Sacral nerve stimulation for faecal incontinence in the UK

BACKGROUND: Sacral nerve stimulation (SNS) is an effective therapy for faecal incontinence. Published studies derive largely from single centres and there is a need to determine the broader applicability of this procedure. METHODS: Prospective data were collected for all patients undergoing SNS in the UK. Records were reviewed to determine the outcome of treatment. RESULTS: In three UK centres 59 patients underwent peripheral nerve evaluation, with 46 (78 per cent) proceeding to permanent implantation. Of these 46 patients (40 women) all but two had improved continence at a median of 12 (range 1-72) months. Faecal incontinence improved from a median (range) of 7.5 (1-78) to 1 (0-39) episodes per week (P < 0.001). Urgency improved in all but five of 39 patients in whom ability to defer defaecation was determined, improving from a median of 1 (range 0-5) to 10 (range from 1 to more than 15) min (P < 0.001). Maximum anal squeeze pressure and sensory function to rectal distension changed significantly. Significant improvement occurred in general health (P = 0.024), mental health (P = 0.008), emotional role (P = 0.034), social function (P = 0.013) and vitality (P = 0.009) subscales of the Short Form 36 health survey questionnaire. There were no major complications. One implant was removed. CONCLUSION: SNS is a safe and effective treatment, in the medium to long term, for faecal incontinence when conservative treatment has failed.     

Experience of restorative proctocolectomy with ileal reservoir

The experience gained with restorative proctocolectomy and ileal reservoir in 60 patients is presented. Fifty-two patients had W reservoirs and the operative technique of the procedure is described in detail. Forty patients had a defunctioning ileostomy and 20 had a single stage procedure. There was no perioperative mortality. The main complications were sepsis (28 per cent), intestinal obstruction (18 per cent) and reservoir ileitis (20 per cent). There was a significant improvement in sepsis rate (from 20 to 4 per cent) and hospital stay (from 31.8 to 15.6 days) with increased experience. The functional results of 48 patients with W reservoirs was assessed. The mean number of evacuations per 24 h (+/- s.d.) was 3.8 +/- 0.2. Sixty-five per cent of patients did not evacuate at all, or rarely, at night and none evacuated more than once at night. Forty-four per cent of patients took antidiarrhoeal agents. Continence was normal in 50 per cent of patients. Minor leakage occurred in 46 per cent of cases, frequent leakage in 4 per cent and incontinence in none. Sexual function in 29 men was normal. Ninety-four per cent of patients considered the results of their operation to be good or excellent.     

Third-party prospective evaluation of patient outcomes after dynamic graciloplasty

BACKGROUND: Dynamic graciloplasty (DGP) is a complex procedure designed to improve bowel function in patients with end-stage faecal incontinence. Outcomes of DGP were examined in comparison with stoma formation or continued medical management. METHODS: This third-party evaluation comprised a prospective case-comparison study of patient-based and clinical outcomes at a London hospital. Forty-nine patients who underwent DGP during 5 years from 1997 were compared with 87 patients with similar bowel disorders who did not undergo DGP. Outcome measures were quality of life (QoL), symptoms, anxiety and depression. RESULTS: At 2 years after surgery, bowel-related QoL and continence had improved by more than 20 per cent compared with the preoperative status for two-thirds of patients who had DGP (P < 0.001). Two-thirds were continent all or most of the time, although one-third experienced disordered bowel evacuation. Large deteriorations on the Nottingham Health Profile pain score occurred in 11 of 34 patients who had DGP, compared with seven of 57 patients in comparison groups (P = 0.027). Patients in comparison groups experienced no significant changes in measured outcomes over the 2 years of follow-up. CONCLUSION: Although DGP is associated with a high level of morbidity, it deserves consideration as an alternative to life with severe and refractory faecal incontinence or stoma formation in people in whom conventional treatments have failed.     

