A case report of antepartum bladder outlet obstruction following transobturator sling placement

We present a case of urinary retention due to bladder outlet obstruction in a pregnant patient who had a prior transobturator synthetic sling procedure for stress urinary incontinence 2 years earlier. After the sling was released at 19 weeks, the voiding dysfunction resolved, but the patient remained incontinent. This case emphasizes a potential unique complication of suburethral sling in pregnancy.     

Pregnancy Complicated by a Suburethral Sling: A Case Report

Incontinence surgery is rarely performed prior to the completion of a woman’s childbearing. The literature is sparse in regard to women with prior incontinence surgery. There are no reports of pregnancy complicated by a sling procedure. A 26-year-old gravida 3, para 2-0-0-2 with prior surgical history of a Pereyra urethropexy followed by a Vesica suburethral sling, was referred at 18 weeks’ gestation for assessment of the sling. Her antenatal course was complicated by pyelonephritis and intermittent urethral obstruction requiring Foley catheter placement. She delivered by scheduled cesarean section at 37 weeks’ gestation. Three months following delivery she presented with pyelonephritis and recurrence of her incontinence. Pregnancy complicated by prior suburethral sling procedure may result in urinary outlet obstruction, pyelonephritis and disruption of the surgical repair.     

Long-term urinary continence rates after simple sling incision for relief of urinary retention following fascia lata pubovaginal slings

PURPOSE: We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings. MATERIALS AND METHODS: A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup. RESULTS: A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6). CONCLUSIONS: Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.     

The voiding after the suburethral sling operation, obstructive or non-obstructive?

To examine whether or not the suburethral sling operation produces obstruction during voiding, seven females who underwent the sling operation using synthetic material (Vesica Sling Kit) were studied postoperatively urodynamically. Uroflowmetry and residual urine measurement showed no overt voiding difficulties in any cases. However, in one case, a pressure flow study indicated equivocal and the position of the sling material was judged to be too proximal by fluoroscopic monitoring. In all other 6 cases pressure flow was shown to be non-obstructive. Fluoroscopic finding also demonstrated in these 6 cases an appropriate bladder neck opening at the time of voiding and the sling was positioned just from the bladder neck to mid-urethra. Thus, it is concluded that the suburethral sling operation produces no obstruction as long as the position of the sling material is carefully determined from bladder neck to mid-urethra and excessive tension is avoided.     

Sling transection of urethra: a rare complication

Common postoperative complications associated with suburethral sling procedures include voiding disorders and urinary retention, de novo development of detrusor instability, sling graft rejection and, rarely, erosion of the graft into the urethra. The authors present a case of a late postoperative complication of polytetrafluoroethylene graft erosion and partial transection of the urethra, with resultant acute urinary retention. A 50-year-old patient presented with acute urethral outflow obstruction due to sling graft erosion into the urethra nearly 2 years after she underwent a curative sling procedure for recurrent genuine stress incontinence. After relieving the acute urinary retention by inserting a suprapulic catheter under ultrasound guidance, the sling graft was accessed and removed. The urethral defect was repaired successfully. At follow-up 5 months later, the patient was continent subjectively and by urodynamic criteria, with no voiding abnormalities. Although erosion of the sling graft into the urethra and transection of this structure is a rare complication after a sling procedure, it should be considered in the patient who experiences progressive voiding difficulties, has transvaginal urinary leakage, and/or cannot be catheterized transurethrally. Expedient relief of the urinary retention and outflow obstruction is necessary, as well as careful surgical reconstruction of the urethra. To minimize the development of this complication we recommend plication of paraurethral connective tissue in the midline beneath the sling graft, and placement of minimal tension on the sling.     

Dynamic suburethral suspension with pedicled external oblique aponeurosis in the management of female urinary incontinence.

PURPOSE: Despite excellent postoperative continence with pubovaginal sling procedures, the resultant morbidities of de novo urgency and urinary obstruction due to sling tension remain valid concerns. The feasibility and outcome of dynamic suburethral suspension using bilateral strips of external oblique aponeurosis left attached medially to the anterior rectus sheath and joined beneath the urethra under no tension were determined. MATERIALS AND METHODS: Between May 1995 and April 1998, 25 women with stress urinary incontinence were evaluated and underwent a dynamic suburethral suspension procedure. All patients were followed annually with a 10-point questionnaire by an independent registered nurse who analyzed the results, complications and satisfaction outcome. RESULTS: At a mean followup of 26 months all patients (100%) were cured of stress incontinence. Associated urge incontinence due to detrusor overactivity persisted in 3 patients postoperatively and, thus, the overall postoperative cure/dry rate was 88% for the study group. Of the 18 patients with preoperative urgency 12 (66%) were cured postoperatively. De novo urgency developed in 1 patient after surgery. No patient had prolonged urinary retention. Overall 92% of the patients were satisfied with the outcome of surgery. CONCLUSIONS: This dynamic suburethral suspension procedure cured stress incontinence in the majority of patients with no resultant urinary obstruction. The mechanism of action is believed to work by providing a viable suburethral "backboard" of support and by dynamic lifting of the proximal urethra cradled by the fascial loop precisely at the time of abdominal strain. Pronounced urge incontinence due to detrusor overactivity is unlikely to benefit from suspension procedures.     

