The Effect of Urinary Tract Reconstruction On Neurologically Impaired Women Previously Treated With An Indwelling Uretheral Catheter

Purpose

We investigated the changes in sexuality and quality of life that evolve after lower urinary tract reconstruction in neurologically impaired women previously treated with an indwelling urethral catheter.

Materials and Methods

A total of 18 neurologically impaired women treated with an indwelling urethral catheter underwent bladder reconstruction. Pubovaginal sling urethral compression was required to restore perineal dryness in 13 patients and was the only operation required in conjunction with intermittent catheterization in 3. Eight patients underwent ileocystostomy, that is creation of a "bladder chimney," and 4 underwent augmentation cystoplasty with creation of a continent catheterizable stoma. In 3 patients ileocystoplasty alone with intermittent urethral catheterization was performed. All patients were followed 6 to 40 months (mean 18) after reconstructive surgery using a 9-part questionnaire to score numerically the effect of surgical reconstruction on sexuality and quality of life issues.

Results

On a scale of 0 (worst) to 5 (best) mean scores for self-esteem improved from 1 preoperatively to 4 postoperatively, self-image from 1 to 4, sexual desire from 2 to 4 and ability to cope with disability from 1 to 4, respectively. In 4 of the 15 women who were sexually active preoperatively the frequency of sexual intercourse doubled from a mean of 3 to 6 times per month, respectively, and all 4 women reported improved sexual satisfaction. All 13 patients with pelvic pain and 5 with symptoms of autonomic dysreflexia noticed significant improvement if not complete resolution of the symptoms.

Conclusions

Neurogenic lower urinary tract dysfunction treated with an indwelling urethral catheter is detrimental to sexuality and quality of life in neurologically impaired women. Urinary tract reconstruction restores not only quality of life but also sexuality by improving self-image, self-esteem and the ability to cope. Indwelling catheterization as a method of long-term urinary treatment should be avoided in women.     

Autologous transobturator midurethral sling placement: a novel outpatient procedure for female stress urinary incontinence

Introduction

We present a novel outpatient transobturator autologous rectus fascia midurethral sling procedure.

Methods

A 55-year old woman presented with stress urinary incontinence (SUI) as documented by history, physical exam, and 24-h pad test. Conservative and surgical treatment options were discussed. The patient was interested only in outpatient surgical options, however, and was adamantly opposed to any mesh procedures due to concerns regarding complications. Therefore, following an in-depth discussion and informed consent, a transobturator, autologous sling procedure was performed. The vaginal dissection was performed in the standard fashion. A rectus fascial strip measuring 7?×?1 cm rectus fascia was harvested. A trocar was passed through each obturator foramen. Fascial stay sutures were retracted through the skin incisions. The sling was then appropriately tensioned and the stay sutures tied together.

Results

The patient had an uncomplicated perioperative course. She voided spontaneously with low postvoid residual. At follow-up, she had no urinary leakage.

Conclusions

The transobturator autologous midurethral sling procedure is technically feasible and, in the short term, effective. Longer follow-up and larger series are needed to validate this procedure, which, however, may become a suitable option for patients and surgeons concerned with potential mesh complications.     

The Endoscopic Fascial Sling for Treatment of Female Urinary Stress Incontinence

Purpose

We describe a new technique, the endoscopic fascial sling, for the treatment of female urinary stress incontinence.

Materials and Methods

A total of 22 women 25 to 84 years old with urinary stress incontinence underwent this procedure.

Results

There were no urethral erosions or wound infections using the fascial strip. Of the women 16 (73 percent) are cured of incontinence and 4 (18 percent) are improved (use pads less frequently than preoperatively), and the procedure failed in 2 (9 percent).

Conclusions

The endoscopic fascial sling offers a new alternative for the treatment of female urinary stress incontinence, combining the reliability of sling procedures and the decreased morbidity of needle suspension techniques.     

TRANSVAGINAL URETHROLYSIS FOR URETHRAL OBSTRUCTION AFTER ANTI-INCONTINENCE SURGERY

Purpose

Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction.

