingplasty (IVS) procedure in women with stress urinary incontinence. Patients and methods: A total of 72 women with urethral hypermobility underwent the pubovaginal sling procedure using IVS with a mean age of 50.35±9.07 years. Average Body Mass Index, mean parity and daily mean pad usage was 29.2±3.5, 3.7±1.74 and 2.9±1.76, respectively. Preoperative urge incontinence was observed in 61.12% of the patients. The mean follow-up was 13.87±2.4 months. The operative time, postoperative urge symptoms, de novo detrusor instability and complications were all documented. Results: The mean operating time was 25 min (18–40 min). Though postoperative first monthly controls proved 95.8% total dryness, the cure and improvement rates declined to 45.4% and 24.2% in 66 patients who completed 1 year of follow-up. The overall success and patient satisfaction rates were 69.6% and 87.5% respectively. De novo detrusor instability was observed in five patients (6.9%) whereas detrusor instability persisted in 25% of the patients. Bladder perforation and prolonged urinary retention developed in 11.1% of the patients. No signs of hematoma, infection and erosion were detected. Conclusion: IVS is an easy procedure with low complication rates and it takes about 25 min. In spite of lower cure rates than the alternative surgical techniques, patient satisfaction rates seemed to be similar. Low cure rates may be due to either from inappropriate patient selection or from the biochemical and biomechanical properties of the polypropylene mesh. For this reason, randomized controlled trials and animal experiments should be evaluated for a further decision on the success rates.     

Surgical treatment of urinary stress incontinence using a method for postoperative adjustment of sling tension (Remeex System)

We present a technique that allows postoperative adjustment of the sling tension in female patients with urinary stress incontinence (USI). Twenty-one female patients with urodynamically proven USI were prospectively evaluated. Subjective and objective evaluation was made preoperatively, 6 months postoperatively and yearly thereafter. Mean age was 63.5; mean parity was 2.3. All patients were postmenopausal and 13 (62%) had had previous surgery for USI. The operating time was 32 minutes (range 25–45). At a mean follow-up of 12 months (6–25), 19 patients (90.5%) were very satisfied. Two patients (9.5%) were considered failures but subjectively were satisfied and refused readjustment. One patient (4.7%) developed 'de novo' detrusor instability. In conclusion, this is a sling procedure for patients with previous failed surgery and those with intrinsic sphincter deficiency (ISD) with the peculiarity that the sling tension can be regulated postoperatively. The readjustment can be made in the office, months or even years after the procedure.Abbreviations USI Urinary stress incontinence - ISD Intrinsic sphincter deficiency - MUCP Maximum urethral closure pressure - VLPP Valsalva leak-point pressureEditorial Comment: Adjusting the sling tension of a bladder neck sling at the time of surgery is diffucult and not very scientific. Slings that are too tight are associated with voiding dysfunction and De Novo urge incontinence. Slings that are too loose may still allow stress incontinence. This sling system allows the surgeon to leave very loose at the time of surgery with the ability to tighten or loosen the sling easily in the post-operative period to achieve continence and still maintain adequate voiding function. Data on long term success or need for surgical removal is not available. The ability to tighten or, more importantly, loosen this sling at a later time in the post-operative period when scarring has occured is not known at present.     

In vivo comparison of suburethral sling materials

In vivo tissue responses were compared for three commercially available polypropylene suburethral slings that differ markedly in fabric structure and in size of resulting interstices and pores. All three elicited the same basic inflammatory response; however, individual fabric structures produced distinct differences in tissue formation within each mesh. The presence of numerous, closely spaced, small diameter filaments prevented formation of extensive fibrous connective tissue within two slings (ObTape and IVS Tunneller mesh). The much larger diameter monofilament and open knit structure of the Monarc sling permitted the most extensive fibrous tissue integration. These differences may be of interest to physicians considering clinical use.     