吊带完整性对恢复大鼠SUI模型漏尿点压作用的实验研究

目的：验证剪断尿道下的吊带未消除吊带抗尿失禁作用的假说,探讨尿道吊带的无张力原则.方法：用持续阴道扩张（VD）的方法预先在40只雌性wistar大鼠建立压力性尿失禁（SUI）模型.10只接受完整的尿道吊带手术;10只植入完整的尿道吊带后,把吊带的尿道下部分剪断一半;10只植入完整的尿道吊带后,把吊带的尿道下部分完全剪断;10只接受了伪吊带手术.术后6周,所有大鼠通过预先放置的耻骨上导管测定crede手法诱导的腹腔漏尿点压（ALPP）,并测定膀胱内压.Kruskal-Wallis H检验比较数据,P〈0.05为差异有统计学意义.结果：吊带完全切断组、吊带切断一半组和吊带完整组都可同样升高ALPP,且都显著高于伪手术组的值（分别为24.9、26.7、27.9vs20.7cmH2O,P〈0.0001）.4组排尿高峰压无显著的差别,表示吊带术的各组不存在膀胱出口梗阻（BOO）.吊带完全切断组、吊带切断一半组和吊带完整组的膀胱顺应性6周后同伪手术组相比显著降低（P=0.007、0.05、0.05）.结论：吊带尿道下部分的完整性并不是吊带治疗SUI大鼠模型所必需的.然而吊带手术可以降低膀胱的顺应性.这可以解释在临床中观察到的同吊带手术有关的排尿功能障碍.     

A microbiological and immunohistochemical analysis of periurethral and vaginal tissue in women with de novo urge symptoms after mid-urethral sling procedures—a prospective case-controlled study

The aims were to determine whether bacteria-infection-elicited immune response after mid-urethral sling (MUS) may cause de novo urge symptoms (DNUS) and to evaluate the efficacy of suburethral sling excision for relieving the urgency. In a period of 40 months, 360 consecutive subjects with urodynamic stress incontinence had undergone one of three different MUS. Sixty-eight women with DNUS were included after exclusion. The suburethral sling of 24 of the 68 women needed to be excised because of refractory urgency. The excised vagina, or periurethral tissue, included sling of the study and control groups were sent for microbiological and immunohistochemical analyses. Statistically significant differences in the cell density percentage of CD68, CD25, CD4+CD25 and positive rate of Gram (+) bacteria were noted between two groups (p=0.024, p=0.053 and 0.016, respectively, p<0.001). The success rate of sling excision was 80.2%. In conclusion, bacteria-infection-related immune hyperreactivity might explain the pathologic basis of DNUS after MUS.     

Role of sling integrity in the restoration of leak point pressure in the rat vaginal sling model

PURPOSE: We tested the hypothesis that cutting the sling at its suburethral section does not cancel its anti-incontinence effect. We also examined the long-term effects of the sling on bladder function in a recently validated rat model of vaginal sling. MATERIALS AND METHODS: Stress urinary incontinence was created in 60 female Sprague-Dawley rats by the previously established method of bilateral pudendal nerve transection. Under anesthesia 20 animals received a vaginal sling, 20 received a vaginal sling in which the suburethral portion of the sling was cut immediately after placement and 20 received a sham vaginal sling. Six weeks after the procedures leak point pressure was determined and a cystometrogram was done using anesthesia in each animal via a previously implanted suprapubic catheter. Kruskal-Wallis and pairwise separate rank multiple comparison tests were performed with a significance level of 0.05. RESULTS: The cut and intact slings increased leak point pressure similarly and these values were significantly higher than that of the sham sling (24.9 and 27.9 cm H2O, respectively, vs 20.7, p <0.0001). Peak micturition pressure was not significantly different among the 3 groups, indicating absent bladder outlet obstruction in the sling groups. Bladder compliance was significantly decreased 6 weeks after placement of a cut or intact sling compared with the sham sling (p = 0.007 and 0.05, respectively). CONCLUSIONS: An intact suburethral portion is not a requirement for sling effectiveness in the rat model of stress urinary incontinence. However, the sling procedure decreases bladder compliance. This may explain the observed voiding dysfunction associated with sling procedures.     