球部尿道包埋术治疗前列腺术后尿失禁

目的 :介绍并评价球部尿道包埋术治疗前列腺术后尿失禁临床疗效。　方法 :6例前列腺术后尿失禁超过 2 0个月者经保守治疗无效后接受该手术。球部尿道包埋于两阴茎海绵体之间 ,使球部尿道转位到阴茎海绵体背侧。结果 :经 9个月至 6年的随访 ,5例一次手术成功、尿控满意 ,另 1例再行 2次加长包埋后症状明显改善。　结论 :前列腺手术损伤内、外括约肌时可致尿失禁 ,保守治疗 12个月无效时可手术。球部尿道包埋术创伤小、操作简便、疗效可靠 ,但包埋力量大小尚待进一步探索。     

Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis. METHODS: Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed. RESULTS: Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34.1 years, increasing from 31.2 years (1981-1985) to 36.3 years (1996-2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96.3, 93.3, 92.4 and 92.1 per cent respectively. Mean daytime stool frequency increased from 5.7 at 1 year to 6.4 at 20 years (P < 0.001), and also increased at night (from 1.5 to 2.0; P < 0.001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0.001) and from 12 to 21 per cent at night (P < 0.001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease. CONCLUSION: IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.     

Meta-analysis to determine the incidence of obstetric anal sphincter damage

BACKGROUND: The reported incidence of anal sphincter injury after first (11.5-35.0 per cent) and subsequent (3.4-12.1 per cent) vaginal deliveries varies widely. In addition, the reported incidence of associated faecal incontinence ranges from zero to 68.2 per cent. The aim of this study was to perform a meta-analysis of reported incidences of postpartum anal sphincter defect diagnosed by endoanal ultrasonography (EAUS) and associated incidences of faecal incontinence. METHODS: A Medline search yielded five studies with more than 100 subjects who underwent EAUS after childbirth for evaluation of anal sphincter disruption and who were questioned about symptoms of faecal incontinence, defined as any impairment in flatus and stool control but not including urgency of defaecation. A Bayesian meta-analysis was performed to produce one inference while accounting for potential heterogeneity among the five study populations. RESULTS: Meta-analysis of 717 vaginal deliveries revealed a 26.9 per cent incidence of anal sphincter defect in primiparous women and an 8.5 per cent incidence of new sphincter defects in multiparous women. Overall, 29.7 per cent of anal sphincter defects were symptomatic. Some 3.4 per cent of women experienced postpartum faecal incontinence without an anal sphincter defect. In a Bayesian calculation, the probability of postpartum faecal incontinence due to a sphincter defect was 76.8-82.8 per cent. CONCLUSION:: The incidence of occult anal sphincter disruption following vaginal delivery is much higher than commonly estimated. However, at least two-thirds of occult defects are asymptomatic postpartum. The probability of faecal incontinence associated with an anal sphincter defect was 76.8-82.8 per cent.     

Outcome in patients with colorectal cancer managed by surgical trainees.

BACKGROUND: The surgeon is an important variable that influences outcome following colorectal cancer surgery. Operative training of suitable quality and quantity is essential if intersurgeon variation is to be reduced. The aim of this study was to examine the outcome of colorectal cancer surgery when a high proportion of the operations were performed by trainee surgeons. METHODS: A prospective 7-year (1989-1996) audit of 306 consecutive colorectal cancers referred to a single general surgeon with a colorectal interest was carried out. The outcome (anastomotic leakage, 30-day mortality rate, local recurrence and cancer-related survival) of operations performed by the consultant was compared with that of his trainees. RESULTS: Some 245 (92.5 per cent) of 265 patients undergoing laparotomy had a resection. Seventy (28.6 per cent) and 67 (27.3 per cent) of operations were performed by supervised and independent trainees respectively. There was no difference between the consultant, supervised and independent trainees for 30-day mortality rate (6.5, 6 and 4 per cent respectively), clinical anastomotic leakage rate (9, 2 and 5 per cent) and local recurrence rate (2, 3 and 7 per cent). There was no difference between the three groups for adjusted 5-year disease-related survival rates. CONCLUSION: Properly supervised trainees can resect a high proportion of colorectal cancers without compromising immediate outcome or long-term survival. Presented in part to the annual meeting of the Association of Surgeons of Great Britain and Ireland, Bournemouth, UK, April 1997, and published in abstract form as Br J Surg 1997; 84(Suppl): 56     

Endoscopic transanal resection of rectal tumours--a preliminary report of its use.

