OUR EXPERIENCE WITH PUBOVAGINAL SLINGS IN PATIENTS WITH STRESS URINARY INCONTINENCE

Purpose

Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling.

Materials and Methods

A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency.

Results

The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence.

Conclusions

Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.     

Expanded Indications for the Pubovaginal Sling: Treatment of Type 2 or 3 Stress Incontinence

Purpose

The usefulness of the pubovaginal sling procedure as primary treatment of stress incontinence associated with urethral hypermobility (type 2) or intrinsic sphincter deficiency (type 3) was determined.

Materials and Methods

A total of 60 consecutive cases of type 2 or 3 stress urinary incontinence was treated with a pubovaginal sling by 1 surgeon using a previously reported technique. Fluoroscopic urodynamic studies with leak point pressures were used to classify the type of incontinence. Of the 60 women 38 (63 percent) were diagnosed with type 2 and 22 (37 percent) with type 3 stress urinary incontinence. Of these patients 24 had previously undergone 1 or more anti-incontinence procedures.

Results

At a mean followup of 25 months 57 of the 60 patients (95 percent) were completely continent. In addition, 69 percent of patients with urgency had resolution of the urgency symptoms following the sling procedure. Transient postoperative urinary retention (median duration 6.5 days) was present in 60 percent of the patients. However, all women subsequently voided spontaneously without requiring further intermittent or Foley catheterization. Other complications occurred infrequently, and included urinary tract infection (13 percent of cases), de novo urgency (12 percent) and persistent incisional pain (5 percent).

Conclusions

These early results suggest that the pubovaginal sling is a safe and effective treatment for primary or recurrent type 2 or 3 stress incontinence. The most worrisome complication, urinary retention, occurred temporarily in more than half of the patients but eventually resolved in all cases, usually within 10 days.     

Pubovaginal sling surgery for simple stress urinary incontinence: analysis by an outcome score

PURPOSE: We assessed the results of pubovaginal sling surgery in women with simple stress urinary incontinence using strict subjective and objective criteria. MATERIALS AND METHODS: Simple incontinence was defined as sphincteric incontinence with no concomitant urge incontinence, pipe stem or fixed scarred urethra, urethral or vesicovaginal fistula, urethral diverticulum, grade 3 or 4 cystocele, or neurogenic bladder. A total of 67 consecutive women with a mean age plus or minus standard deviation of 56 +/- 11 years who underwent pubovaginal sling surgery for simple sphincteric incontinence were prospectively followed for 12 to 60 months (mean 33.9 +/- 22.2). Treatment outcomes were classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence, as documented by 24-hour diary and pad test, with the patient considering herself cured. Failure was defined as poor objective results with the patient considering surgery to have failed. Cases that did not fulfill these cure-failure criteria were considered improved and further classified into a good, fair or poor response. RESULTS: Of the 67 patients 46 (69%) had type II and 21 (31%) had type III incontinence. Preoperative diary and pad tests revealed a mean of 5.9 +/- 3.6 stress incontinence episodes and a mean urinary loss of 91.8 +/- 81.9 gm. per 24 hours. There were no major intraoperative, perioperative or postoperative complications. Two patients (3%) had persistent minimal stress incontinence and 7 (10%) had new onset urge incontinence within 1 year after surgery. Overall using the strict criteria of our outcome score 67% of the cases were classified as cured and the remaining 33% were classified as improved. The degree of improvement was defined as a good, fair and poor response in 21%, 9% and 3% of patients, respectively. CONCLUSIONS: Mid-term outcome results defined by strict subjective and objective criteria confirm that the pubovaginal sling is highly effective and safe surgery for simple sphincteric incontinence. A followup of more than 5 years is required to establish the long-term durability of this procedure.     

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.     

Suburethral sling at the time of radical prostatectomy in patients at high risk of postoperative incontinence