Clinical and urodynamic evaluation of the polypropylene (marlex) sling for genuine stress incontinence

Ten women undergoing a polypropylene suburethral sling procedure for treatment of genuine stress incontinence were assessed pre- and post-operatively by standard urodynamic methods and by urethral pressure profile measurements at rest and on stress. Eight patients were subjectively and seven objectively cured of stress incontinence. A significant reduction in urine flow rate was found although this appeared to be of little relevance to the successful outcome of surgery. An increase in resting urethral profile length was seen in both successful and unsuccessful cases. The former also had an improvement in maximum urethral closure pressure on stress due to improvement in pressure transmission in the proximal three quarters of the functional urethral length. The urethra appeared relocated in a retropubic position following successful and unsuccessful operations. It is likely that failure was associated with periurethral fibrosis causing failure of pressure transmission despite adequate elevation.     

Use of the adjustable trans-obturator male sling system for the treatment of male incontinence. An initial experience

ObjectiveTo evaluate the safety and efficacy of the “Adjustable Trans-Obturator Male Sling System (ATOMS)” as a new surgical technique for the treatment of different types of male urinary incontinence.Subjects and methodsBetween March 2012 and December 2013, 9 patients with a mean age of 56 (range 15–74) years were operated for urinary incontinence using the ATOMS system. Incontinence had developed following bladder exstrophy repair in 2, after radical cystectomy with construction of an orthotopic neobladder in 3, after transvesical open prostatectomy in one and after radical prostatectomy in 3 patients. Preoperative evaluation included a detailed medical history, physical examination, 24-h pad tests, urodynamic assessment and sonography.ResultsThe mean number of pads used preoperatively was 4.6 (range 3–6). The mean operative time was 45 (range 36–50) min. No intraoperative complications were encountered. The mean hospital stay was 3.8 (range 3–6) days. Transient perineal/scrotal pain was observed in 6 patients (66.7%) and controlled with non-opioid analgesics. There were no perineal infections; however, two port infections occurred (22.2%) and repositioning of the port was done in these cases. At a mean follow-up of 9 (range 6–12) months, the overall success rate was 100% with 77.8% of the patients being completely dry (0 pads per 24 h) and 22.2% using less than 2 pads per 24 h.ConclusionsOur early experience demonstrated that the ATOMS system may be a safe and effective procedure for the treatment of male urinary incontinence. It has the advantage of being feasible any time after an operation when necessary. However, long-term follow-up on a large number of cases is required to ensure its long-term efficacy and safety.     

The pathophysiology of genuine stress incontinence

Urinary continence in the female is maintained as long as intraurethral pressure exceeds bladder pressure. The elements which maintain this condition at rest and during stress include: internal urethral sphincter, external urethral sphincter, anatomic support of the urethrovesical junction, and intact innervation. Urethral junction and presence of genuine stress incontinence may be best assessed by measurement of resting and stress urethral closure pressure profiles using multichannel urodynamic testing. The findings subsequent to urethral closure pressure profilometry influence the kind of therapy selected, including types of surgery, when this treatment option is chosen.     

Gore-tex sling urethral suspension in type III female urinary incontinence: Clinical results and urodynamic changes