Endoscopic transanal resection (ETAR) of rectal tumours is a simple and inexpensive procedure, well tolerated in elderly patients or those undergoing palliation. We have performed 137 ETARs in 81 patients with a 30-day mortality rate of 11.1 per cent and a postoperative complication rate of 15.3 per cent. Thirty-one patients (38 per cent) had ETAR for palliation: in this group rectal bleeding was abolished or improved in 66 per cent of patients, altered bowel habit (diarrhoea) corrected in 77 per cent of patients, faecal incontinence improved in 50 per cent of patients and rectal pain (including tenesmus) improved in 50 per cent of patients. Twenty-three patients (28 per cent) were treated for large benign rectal polyps: in this group symptoms were universally abolished. The technique is particularly suited to the management of these patients. Twenty-seven elderly patients with theoretically 'curable' rectal cancer underwent ETAR with a 78 per cent crude survival rate at 1 year. While long-term results remain to be assessed, ETAR appears a useful technique for treating selected patients with rectal tumours.     

Urodynamic evaluation of incontinence in patients undergoing modified Campbell radical retropubic prostatectomy: a prospective study

A prospective urodynamic study was performed on 17 consecutive patients undergoing a modified Campbell radical retropubic prostatectomy for prostatic carcinoma. There was 1 postoperative death, leaving 16 evaluable patients. Patients were evaluated preoperatively and at 6 weeks, 3 months and 6 months postoperatively. The only urodynamic parameter 6 months postoperatively that differed significantly from the preoperative value was the functional urethral length, 1.6 and 4.3 cm., respectively. The incidence of clinical and/or urodynamic urinary incontinence preoperatively was 19 per cent and 6 months after the procedure it was 87 per cent. The incontinence rate did not correlate with the pathological stage or histological grade of the tumor. There was a strong trend toward improvement of continence with time but all patients who were incontinent 6 months postoperatively and followed for more than 1 year remained incontinent. While this incontinence rate is the highest reported, we believe that it reflects detailed patient interviews and objective fluoroscopic evidence of urethral urinary loss. These results and those of others suggest that modification of the technique of radical prostatectomy to produce a functional urethral length of at least 2.8 cm. may be desirable.     

Neosphincters in the management of faecal incontinence

BACKGROUND: Surgical treatment of end-stage faecal incontinence has its origin in the early 1950s. Interest has been revived as a result of technical advances achieved in the recent past. The purpose of this article is to review the principles that underlie the use of skeletal muscle transposition around the anal canal and of electrical stimulation in the treatment of incontinence, and to explore new methods of treatment of this condition. METHODS: A literature search was performed using Pubmed and Medline, employing keywords related to treatment of faecal incontinence by neosphincter reconstruction. Basic science and clinical aspects of neosphincter reconstruction were gathered from relevant texts, original articles and recently published abstracts. RESULTS: The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence. However, electrostimulator failure may result in explantation in a proportion of patients. Impairment of evacuation is a functional setback in approximately one-third of patients with the gracilis neosphincter. Overall, improvement of continence may be expected in up to 90 per cent of patients according to some reports. By contrast, experience with the artificial neosphincter, which is less expensive, has been limited to a few tertiary centres across the world. Reported continence of stool is 100 per cent, and that of gas and stool 50 per cent, following implantation of the artificial sphincter. Both of the above operations have been associated with implant-related infection and impaired evacuation. CONCLUSION: Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres. Patients are likely to benefit from a plan that incorporates preoperative counselling and a selective approach.     

Controlled digital anal dilatation under total neuromuscular blockade for chronic anal fissure: a justifiable procedure.