OBJECTIVE: To evaluate the insertion of a urethral sling at the time of radical prostatectomy (RP) in men at high risk of urinary incontinence after RP. PATIENTS AND METHODS: Between 1998 and 2000, 49 of 871 men undergoing RP at The University of Texas M.D. Anderson Cancer Center, were identified as at risk of urinary incontinence after RP, based on their age (>65 years), previous transurethral resection of the prostate, previous radiation therapy, clinical stage, and obesity (body mass index of > or = 30 kg/m2). These 49 men had a suburethral sling inserted at the time of RP, and incontinence after surgery was evaluated using pad counts and patient-completed questionnaires. Retrospectively, incontinence rates and complications in these men were compared with 122 men also at high risk of urinary incontinence after RP who did not have a sling inserted at the time of RP (control group). RESULTS: In all, 29 of 49 men (59%) with a suburethral sling reported using either no pad or one pad per day for urinary leakage at 6 months after RP, compared with 83 of 118 (70%) in the control group. At 12 months after RP, 34 of 46 (74%) men with a suburethral sling reported using no or one pad, compared with 75 of 89 (84%) in the control group. Seventeen (35%) men were treated for urethral stricture in the sling group and 17 (14%) in the control group (P = 0.001). CONCLUSIONS: The urethral sling modification concurrent with RP is feasible, but does not decrease incontinence compared with a similar group of high-risk patients who did not have the sling modification. In addition, the stricture rate in the sling group was unacceptably high. Currently, we do not recommend the use of a urethral sling at the time of RP.     

The YAMA UroPatch sling for treatment of female stress urinary incontinence: a pilot study

BACKGROUND AND PURPOSE: We report our initial experience using a new suburethral sling made from bovine pericardium for the treatment of urinary incontinence. To prevent rolling and curling of the sling, a unique anti-roll clip is incorporated into the UroPatch. In addition, the sling has a series of perforations that create evenly distributed tissue integration and avoid delayed seroma or hematoma formation, thereby reducing the risk of sling rejection, infection, and erosion. PATIENTS AND METHODS: Twenty-two female patients underwent suburethral sling procedures using the UroPatch. All patients demonstrated urethral hypermobility, intrinsic sphincteric deficiency, or both. Five patients had previous surgical treatment for urinary incontinence. RESULTS: All operations were completed successfully. No intraoperative or postoperative complications occurred. There was no evidence of local or systemic reaction to the UroPatch in any of the patients. With a mean follow-up of 20 months, sling rejection, erosion, or infection has not been demonstrated, and no sling required removal to date. Urinary incontinence was corrected in all but one case. CONCLUSION: The results of this pilot study suggest that the UroPatch is a promising alternative to current slings for the treatment of female urinary incontinence.     

Is modified in situ vaginal wall sling operation the treatment of choice for recurrent genuine stress incontinence?

PURPOSE: We evaluate objectively the results of a modified in situ vaginal wall sling operation for recurrent genuine stress incontinence and whether it is a substitute for the traditional sling procedure. MATERIALS AND METHODS: A total of 23 patients with urodynamically proved recurrent genuine stress urinary incontinence were recruited in this study. Patients were treated with a modified needle urethropexy technique using an island of in situ vaginal skin as a sling to support the bladder neck and urethra. Surgical outcome was evaluated subjectively and objectively at a median of 15 months. A total of 42 patients who underwent a traditional polytetrafluoroethylene sling operation served as controls. RESULTS: The cure rate of the vaginal wall sling operation was 34.8% by objective assessment, which was lower than that of the traditional sling procedure (88.1%, p <0.05). The subjective success rate demonstrated the same results (vaginal sling 60.9% versus traditional sling 92.9%, p <0.05). The risk factors for operation failure were lower maximal urethral pressure, lower urethral closing pressure, narrow vaginal capacity and previous anterior colporrhaphy or a Stamey operation (all p <0.05). In 3 cases suburethral epithelial inclusion cysts were specific complications of the operation. There was no prolonged urinary retention or urethral erosion. CONCLUSIONS: Based on our results, we do not believe that the vaginal wall sling operation should be recommended for all recurrent genuine stress urinary incontinence cases and especially not for those with factors predictive of surgical failure. Further studies are needed to investigate and clarify the possible causes of failure.     

Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure

PURPOSE: We evaluated the success of several techniques for treating urethral obstruction and erosion after a pubovaginal sling procedure. MATERIALS AND METHODS: Between April 1998 and June 1999, 32 women 33 to 79 years old (average age 62) who underwent a pubovaginal sling procedure with various materials were referred for the assessment of urethral obstruction. Patients were evaluated with a urogynecologic history, physical examination, voiding diary, cystoscopy and video urodynamics. Surgical procedures to resolve urethral obstruction were performed transvaginally and the specific techniques used were based on the type of sling material, urethral erosion and concomitant stress incontinence or other urethral pathology. Outcome measures were assessed by disease specific quality of life questionnaires, voiding diary and urogynecologic questionnaire. RESULTS: Preoperatively 30 of the 32 women (93.7%) noticed urge incontinence, 20 (62.5%) performed intermittent self-catheterization, 6 (18.7%) had an indwelling catheter and 3 (9%) complained of concomitant stress urinary incontinence. After the sling takedown 29 patients (93.5%) achieved efficient voiding within week 1 postoperatively. Urge incontinence symptoms resolved in 20 cases (67%) but stress incontinence developed in 3 (9%). Of the 32 women 27 (84%) indicated that continence was much better than before the initial sling procedure. CONCLUSIONS: Managing urethral obstruction after a pubovaginal sling procedure is challenging. Using various techniques based on sling material, urethral erosion and bladder neck integrity a successful outcome is possible in the majority of cases.     