The authors prospectively evaluated 24 consecutive female patients with type III stress urinary incontinence, ranging in age from 36 to 70 years (mean 55 years). All patients were operated upon and had a vesicourethral suspension by a Gore-Tex suburethral sling. All were evaluated urodynamically 6 and 30 months after surgery. In this group of patients clinical cure of incontinence was observed in 83.3% (20) and in the remaining 4 patients it was significantly improved. In 2 patients there was an erosion of the urethra and the sling had to be removed 3.5 years later. Five other women remained dry but complained of occasional irritative symptoms, and several urinary tract infections were recorded (2–3 per year), which were documented by positive urine cultures. In the remaining 17 patients no erosion was observed and no irritative symptoms were reported. The urodynamic evaluation revealed an excellent postoperative result both 6 months and 30 months after surgery. EDITORIAL COMMENTS: This study reports the author’s experience with the use of the Gore-Tex suburethral sling procedure in women with type III stress incontinence, excluding patients with urethrovesical junction hypermobility. Diagnosis is based on videourodynamic criteria, as is postoperative follow-up and the definition of cure/failure. It is interesting that the technique used specifically refrains from placing extensive tension on the sling, although extra sutures are placed attaching the sling to ‘fascial tissue in the vicinity of the puboiliac bone’, even including the periosteum. Typically the use of a sling procedure in patients with a fixed drainpipe urethra has been based on the obstructive characteristics of the sling, rather than giving support to an already well supported urethrovesical junction. Previous reports have described postoperative voiding dysfunction requiring intermittent self-catheterization, recurrent urinary tract infections, elevated postvoid residuals and detrusor instability as possible consequences of ‘tight’ slings. Hints that these sequelae did occur in the study population include the high incidence of urinary tract infections and detrusor instability (persistent and de novo), and the fact that 2 patients required removal of the sling because of erosion into the urethra. Although the authors report a significant cure rate (84%) of stress incontinence, clearly this report again cautions against the use of slings in patients with ISD and a well supported bladder neck.     

Narrative review of male urethral sling for post-prostatectomy stress incontinence: sling type,patient selection,and clinical applications

Male stress urinary incontinence (SUI) following prostate treatment is a devastating complaint for many patients. While the artificial urinary sphincter is the gold standard treatment for male SUI, the urethral sling is also popular due to ease of placement, lack of mechanical complexity, and absence of manual dexterity requirement. A literature review was performed of male urethral sling articles spanning the last zz20 years using the PubMed search engine. Clinical practice guidelines were also reviewed for comparison. Four categories of male urethral sling were evaluated: the transobturator AdVance and AdVance XP, the bone-anchored InVance, the quadratic Virtue, and the adjustable sling series. Well selected patients with mild to moderate urinary incontinence and no prior history of radiation experienced the highest success rates at long-term follow up. Patients with post-prostatectomy climacturia also reported improvement in leakage after sling. Concurrent penile prosthesis and sling techniques were reviewed, with favorable short-term outcomes demonstrated. Male urethral sling is a user-friendly surgical procedure with durable long-term outcomes in carefully selected men with mild stress urinary incontinence. Multiple sling types are available with varying degrees of efficacy and complication rates. Longer follow-up and larger cohort sizes are needed for treatment of newer indications such as climacturia as well as techniques involving dual placement of sling and penile prosthesis.     

Placard-shaped in situ vaginal wall sling for the treatment of stress urinary incontinence

PURPOSE: To evaluate the efficacy of a simple and economic procedure using a placard-shaped in situ anterior vaginal wall sling for the treatment of stress urinary incontinence, with or without cystocele repair. METHODS: From July 2003 to July 2004, 14 female patients (mean age 45.21 years, range 37-57) were operated upon because of stress urinary incontinence (SUI) with the placard-shaped in situ anterior vaginal wall sling technique. The average follow-up period was 11 months (range 4-14.5 months). Twelve patients were operated primarily with this technique and only two patients had undergone previous surgeries for the treatment of SUI (one patient had had two previous surgeries and the other had had one previous surgery). In all patients urethral hypermobility or/and bladder prolapse were observed. Filling cystometry showed sufficient bladder capacity with no detrusor overactivity. RESULTS: No urinary retention was observed in any patient in the postoperative period. While 11 patients have 100% cure of incontinence, three patients started leakage of urine after 1-2 months after the operation (one patient had been operated upon twice before (and who was diabetic and obese) and two patients were primarily repaired by our technique). In two patients, suprapubic tenderness and redness were observed, and were treated by oral antibiotic and anti-inflammatory drugs. CONCLUSION: The placard technique is simple, cost-effective and has low incidence of urinary retention in the post-operative period. The success rate seems to be satisfactory and it can be applicable to patients who are primary cases of SUI with average body mass index. Yet longer term follow up and larger number of patients are needed before final conclusion can be drawn.     