Vaginal Erosion of Cadaveric Fascia Lata following Abdominal Sacrocolpopexy and Suburethral Sling Urethropexy

The aim of this paper is to report vaginal erosion of cadaveric fascia lata used for abdominal sacrocolpopexy and suburethral sling urethropexy. The charts of patients who underwent abdominal sacrocolpopexy or suburethral sling urethropexy between March 1994 and February 1999 were reviewed for perioperative data. In 47 cases of abdominal sacrocolpopexy or suburethral sling, 32 utilized cadaveric fascia lata, with 11 for sacrocolpopexy and 22 for suburethral sling. Vaginal erosion of cadaveric fascia lata graft was noted in 5 (23%) following sling procedure and 3 (27%) following sacrocolpopexy, diagnosed a mean of 36.8 days (t 7.1, range 27–45) following surgery. These women were treated conservatively with estrogen vaginal cream, and both vaginal and oral antibiotics. Four of the 8 (50%) underwent excision of the exposed graft and reapproximation of the vaginal edges under local anesthesia, whereas the remainder responded to medical therapy alone. None of the patients experienced recurrence of vaginal vault prolapse or urinary incontinence following graft erosion. Comparison of women with vaginal erosion of cadaveric fascia lata to those without revealed an association with perioperative febrile morbidity (P = 0.04), but not with age, hormonal or insurance status, body mass index, history of diabetes mellitus or smoking, length of surgery, estimated blood loss, change in hematocrit, or other perioperative complications. Vaginal erosion of cadaveric fascia lata utilized for abdominal sacrocolpopexy and suburethral sling was noted in 25% of our patients and may have an infectious etiology. Conservative treatment with antibiotics and estrogen is effective, but removal of exposed graft with vaginal closure may be necessary.     

Effect of detrusor function on the therapeutic outcome of a suburethral sling procedure using a polypropylene sling for stress urinary incontinence in women

OBJECTIVE: To assess the effect of detrusor function on the therapeutic outcome of a suburethral sling procedure in women with stress urinary incontinence (SUI). MATERIAL AND METHODS: A total of 192 women with SUI who had undergone a suburethral sling procedure were enrolled. According to the baseline urodynamic results, patients' bladder functions were classified as follows: (i) normal detrusor function; (ii) detrusor overactivity; and (iii) detrusor underactivity or acontractile detrusor. Surgical results, urodynamic parameters and patient satisfaction were compared among these three groups. RESULTS: Overall, 106 patients had normal detrusor function, 36 had detrusor overactivity and 50 had detrusor underactivity or an acontractile detrusor. A continent outcome was achieved in 135 women (70.3%), urge incontinence in 23 (12%), minimal SUI in 32 (16.7%) and moderate SUI in two (1%). Persistent urge incontinence was noted in 13 women (36%) with detrusor overactivity, and recurrent SUI occurred in 18 women (36%) with detrusor underactivity or an acontractile detrusor. No significant change in urodynamic parameters between baseline and after treatment was found in any of the patient groups. The satisfaction rate was 98.1% in patients with normal detrusor function, 82% in patients with detrusor underactivity or an acontractile detrusor and 75% in patients with detrusor overactivity (p<0.05). CONCLUSION: Compared to women with normal detrusor function, those with preoperative detrusor overactivity and those with detrusor underactivity or an acontractile detrusor experienced an unfavorable therapeutic outcome of the suburethral sling procedure in terms of urge incontinence and recurrent SUI after surgery.     

Complications of silicone sling insertion for stress urinary incontinence

PURPOSE: A pilot study was performed to evaluate the suitability of silicone as a substance for suburethral sling placement. Using rectus sheath for sling placement can be time-consuming and can result in increased morbidity. Adjustable synthetic materials of consistent strength are available. Silicone has previously been used successfully and was chosen for this trial. MATERIALS AND METHODS: Slings were inserted in 7 women with stress urinary incontinence. Of the patients 3 had a history of continence surgery and presented with reduced vaginal mobility, and 2 who had not previously undergone continence surgery had intrinsic sphincter deficiency. RESULTS: In all women stress urinary incontinence was subjectively cured. However, after 7 slings were inserted the study was terminated due to a high complication rate related to erosion and sinus formation in 5 slings which were removed. Complications developed immediately or up to 11 months after sling insertion. Continence was maintained in 4 of the 5 women after the slings were removed. CONCLUSIONS: Silicone is an inappropriate material for suburethral sling placement when used as described in our cases, caution should be exercised when placing silicone slings at this site.     