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.     

尿道压监测下球部尿道悬吊术治疗男性获得性尿失禁

目的探讨尿道压监测下球部尿道悬吊术治疗男性获得性尿失禁的疗效。方法2000年lO月至2004年9月收治男性获得性尿失禁25例，年龄18～81岁，平均66岁。其中后尿道狭窄行尿道成形术后6例，根治前列腺切除术后4例，良性前列腺增生（BPH）行经尿道前列腺电切术（TURP）后6例，BPH行前列腺摘除术后9例。尿失禁病程1～12年，平均4年。完全性尿失禁8例，压力性尿失禁17例，需尿垫1～5块／d，平均3块／d。术前均经盆底肌锻炼无效。尿动力学检查平均最大尿道压52cm H2O（1cm H2O=0．098kPa）。平均功能性尿道长度1．4cm。均在尿道压监测下行球部尿道悬吊术。结果手术结束时平均尿道压96cm H2O，平均功能性尿道长度3．5cm。术后完全控尿21例，尿失禁改善3例，排尿困难1例，经膀胱颈部电切后排尿通畅。术后1个月B超检查剩余尿均〈20ml；23例平均最大尿流率15ml／s。随访1年以上22例，1例于术后2年死于脑溢血，2例于术后1年和2年压力性尿失禁复发，其余19例排尿和控尿良好。结论尿道压监测下球部尿道悬吊术是治疗男性尿失禁的有效方法。     

Rectus fascial sling for the treatment of neurogenic sphincteric incontinence in boys: is it safe and effective?

PURPOSE: While a fascial sling for treating children with intractable urinary incontinence is often successful in girls, its effectiveness in boys remains unclear. We determined the long-term efficacy of a rectus fascial sling in boys with neurogenic sphincteric incontinence and defined its urodynamic characteristics for achieving continence. METHODS AND METHODS: We reviewed the charts of all boys who underwent a rectus fascial sling procedure for neurogenic incontinence to determine urinary continence status at the most recent office visit or by telephone interview, the type and dose of anticholinergic and sympathomimetic medications, the frequency of intermittent clean intermittent catheterization, status of the upper urinary tract and comparative urodynamic findings preoperatively and postoperatively. RESULTS: We evaluated 7 boys 7 to 19 years old, of whom 4 were postpubertal, who fulfilled study criteria and had a followup of 1 to 9 years. In 4 patients a continent stoma was created concurrently at surgery. Postoperatively all patients were dry during the first 3 months after surgery. At the last followup 1 patient was completely dry, 3 had occasional nighttime wetting, 2 had occasional stress incontinence, and 1 had frequent daytime and nighttime wetting requiring subsequent bladder neck closure. Prepubertal and postpubertal males performed catheterization without difficulty and all required less frequent clean intermittent catheterization and medication postoperatively compared to preoperative status. None had hydronephrosis. Postoperatively urodynamic evaluation revealed normal bladder compliance, improved urethral resistance that did not decay with bladder filling and no uninhibited contractions. CONCLUSIONS: The rectus fascial sling is effective for increasing bladder outlet resistance and decreasing the degree of incontinence in prepubertal and postpubertal males with neurogenic sphincteric incontinence. It has no long-term deleterious effects on bladder function and does not impair the ability to catheterize postoperatively. A fascial sling is an effective alternative to bladder neck closure when creating a continent stoma.     