BACKGROUND: There is widespread antipathy to digital dilatation of the anus (DDA) for medically resistant anal fissure. A retrospective study was therefore undertaken to test the validity of the criticism of this technique. METHODS: Some 273 patients who underwent DDA for fissure between November 1982 and July 1997 were sent a questionnaire and/or telephoned. Those with impaired control were offered investigation. In addition, routine clinic follow-up data were scrutinized in the 302 available notes of the 307 patients who had undergone DDA for fissure to determine its efficacy. RESULTS: Some 241 patients (88.3 per cent) were contacted successfully a median of 7.8 years after operation. Follow-up records showed the fissure to have healed in 89.1 per cent of 302 patients. No patient was rendered incontinent. Fifteen patients indicated persistently impaired control in the questionnaire, nine (3.8 per cent) as a result of the DDA and six preceding it. All 23 patients who had experienced either temporary or permanent impairment, whether or not pre-existing, were invited to attend for ultrasonography and manometric measurements, of whom 18 accepted. No sphincteric fragmentation was seen, and resting and squeeze pressures did not differ from normal. CONCLUSION: A single DDA appears to heal 89 per cent of chronic anal fissures. Consequent impairment of control is infrequent and minor if the procedure is performed carefully and with the patient paralysed.     

Routine early laparoscopic cholecystectomy for acute cholecystitis after conclusion of a randomized controlled trial

BACKGROUND: The aim of this retrospective review was to assess the clinical outcomes of laparoscopic cholecystectomy for acute cholecystitis since the conclusion of a randomized controlled trial in 1997. METHODS: Records of all patients admitted for acute cholecystitis in whom early laparoscopic cholecystectomy was attempted between July 1997 and December 2004 were reviewed. RESULTS: A total of 209 patients were recruited to this study. Forty-three surgeons performed the procedures. The conversion rate increased significantly in the early period after the trial from 21 per cent to 42 per cent (39 of 92 patients) and decreased significantly to 24 per cent (13 of 54 patients) in the later period. The proportion of operations performed by higher surgical trainees increased significantly from 17 per cent in the early period to 56 per cent in the later period. This increase was associated with a fall in conversion rate without any significant increase in duration of operation or complication rate. CONCLUSION: This study has demonstrated that the results achieved in a randomized trial can be translated into clinical practice by the entire surgical unit. A structured training programme with the inclusion of an experienced surgeon assisting both trainees and specialists should minimize this learning curve.     

Prospective audit following the introduction of short-course preoperative radiotherapy for rectal cancer

BACKGROUND: The value of introducing a short course of preoperative radiotherapy before operation for rectal cancer is still subject to debate. METHODS: One hundred consecutive patients, of mean age 68 (range 29-87) years undergoing pre- operative radiotherapy for rectal cancer between January 1997 and December 1998 at two radiotherapy centres were audited prospectively. RESULTS: The time from referral to radiotherapy was 33 (11-74) days and from radiotherapy to operation 5 (1-42) days. There was a higher than expected anastomotic leak rate (15 per cent) and perineal wound infection rate (18 per cent). Patients waiting more than 7 days were more likely to suffer perineal wound breakdown: 15 per cent (n = 39) versus 30 per cent (n = 10). CONCLUSION: The high anastomotic leak and perineal wound infection rates suggest that the introduction of preoperative radiotherapy combined with total mesorectal excision should be audited carefully or performed as part of the CRO7 trial. Presented to the Association of Coloproctology of Great Britain and Ireland in St Helier, Jersey, June 1998     

Urethral compression procedure for the treatment of male urinary incontinence.

We believe that there still is a place for passive compression of the bulbous urethra in the treatment of male urinary incontinence after prostatectomy or sphincterotomy. The procedure is simple to do and it is relatively free of complications. However, since it provides only passive resistance and cannot compensate for sudden increases in intravesical pressure, stress incontinence of minor degree is not uncommon. In our series of 184 cases 61 (33 per cent) became completely dry, required no protection and voided with a good stream and without residual urine. Another 51 patients had some stress incontinence but were pleased with the results so that 61 per cent derived definite benefit from the operation. There were 20 (11 per cent) major complications in this series. With recent modifications of the technique and the prosthesis the complication rate has been reduced to 7 per cent in the last 50 cases. The opportunity to adjust the compression postoperatively by injection provides advantages over other passive compression procedures.     