Pubic bone suburethral stabilization sling: laparoscopic assessment of a transvaginal operation for the treatment of stress urinary incontinence

The objective was to examine laparoscopically the mechanism and precision of a new transvaginal method for fixation of a suburethral stabilization sling prosthesis designed for the treatment of recurrent stress urinary incontinence. Nine patients with recurrent stress urinary incontinence after previous anti-incontinence surgery underwent transvaginal placement of a pretrimmed 2.0 x 5.5 cm synthetic pubic bone suburethral stabilization sling prosthesis with pubic bone anchors. Before the sling fixation sutures were tied, the space of Retzius was opened laparoscopically with an operative laparoscope, and sling placement was assessed. Patients were followed up postoperatively at routine intervals. All nine procedures were accomplished uneventfully and as planned. Laparoscopic surveillance demonstrated that bone anchor placement by palpation was accurate and that low-tension sling fixation necessitated 2.0- to 2.5-cm suture bridges between the lateral sling edges and the pubic bone anchors in all cases. Continence was restored in all cases; two patients experienced mild, transient urinary retention; one patient experienced transient detrusor instability. No significant postoperative complications were noted. Low-tension pubic bone suburethral sling placement requires suture bridging of approximately 2.0 to 2.5 cm per side when a prosthesis 5.5 cm long is employed.     

Various surgical approaches to treat voiding dysfunction following anti-incontinence surgery

Objective The aims of this study are to report the efficacy of retropubic urethrolysis, vaginal urethrolysis, and cutting of synthetic suburethral slings in treating postoperative voiding dysfunction that occurs after anti-incontinence surgery and to report the recurrence rate of stress urinary incontinence (SUI).Methods All patients from January 1996 to October 2003 who presented with voiding dysfunction following an anti-incontinence procedure and who subsequently underwent either retropubic urethrolysis, vaginal urethrolysis, or synthetic suburethral sling takedown were included in the study. Pre- and postoperative irritative symptoms (urinary frequency or urgency), obstructive symptoms (hesitancy, voiding difficulty, and incomplete emptying), and stress urinary incontinence symptoms were obtained in a standardized fashion. The Incontinence Impact Questionnaire and Urogenital Distres Invetory quality of life (QOL) questionnaires were also obtained to objectify these symptoms. Other objective postoperative analysis included simple uroflowmetry, measurement of postvoid residual (PVR), and simple or subtracted cystometry.Results Forty-four patients were included in the study (suburethral sling takedown=14, vaginal urethrolysis=20, and retropubic urethrolysis=10), 77% of whom had objective follow-up. Preoperatively, 31 patients (70.5%) had irritative symptoms, 41 (93.2%) had obstructive symptoms, and 6 (13.6%) had symptoms of stress urinary incontinence (SUI), while postoperatively, these symptoms were found in 30 (68.2%), 11 (25.0%), and 18 (40.9%), respectively. Postoperatively, 6 patients (17.6%) had a PVR> 100 cc, 5 patients (14.7%) had a bladder contractions, and 16 patients (47.1%) demonstrated the sign or diagnosis of (SUI). Additionally, there was a statistically significant improvement in both QOL questionnaires.Conclusions Various surgical approaches may be used to treat voiding dysfunction following an anti-incontinence procedure. Following a vaginal or retropubic urethrolysis or takedown of a synthetic suburethral sling, obstructive symptoms are likely to improve, irritative symptoms may remain unchanged, and almost half will develop recurrence of SUI.     

Suburethral sling procedures in the United States: complications,readmission, and reoperation

Introduction and hypothesis

Hospital readmission is increasingly used as a measure of quality care. Our objective was to evaluate the rate of readmission and associated factors in women undergoing suburethral sling placement in the USA.

Methods

This is a cohort study of suburethral sling procedures performed in the USA from 2012 to 2014 using the American College of Surgeons’ National Surgical Quality Improvement Program database. The database was queried for suburethral sling procedures. Records were excluded if concomitant surgery had been performed. Patient and surgical characteristics were evaluated for association with readmission using Chi-squared test for categorical variables and Student’s t test for continuous variables. All results yielding p?<?0.05 were deemed statistically significant.

Results

A total of 7,117 suburethral sling procedures were identified. There were 83 (1.16%) hospital readmissions. Those who were readmitted tended to be older (p?=?0.011), non-Hispanic (p?=?0.04), smokers (p?<?0.001), and have an American Society of Anesthesiologists Physical Status Classification System score of 3 or 4 (p?=?0.001). A history of bleeding disorder (p?<?0.001), congestive heart failure (p?<?0.001), or chronic obstructive pulmonary disease (p?<?0.001) was associated with readmission. Fifty-four (0.75%) patients underwent reoperation within 30 days of suburethral sling placement. The most common reoperation procedure was sling excision (20 patients). The most common complication was urinary tract infection, which occurred in 189 patients (2.7%).