Prospective analysis of patients treated with a distal urethral polypropylene sling for symptoms of stress urinary incontinence: surgical outcome and satisfaction determined by patient driven questionnaires

PURPOSE: We evaluated the safety and efficacy of the distal urethral polypropylene sling for stress urinary incontinence using patient self-assessment by questionnaires. MATERIALS AND METHODS: We performed a prospective study of all consecutive patients who underwent a mid distal urethral sling procedure between November 1999 and February 2002. Surgical outcome was determined by symptom, bother and quality of life questionnaires completed by the patients. The physicians were blinded to patient responses. These outcomes were compared to the SEAPI determined by the physician and to physical examination findings. RESULTS: There were 301 patients, of whom 2.3% required treatment for persistent stress urinary incontinence (SUI) after the polypropylene sling procedure. In the 92 patients with a minimum followup of 12 months the objective cure rate was 92%. The patient determined subjective success rate (cure and improved greater than 50%) was 89%. On questionnaires only 69% of the patients reported no symptoms of SUI under any circumstance and the same number reported never being bothered by SUI. The physician determined SEAPI overestimated patient self-reported symptoms by 10% to 50% depending on the symptom. CONCLUSIONS: The polypropylene sling represents an inexpensive, safe and simple alternative treatment for patients with stress urinary incontinence. The procedure provides high objective and physician determined cure rates but a lower patient self-reported subjective cure rate. Patient self-assessment of symptoms, bother and quality of life should be an integral part of the outcome of stress urinary incontinence surgery.     

Surgical treatment possibilities of severe urinary incontinence in women

Severe female urinary incontinence type 3 is a most difficult challenge to a urologic surgeon. In 40 of more than 800 patients evaluated for stress incontinence, type 3 urinary incontinence was diagnosed by clinical, urodynamic, and radiographic examination. The etiology was neurogenic or non-neurogenic. The first step of treatment in all patients was a modified pubovaginal sling to increase urethral resistance; this procedure was successful in 65%. Severely damaged periurethral tissues resulting from earlier multiple pelvic surgery (111 operations in 28 patients with non-neurogenic etiology), radiation, or prior local infections were responsible for failures. Patients whose incontinence was not corrected by this initial treatment required further surgical procedures, such as suburothelial Teflon injection, urethral reconstruction, and continent urinary diversion. This additional surgery resulted in an overall 92% success rate after a minimum follow-up of 18 months. In view of the severe nature of the incontinence of these individually problematic patients, this is a satisfactory results.     

Management of type III stress urinary incontinence using artificial urinary sphincter.

Type III stress urinary incontinence due to severe intrinsic urethral weakness without significant urethrovesical descensus may be treated by periurethral injection, sling cystourethropexy, bladder neck reconstruction, or artificial urinary sphincter implantation. The rationale for procedure selection depends on a number of patient factors and the surgeon's experience. We herein report on 25 women who were identified as having such incontinence by evaluation which included videourodynamic study and lateral voiding cystography and who were managed by the implantation of an artificial urinary sphincter. The etiology of the severe intrinsic urethral weakness in most patients was multiple prior failed cystourethropexies. Postoperatively, 1 patient died of a cerebral vascular accident. The remaining 24 women had significantly improved continence and were completely satisfied at latest follow-up. No revisions have been required for patients receiving an artificial sphincter after 1983. No sphincter erosions or infections have occurred. Our experience and review of the literature shows that the artificial sphincter provides an excellent first option for women with type III urinary stress incontinence due to intrinsic urethral weakness of various etiologies.     

Sling removal after the Vesica sling and tension-free vaginal tape (TVT) procedures

PURPOSE: We describe our experience of sling removal performed after either the Vesica sling procedure (due to vaginal erosion or at the time of reoperation for recurrent stress incontinence) or the tension-free vaginal tape (TVT) procedure (due to persistent urinary retention). MATERIALS AND METHODS: From May 1997 to December 2002, we performed 19 Vesica sling procedures and 66 TVT procedures for the treatment of urodynamic stress incontinence. In the former procedures, four patients (21%) developed vaginal erosion and underwent total or partial removal of sling material (Hemashield made from bovine-collagen-injected woven polyester). In another three patients, stress incontinence recurred 2-4 years after the Vesica sling procedure, and they underwent total sling removal and the TVT procedure. Before using the urethral pull-down process (UPDP) in TVT procedures, 2 out of 23 patients (8.7%) developed persistent urinary retention and underwent either sling release alone or partial sling removal concomitant with a second TVT procedure. After the introduction of the UPDP, no patient developed urinary retention. RESULTS: Three patients in whom total sling removal was performed due to vaginal erosion after a Vesica sling procedure developed recurrent stress incontinence. One patient who underwent partial sling removal remained continent, but vaginal erosion recurred 2 years later. Patients who had total sling removal and TVT procedures due to recurrent stress incontinence after Vesica sling procedure became continent with an uneventful postoperative course. One patient who underwent transvaginal release of TVT tape (polypropylene mesh) due to urinary retention after the TVT procedure developed recurrent stress incontinence, and the other who underwent partial removal of TVT tape and a second TVT procedure had resolution of urinary retention without recurrence of stress incontinence. CONCLUSION: Prompt and total sling removal should be recommended for vaginal erosion after the Vesica sling procedure. In patients with urinary retention after the TVT procedure, partial removal of TVT tape and a second TVT procedure using the UPDP to prevent overtightness may be a preferable choice to attain both continence and resolution of urinary retention.     