Transvaginal electrical stimulation in the treatment of genuine stress incontinence and detrusor instability

Electrical stimulation has been widely used in Europe to treat incontinence, but original studies and overall use of the device has been limited in North America. Forty-five patients with documented genuine stress incontinence, detrusor instability or mixed incontinence had self-administered therapy for 15 minutes twice daily, for a duration of 6 weeks. Treatment was delivered by a new stimulation device with an attached vaginal probe. Patients recorded treatment times, leak episodes and pad use. Objective measures included a pad test, standing stress test, standing CMG, and resting and dynamic urethral closure pressure profiles. The subjective success rates based on a questionnaire were 71% for genuine stress incontinence, 70% for detrusor instability, and 52% for combined incontinence. Objective testing for both types of incontinence did not show significant improvement after treatment. Four patients reported pain during use of the device, but most wished to continue the device in preference to other therapy.Supported in part by a grant from Hollister Incorporated.     

加压尿道压力测定在压力性尿失禁诊断与治疗中的应用

目的应用加压尿道压力测定（ＳＵＰＰ）方法诊断真性压力性尿失禁（ＧＳＩ）,并评价其手术疗效。方法对２２例临床诊断为ＧＳＩ的患者进行ＳＵＰＰ及静态尿道压力测定（ＲＵＰＰ）,比较其结果,并对５例接受手术治疗的女性患者术后再次进行ＳＵＰＰ,以１７例正常女性作为对照组。结果２２例患者ＳＵＰＰ结果中尿道闭合压（ＵＣＰ）为－０６２±０２２ｋＰａ,压力传导率（ＰＴＲ）为０６８±００６;与ＲＵＰＰ比较ＳＵＰＰ对ＧＳＩ的诊断阳性率为９００％,高于ＲＵＰＰ的７７３％;两者的诊断符合率为６８２％;ＲＵＰＰ阳性而ＳＵＰＰ阴性者２例,相反者有５例。５例ＧＳＩ女性患者经手术治疗后,ＳＵＰＰ测定各参数明显改善,各患者术前、术后ＵＣＰ及ＰＴＲ明显增高。结论ＳＵＰＰ在ＧＳＩ的诊断与疗效评价中均具有一定意义,但也具有某些局限性;临床应用时应与其它方法结合使用,以提高诊断水平     