Long-term results of Ingelman-Sundberg denervation procedure for urge incontinence refractory to medical therapy

PURPOSE: Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence. MATERIALS AND METHODS: Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve. RESULTS: A total of 28 patients 28 to 83 years old (mean age 54.6) underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean followup was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged. CONCLUSIONS: Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.     

Colorectal 25

Aims: To assess anal sphincter structure and functional outcomes following third-degree perineal tears and the effect of its disruption on the development of anal incontinence. Methods: Fifty-one consecutive patients, 41 primigravidae and 10 multigravidae, with third-degree intrapartum perineal tears, primarily repaired, were recruited 4 months postpartum. Patients completed questionnaires assessing faecal incontinence. Anal manometry and endosonography were then performed. Results: No patient reported incontinence prior to pregnancy. The incidence of faecal incontinence was 12 per cent. Six patients were incontinent of faeces and 10 incontinent of either flatus and/or fluid. Eighty-one per cent of anal incontinent patients were primigravidae (OR 0.96). Three women had previous third-degree tears, with one anal incontinence on subsequent delivery. Disruption of the external anal sphincter (EAS) was identified endosonographically in 26 patients. In 13 patients, there was an associated internal anal sphincter (IAS) defect. Clinically unsuspected tears of the Anal sphincter mechanism were diagnosed by anal endosonography in 46 per cent of asymptomatic patients. The EAS alone was involved in 14, IAS in three, and both in five patients. Clinical examination of women with anal incontinence identified an anal sphincter defect in 46 per cent. Ultrasound in anal incontinent patients showed an IAS defect in 42 per cent and an EAS defect in 52 per cent. All patients with faecal incontinence had a disruption of the EAS identified by endosonography (P < 0.05). No significant relationship was demonstrated between symptoms and anal manometry (P = 1.0, n.s.). Conclusions: Third-degree tears cause significant, although clinically unsuspected anal sphincter defects. It may be that anal manometry alone is not sufficient to exclude sphincter injury.     

Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice

BACKGROUND: The aim of the present randomized trial was to compare the Shouldice procedure and the Lichtenstein hernia repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice were able to reproduce the excellent results reported from specialist hernia centres. METHODS: Three hundred patients with primary inguinal hernia were randomized to either a Shouldice repair or to a tension-free Lichtenstein repair. In a pretrial training programme the five participating general surgeons were taught to perform the two techniques in a standard manner. Follow-up was performed after 8 weeks, 1 year and 3 years. The last examination was performed by an independent blinded assessor. RESULTS: There was a significant difference in operating time in favour of the Lichtenstein technique. After a follow-up of 36-77 months seven recurrences were found in the Shouldice group (95 per cent confidence interval (c.i.) 1.3 to 8.1) and one in the mesh group (95 per cent c.i. 0.0 to 2.0). Chronic groin pain was reported by 4.2 and 5.6 per cent in the Shouldice and Lichtenstein groups respectively. It was characterized as mild or moderate in all except two patients who had the Shouldice operation. CONCLUSION: Lichtenstein hernia repair was easier to learn, took less time and resulted in fewer recurrences. It was possible to achieve excellent results with this technique in a general surgical unit.     

Total mesorectal excision preserves male genital function compared with conventional rectal cancer surgery.