Conclusions

Suburethral sling placement is a safe procedure with a low rate of readmissions, reoperations, and complications. Consistent with other types of surgery, infection is the most common post-operative complication.

     

Ureteral injuries in conjunction with Burch colposuspension

Ureteral obstruction following Burch colposuspension is a rare complication: a review of the literature revealed only 11 cases. The authors present four more cases of ureteral obstruction following Burch colposuspension. None of the patients had had previous pelvic surgery. Three of the patients developed bilateral ureteral obstruction. Surgical intervention was able to prevent permanent renal damage in all patients. Two of the patients had recurrence of stress urinary incontinence, which was subsequently successfully repaired with a pubovaginal sling procedure.     

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.     

Failure of allograft suburethral slings.

OBJECTIVES: To report our experience of using freeze-dried irradiated fascia lata allografts for suburethral sling procedures. PATIENTS AND METHODS: Between December 1996 and September 1998, 35 patients (mean age 60.25 years, range 37-79) underwent suburethral sling placement with fascia allograft. These patients were reviewed, with the findings at the time of any surgical re-exploration. Eleven (31%) had undergone prior surgery for genuine stress incontinence and 32 (91%) had a preoperative diagnosis of intrinsic sphincter deficiency. RESULTS: On re-operation for persistent or recurrent stress incontinence, the allograft was present but grossly degenerated in two (6%) patients and completely absent in five (14%) patients. Histology of a retrieved graft fragment showed both fibroblast proliferation and degeneration within the graft. CONCLUSION: The use of freeze-dried, irradiated fascia lata for suburethral sling procedures was associated with a material failure rate of >/=20%. We caution against its use in this setting.     

Outcomes of autologous fascial slingplasty procedure for treating female urinary incontinence

The aims of this study were to compare the pre- and postoperative urodynamic findings of the suburethral autologous rectus fascial sling procedure and to determine patient satisfaction with the procedure by telephone interviews. Eight-four female patients with urodynamic stress incontinence completed a multi-channel urodynamic study and pad test before and after the operation. Subjective and objective satisfaction were also recorded. Significant changes were noted in the stress maximal urethral closure pressure, pad test, voided volume, and peak flow rate (P < 0.05). The success rate was about 94%, and subjective satisfaction was about 72%. The most common complication was transient urinary tract infections. The suburethral sling resolved 50% of detrusor overactivity (DO), but de novo DO was 24%. The procedure combined with anterior colporrhaphy corrected or improved 97% of anterior vaginal wall prolapses (> or =stage II). This retrospective study demonstrates that suburethral autologous facial slingplasty has a high cure rate, high patient satisfaction, and is a less complicated procedure. It can also correct and prevent a recurrence of anterior vaginal wall prolapse when combined with anterior colporrhaphy.     

Double forced sling by combining in situ vaginal wall and Infast pubic bone suburethral stabilization techniques: a new method

PURPOSE: We evaluated the results and effectiveness of the double forced sling by combining in situ vaginal wall and Infast (Influence, Inc., San Francisco, California) pubic bone suburethral stabilization techniques as a new method. MATERIALS AND METHODS: The new technique was used in 40 patients, of whom 32 completed 2 years of followup. Previous surgery included hysterectomy in 8 cases, anterior and posterior vaginal wall repair in 6, and 1 or 2 incontinence procedures in 24. Types 2, 3 and mixed incontinence were diagnosed in 12, 12 and 8 patients, respectively. With this technique a gelatin coated synthetic sling was fixed to the previously prepared vaginal sling surface with watertight stitches to create a doubled forced sling, which was fixed to the pubic bone with 2 screws using an Infast inserter. Patient outcomes were evaluated by questionnaire analysis and the pad test. RESULTS: The cure, improvement and failure rates were 81.25%, 6.25% and 12.5% in the 32 patients who completed 2 years of followup. Surprisingly successful results were achieved in all 24 secondary cases. Moderate cystocele in 4 patients and rectocele in 8 were corrected simultaneously. Temporary urinary retention in 4 patients resolved in 2 weeks. Of the 32 patients 28 reported that they would repeat the procedure and recommend it to others. CONCLUSIONS: The double forced sling has 2 advantages that make it superior to other techniques, namely a minimal complication rate and enhanced support accomplished by an easy and noninvasive technique.