经耻骨后与经闭孔尿道吊带术治疗女性压力性尿失禁中远期疗效比较

目的 探讨经耻骨后(SPARC)与经闭孔(TOT)路径尿道吊带术治疗女性压力性尿失禁(SUI)的中远期疗效及安全性.方法 回顾性分析2008年9月至2011年1月收治尿动力学资料完整的SUI患者275例,分别行SPARC吊带术(136例)和TOT吊带术(139例).随访3～ 28个月,平均19.4个月.填写国际尿失禁咨询委员会尿失禁问卷简表(ICI-Q-SF),国际盆底器官脱垂/尿失禁患者性生活质量问卷简表(PISQ-12),分组测量膀胱残余尿量(PVR)、最大尿流率(Qmax),比较两种术式的中长期疗效和并发症.结果 ①TOT组手术时间(25.1±3.3) min,SPARC组(34.8±5.6) min,组间差异有统计学意义(P=0.00);②TOT组症状评分由术前(7.0±1.9)分降至末次随访(0.4±1.2)分,QOL评分由术前(6.2±2.0)分降至(1.1±1.4)分;SPARC组症状评分由(7.2±2.1)分降至末次随访(0.6±1.7)分,QOL评分由(6.6±2.0)分降至(1.0±1.6)分;2组评分与术前比较差异均有统计学意义(P=0.00).TOT组有性生活患者PISQ-12评分由术前(24.2±5.0)分增至末次随访(29.5±4.8)分,SPARC组由(23.0±4.4)分增至(26.9±4.8)分,与术前比较差异均有统计学意义(P＜0.05).TOT组总治愈率89.9％,有效率94.2％;SPARC组总治愈率89.0％,有效率91.2％,2组比较差异无统计学意义(P＞0.05).③TOT组术后短期排尿障碍23例,SPARC组20例,均于术后1～2周内缓解.④TOT组和SPARC组术前Qmax分别为(30.2±8.7)、(31.7±9.4)ml/s,术后1周内降至(24.9±8.6)、(26.9±8.9)ml/s;PVR分别由术前(1.6±4.2)、(1.4±3.7)ml增至术后(3.2±6.5)、(3.5±6.3)ml,手术前后差异均有统计学意义(P＜0.05).TOT组患者术后3个月(109例)Qmax为(31.5±8.2)ml/s,PVR(2.6±5.4) ml;术后12个月(69例)Qmax为(29.2±7.9) ml/s,PVR(3.2±7.3)ml;术后≥24个月(30例)Qamx为(27.6±9.4)ml/s,PVR(7.4±9.4)ml;随访阶段数据与术前比较差异无统计学意义(P＞0.05).SPARC组患者术后3个月(106例)Qmax为(29.2±8.9) ml/s,PVR(3.6±7.2) ml;术后12个月(65例)Qmax为(28.2±8.3)ml/s,PVR(4.6±7.2)ml;与术前比较差异均无统计学意义(P＞0.05).但SPARC组术后≥24个月患者(30例)Qmax为(26.2±9.1 )ml/s,PVR为(4.7±8.8)ml,与术前相比差异均有统计学意义(P＜0.05).结论 经闭孔路径及经耻骨后路径尿道吊带术治疗SUI中、远期疗效均满意,但前者在安全性、微创及并发症等方面更有优势.     

Fascia lata sling cystourethropexy for the management of female urinary incontinence

Pubovaginal sling cystourethropexy has rapidly become one of the primary surgical treatment options for women with urinary incontinence. The procedure has evolved over time with regard to clinical indications, patient selection criteria and surgical techniques. This article reviews the historical development of pubovaginal sling cystourethropexy, including recent technical advances. The selection of graft materials is considered and the utility of fascia lata emphasized. Clinical results and potential complications of the procedure are also reviewed.     

改良Stamey手术治疗压力性尿失禁（附32例报告）

报告１９８６年７月以来应用Ｓｔａｍｅｙ手术，并以自制长导针将该法加以改进治疗女性压力性尿失禁共３２例，无明显并发症。术后平均随访３．６年，治愈９０．６％（２９／３２），改善６．２％（２／３２），失败３．２％（１／３２），并就Ｓｔａｍｅｙ手术的手术径路，尿道膀胱连接部的确认和悬吊力量大小的确定进行讨论。     

Polytetrafluoroethylene patch sling for type 2 or type 3 stress urinary incontinence

BACKGROUND: Surgical success rates and complications of anti-incontinence surgery were evaluated according to the type of stress incontinence and the type of surgery. METHODS: From 1989 to 1998, we treated 137 women for stress urinary incontinence with anti-incontinence surgery. Of the 137 patients, 110 had type 2 stress urinary incontinence and 27 had type 3 stress urinary incontinence. Of 110 patients with type 2 stress urinary incontinence, 57 underwent pubovaginal sling procedure and 53 were treated with the Gittes procedure. All of the patients with type 3 stress urinary incontinence underwent the pubovaginal sling procedure. RESULTS: Cure rates with the pubovaginal sling procedure were 82% in type 2 incontinence and 70% in type 3 incontinence. Cure rates with the Gittes procedure were 56%. The occurrence of de novo urge symptom and pelvic pain was low and bore no relation to either operative method or type of stress incontinence. CONCLUSIONS: The pubovaginal sling procedure using the polytetrafluoroethylene patch was effective for type 2 or 3 stress urinary incontinence.