BACKGROUND: The introduction of total mesorectal excision (TME) has been shown to improve local recurrence rates in rectal cancer. The present study investigated the impact of this more extensive and radical procedure with regard to autonomic pelvic nerve function. METHODS: Patients with resected primary rectal cancer were interviewed by means of a questionnaire asking about preoperative and postoperative urinary bladder and genital function. The results in patients after rectal cancer surgery without TME (group 1; n = 29) were compared with those obtained after introduction of the TME technique (group 2; n = 31). Patients in group 2 were older and had a lower level of anastomosis than patients in group 1. Other patient, treatment and tumour characteristics were comparable between the groups. RESULTS: : Newly acquired and permanent symptoms of bladder dysfunction after rectal excision were present as follows (group 1 versus group 2): difficulty in bladder emptying 7 versus 19 per cent; sensation of incomplete bladder voiding 17 versus 17 per cent; urgency 17 versus 14 per cent; incontinence 10 versus 3 per cent; dysuria 7 versus 7 per cent; and dribbling 14 versus 8 per cent. Male patients stated the following sexual functions before operation/after operation in group 1 versus group 2: interest in sex 80 per cent/40 per cent versus 63 per cent/37 per cent; sexually active 67 per cent/7 per cent versus 53 per cent/22 per cent; impotence 75 per cent/6 per cent versus 58 per cent/26 per cent; ability to have intercourse 75 per cent/13 per cent versus 67 per cent/29 per cent; ability to achieve orgasm 88 per cent/13 per cent versus 76 per cent/47 per cent; and orgasm with ejaculation 88 per cent/9 per cent versus 76 per cent/53 per cent. CONCLUSION: While both conventional rectal cancer surgery and TME result in similarly favourable postoperative bladder function, both techniques decrease sexual function. However, TME offers a significant advantage with regard to preservation of postoperative sexual function in men and constitutes a true advance in rectal cancer surgery compared with conventional techniques.     

Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease

BACKGROUND: The choice of operation for complicated diverticular disease is contentious. The aim of this study was to investigate adverse events following restorative (primary resection and anastomosis, PRA) and non-restorative (Hartmann's procedure, HP) surgery for complicated diverticular disease. METHODS: Five hundred and thirty-nine patients who presented with complicated diverticular disease in 42 centres over a 12-month period from January 2003 were considered for the study. Data were collected prospectively from 248 patients (46.0 per cent) who underwent PRA and 167 (31.0 per cent) who had HP. A propensity score was developed for case-mix adjustment. Multifactorial logistic regression was used to evaluate differences in operative outcomes. RESULTS: Mortality, surgical and medical complication rates were 4.0, 31.0 and 13.7 per cent respectively after PRA, and 23.4, 53.3 and 40.7 per cent for HP (all P < 0.001). After adjusting for the propensity score, the HP group had a 2.1- and 1.9-fold increase in medical and surgical complications respectively compared with those who had PRA, whereas the operative mortality rate was not significantly different. Non-colorectal surgeons performed a significantly higher proportion of HPs in the non-elective setting than colorectal surgeons (80.6 versus 60.4 per cent; chi(2) = 8.31, 1 d.f., P = 0.004). CONCLUSION: PRA with or without a proximal diversion is more often performed non-electively by specialist colorectal surgeons. It may be a safe procedure for complicated diverticular disease in selected patients as it may be associated with fewer postoperative adverse events.     

The use of porcine dermal implant in a minimally invasive pubovaginal sling procedure for genuine stress incontinence

OBJECTIVE: To assess the outcome of a suburethral sling using a porcine dermal implant (Pelvicoltrade mark, Bard Urology, UK) in the surgical management of urinary stress incontinence. PATIENTS AND METHODS: Forty women with urodynamically confirmed genuine stress incontinence were recruited into the study and followed up at 6 weeks and at least 6 months (mean 12 months, range 6-18). The sling was inserted using a minimal-access technique, which allowed 23 women to be operated as day-cases. Outcome measures included continence rates, voiding dysfunction, satisfaction scores and whether the patients would recommend the operation to a friend or relative. RESULTS: The cure rate was 85%, with sustained benefit; a further 10% of the women were improved by surgery. Voiding dysfunction rates were low and satisfaction scores high. Most women would undergo the procedure again if they became incontinent in the future and would recommend the procedure to a friend or relative. CONCLUSION: A minimal access pubovaginal sling using Pelvicoltrade mark is effective in treating stress incontinence. The complication rate is low and the procedure can be performed as a day-case with no loss of efficacy.