Materials and Methods

A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done.

Results

All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms.

Conclusions

Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.     

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.     

Modified Pubovaginal Sling for Treatment of Intrinsic Sphincteric Deficiency

Purpose

We report on 63 women undergoing modified pubovaginal fascial sling construction for treatment of intrinsic sphincteric deficiency. We specifically evaluated duration of postoperative urinary retention, persistence of urinary incontinence and incidence of detrusor instability.

Materials and Methods

Preoperative questionnaires, fluoro-urodynamic studies, hospital and clinical records, and postoperative questionnaires were reviewed to assess comparative outcome among the patients. Failed procedures were studied with fluoro-urodynamics. Patient followup ranged from 3 to 27 months (mean 11.7).

Results

Of the 63 patients 2 (3.2 percent) remained in long-term urinary retention, 4 (6.3 percent) had persistent stress incontinence and 3 (4.8 percent) had long-term detrusor instability. Two patients (3.2 percent) required reoperation for relief of persistent urinary retention (1) and for repair of anteriorly disrupted suspensory sutures (1). Review of preoperative fluoro-urodynamic studies did not provide insight into patients who would experience the aforementioned outcomes.

Conclusions

Our study confirmed the success of the modified pubovaginal fascial sling for treatment of intrinsic sphincteric deficiency. We were unable to obtain useful preoperative information from fluoro-urodynamic studies to predict which patients would experience failure to return to normal voiding.     

Pedicled rectus abdominis muscle and fascia flap sling the bulbar urethra for treatment for male-acquired urinary incontinence: report of ten cases

Purpose

Male urinary incontinence is relatively common complication of radical prostatectomy and of posterior urethroplasty following traumatic pelvic fracture. Here, we investigate the use of pedicled rectus abdominis muscle and fascia flap sling of the bulbar urethra for treatment for male-acquired urinary incontinence.

Materials and methods

Ten patients with acquired urinary incontinence were included in the study. Urinary incontinence was secondary to TURP in three patients and was secondary to posterior urethroplasty performed following traumatic pelvic fracture in seven patients. Pedicled rectus abdominalis muscle and fascial flaps, approximately 2.5 cm wide and 15 cm long, were isolated. The flaps were inserted into a perineal incision through a subcutaneous tunnel. The free end of the flap was sectioned to form two muscle strips, each 3 cm in length, and inserted into the space between bulbar urethra and corpus cavernosa. After adequate sling tension had been achieved, the two strips of muscle were anastomosed around the bulbar urethra using a 2-zero polyglactin suture.

Results

The patients were followed up for between 12 and 82 months (mean 42.8 months). Complete continence was achieved with good voiding in seven of the 10 patients. In other three patients achieved good voiding following catheter removal, but incontinence was only moderately improved.

Conclusions

A pedicled rectus muscle fascial sling of the bulbar urethra is an effective and safe treatment for male patients with mild to moderate acquired urinary incontinence, but it may not be suitable for severe incontinence or for patients with weak rectus abdominalis muscles.     

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.     

Neurogenic Bladder Dysfunction Due to Myelomeningocele: Neonatal Versus Childhood Treatment

Purpose

We sought to determine whether the neonatal institution of treatment of neurogenic bladder dysfunction in myelomeningocele patients at high risk of urinary tract deterioration improves renal and bladder outcome.

Materials and Methods

We reviewed the records of patients with bladder dysfunction believed to be at high risk for renal deterioration based on urodynamic studies. All patients were treated with clean intermittent catheterization. We compared rates of urinary infection, hydronephrosis, reflux, continence and surgical intervention in 46 patients in whom treatment was started in year 1 of life and 52 treated after age 4 years.

Results

Renal outcome was similar in both groups with persistent hydronephrosis in 6 of 46 patients (13%) and 7 of 52 (14%), respectively. However, significantly fewer bladder augmentation procedures were required in patients started on treatment during year 1 of life (5 of 46, 11% versus 14 of 52, 27%, p <0.05).