Treatment of Stress Urinary Incontinence in Women with Urethral Hypermobility and Intrinsic Sphincter Deficiency

Purpose

We compared 2 treatment modalities (sling cystourethropexy and periurethral collagen injection) in patients with intrinsic sphincter deficiency alone or with urethral hypermobility (combined stress urinary incontinence).

Materials and Methods

We retrospectively reviewed a series of 50 consecutive patients treated surgically for intrinsic sphincter deficiency during a 2-year period. All patients were evaluated by history and physical examination to assess urethral hypermobility and urodynamic testing. Intrinsic sphincter deficiency was assessed by abdominal leak point pressure and video urodynamics. Of the 50 patients 28 underwent a pubovaginal sling operation and 22 received a periurethral injection of collagen.

Results

Of the patients studied 40 percent had combined stress urinary incontinence. A pubovaginal sling procedure resulted in a cure rate of 81 percent in this group, compared to 25 percent for periurethral injection of collagen.

Conclusions

A subgroup of women exists with combined stress urinary incontinence due to urethral hypermobility and intrinsic sphincter deficiency. When treated with sling cystourethropexy women with combined stress urinary incontinence do as well or better than those with intrinsic sphincter deficiency alone and those treated with periurethral collagen injection do worse.     

Autologous fascial sling vs polypropylene tape at short-term followup: a prospective randomized study

PURPOSE: The incidence of urinary incontinence in women of childbearing age is about 30%. Around half have stress incontinence. Many treatment modalities have been elucidated to treat stress incontinence, and among the most popular are rectus fascia sling and tension-free vaginal tape (TVT). The introduction of TVT to the urological armamentarium put a multiplicity of synthetic materials into use in the correction of stress urinary incontinence. A comparison of the impact of these 2 commonly used techniques is needed. MATERIALS AND METHODS: A total of 53 female patients older than 21 years (mean age 45.09) were randomized, using closed envelopes, to undergo TVT or rectus fascia sling. Randomization was performed after patients received spinal anesthesia. One surgeon performed the 2 types of treatment. Associated grade 2 cystocele was simultaneously corrected. Patients with bladder or urethral pathology, as well as those with cystocele greater than grade 2, were excluded from analysis. RESULTS: All 53 patients completed 6 months of followup and all had stress urinary incontinence. There were 15 patients who underwent sling surgery and 17 who underwent TVT who had concomitant grade 1 or 2 cystocele. No statistically significant difference was found between the 2 groups at baseline. Cure was accomplished in 23 of 25 (92%) with sling and in 26 of 28 (92.9%) with TVT at first followup visit (1 week). There were 7 patients who needed at least 1 extra week of catheterization in the sling group and 3 in the TVT group. No significant difference was detected in terms of post-void residual urine, symptom score, and filling and voiding parameters. At 6 months 1 patient had de novo detrusor overactivity and 7 had wound pain. Compared to those with TVT, 2 cases of sling were considered treatment failures, none had de novo overactivity and 2 had wound pain. None of the patients had symptoms suggestive of urethral erosion. CONCLUSIONS: Rectus fascia sling and TVT seem to be equally effective regarding primary outcome measure (ie cure of stress incontinence). Symptom score related to incontinence surgery as well as simultaneous correction of cystocele are comparable in the 2 groups. Fascial sling is a longer treatment process yet it is more economical. Longer followup is vital before rigorous conclusions can be drawn.     

A SIMPLE OBJECTIVE METHOD OF ADJUSTING SLING TENSION

PURPOSE: Pubovaginal sling is gaining widespread acceptance as a primary form of treatment for types II and III stress urinary incontinence. However, a major drawback is postoperative obstructed voiding due to excessive force placed on the suspension suture. We describe a simple objective method for intraoperative adjustment of sling tension that can be performed by a single surgeon during pubovaginal sling surgery. MATERIALS AND METHODS: A cotton swab is inserted into the urethra and placed at the urethrovesical junction after the sling is fixed suburethrally and the vaginal mucosa is closed. The suspension sutures are tied down directly onto the rectus fascia with enough tension to keep the cotton swab angle between 0 and 10 degrees to the horizontal plane. A total of 29 patients with an average age of 62 years underwent pubovaginal sling surgery with rectus and cadaveric fascia using this technique for tension adjustment. Of the patients 21 were diagnosed with types II and III, 5 had type II only and 3 had type III only incontinence. Preoperative evaluation revealed detrusor instability in 5 patients. Mean postoperative indwelling catheterization period was 6.2 days. Average followup was 15.6 months. RESULTS: To date no permanent urinary retention has occurred. Of the patients 15 voided without difficulty after catheter removal, 13 had urinary difficulty requiring intermittent catheterization for 1 week or less and 1 had retention requiring intermittent catheterization for 10 weeks. Preoperative symptoms of detrusor instability resolved in all cases. De novo detrusor instability in 3 cases was controlled with anticholinergics. CONCLUSIONS: Overzealous sling tension adjustment has been recognized as a cause of treatment failure leading to urethral obstruction. Our technique is effective in preventing over adjustment of tension, is reproducible and can be performed by 1 surgeon.     

Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome

PURPOSE: We present a series of urethral erosion following a pubovaginal sling procedure due to synthetic and nonsynthetic materials and discuss their management and continence outcome. MATERIALS AND METHODS: During a 3-year period 57 patients underwent urethrolysis for urethral obstruction after receiving a pubovaginal sling. Urethral erosion, defined as sling material entering the urethral lumen, was present in 9 patients and this cohort comprises the focus of our review. In 3 patients the eroded material was synthetic, that is ProteGen (Boston Scientific, Natick, Massachusetts) in 2 and polypropylene in 1. This condition was treated with removal of the whole sling, multilayer closure of the erosion and selective use of a Martius flap. In 6 patients the eroded material was nonsynthetic, that is allograft fascia in 5 and autograft fascia in 1. This condition was treated with sling incision and multilayer closure of the urethra. Preoperative assessment included a urogynecologic questionnaire, measurement of pad use, a voiding diary, cystourethroscopy and videourodynamics. Postoperatively similar parameters were used to assess continence outcomes and the need for subsequent procedures. RESULTS: Nine patients were followed 30 months after urethrolysis. All 9 women had some manifestation of voiding dysfunction following the pubovaginal sling procedure, including urinary retention in 4, urge incontinence in 3 and mixed incontinence in 2. Urinary retention resolved in 3 patients and urge incontinence resolved in 4. Stress urinary incontinence (SUI) persisted in 2 of the 3 patients in the synthetic group, while no patient in the nonsynthetic group had recurrent SUI. There were no recurrent urethral erosions or fistulas in either group. CONCLUSIONS: Urethral erosion after a pubovaginal sling procedure can occur irrespective of the sling material. However, recurrent SUI is not an invariable outcome of the management of urethral erosion following the pubovaginal sling procedure.     

Bulbourethral composite suspension for treatment of male-acquired urinary incontinence

OBJECTIVES: We evaluated the efficacy of bulbourethral composite sling procedure in the treatment of male urinary incontinence after radical prostatectomy, transurethral resection of the prostate, or prostatic enucleation for benign prostatic hyperplasia, and posterior urethroplasty. METHODS: Between May 2000 and April 2005, a bulbourethral composite sling was performed in 26 patients with acquired urinary incontinence. Eight (30.8%) of these patients had severe urinary incontinence, and 18 (69.2%) had mild to moderate urinary incontinence. A polyester patch plus tension-free vaginal tape (TVT) device was used in the procedure. Prolene threads were attached to the two ends of polyester taper then passed from the perineal incision to a suprapubic incision with a TVT needle. The ends of the sutures and TVT were tied over the rectus fascia in the midline after repeated urethral pressure measurements reached 80-90 cm H2O. RESULTS: The follow-up period was 8-54 mo (mean: 28.3). The primary procedure failed in one patient. Of the remaining 25 patients, 1 patient died of cerebral hemorrhage 2 yr postoperatively, and 2 patients had recurrent stress incontinence in 1.5 and 2 yr postsurgery, respectively. The recurrent incontinence was severe in one patient and mild (one to two pads per day) in the other. The remaining 22 patients maintained urination and continence. The total success rate (cure and improved) was 92% (23 of 25). CONCLUSIONS: Bulbourethral composite sling procedure is a minimally invasive, safe, effective surgical option in the treatment of male patients with mild to moderate incontinence, but is not suitable for severe incontinence. Temporary perineal discomfort or pain is a common complication of the procedure.