Conclusions

In addition to any psychological benefit, early intervention with clean intermittent catheterization in children with neurogenic bladder dysfunction may help to prevent irreversible bladder dysfunction and limit the need for bladder augmentation.     

MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE

Purpose

We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion.

Materials and Methods

Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed.

Results

Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion).

Conclusions

Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Pubovaginal Slings Using Fascia Lata for the Treatment of Intrinsic Sphincter Deficiency

Purpose

Various materials and techniques have been used to construct a pubovaginal sling. We believe that fascia lata has several advantages and report our experience.

Materials and Methods

A total of 32 female patients with urodynamically proved intrinsic sphincter deficiency underwent a pubovaginal sling procedure using fascia lata. An unscarred fascial strip 24 to 28 x 2 cm. was attached to itself over a 3 to 4 cm. bridge of abdominal wall fascia. Results were tabulated by chart review and an independent patient survey.

Results

Chart review revealed that 28 of 32 patients (87%) required no pads, and 3 improved and 1 did not. An independent patient survey revealed that 70% of patients (21 of 30) required no pads, 20% required 1 to 3 small pads and 10% required more than 3 small pads per day. Of the patients 80% would undergo the procedure again.

Conclusions

Excellent results can be obtained with fascia lata for the treatment of intrinsic sphincter deficiency. A long, wide strip of fascia attached to itself allows for precise tensioning and good urethral closure, and minimizes the risk of obstruction.     

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.     

Rectus fascia sling for the treatment of total urethral incontinence in males

Objectives  

Urinary incontinence in patients with neurological disease is a major health problem. A modified rectus fascial sling has been assessed in incontinent male patients.     

Comparison of fascial and vaginal wall slings in the management of intrinsic sphincter deficiency

Objectives

To compare safety and efficacy of fascial versus vaginal wall slings in the management of women with intrinsic sphincter deficiency (ISD).

Methods

The hospital and office records of 79 consecutive women with ISD were retrospectively analyzed from January 1991 to September 1995. There were 43 fascial slings (group A) and 36 vaginal wall slings (group B). Parameter of evaluation included efficacy based on postoperative presence of stress or urge incontinence and number of pads used, complications, and miscellaneous factors, including length of catheterization time, length of hospitalization, quantity of analgesics used, and loss of work days.

Results

Baseline clinical and urodynamic data were the same for both groups. Pad use decreased from 6.9 to 0.6 for group A and from 5.7 to 0.3 for group B. Persistent stress and urge incontinence was present in 5% and 16% of group A patients and in 3% and 11 % of group B patients, respectively. Group A (89%) and group B (94%) patients were either very satisfied or satisfied with their surgical outcome. The operative time, hospital days, and days lost from work for group B patients (42.3 ± 13.4 minutes, 1.4 ± 0.9 days, 18.4 ±3.2 days, respectively) were significantly lower than for group A patients (84.2 ± 17.8 minutes, 3.7 ± 1.9 days, 28.4 ±7.8 days, respectively).

Conclusions

Both fascial and vaginal wall slings are effective in treating women with ISD. However, the use of vaginal wall slings resulted in significantly shorter hospital stay, decreased catheterization time, decreased use of analgesics, and decreased loss of days of work compared with fascial slings. Therefore, the vaginal wall sling should be the preferred surgical method of treating intrinsic sphincter deficiency.     

Treatment Results Using Pubovaginal Slings in Patients With Large Cystoceles and Stress Incontinence

Purpose

We determined the efficacy of performing a pubovaginal sling concurrently with a formal cystocele repair in patients with grade III to IV cystoceles.

Materials and Methods

We studied 42 women with grade III to IV cystoceles diagnosed by physical examination and video urodynamics. Of the patients 9 (22%) had intrinsic sphincter deficiency diagnosed by an abdominal leak point pressure of less the 60 cm. water, and 24 (57%) had type II stress incontinence with urethral hypermobility and an abdominal leak point pressure greater than 90 cm. water. A pubovaginal sling and anterior colporrhaphy were performed and, if indicated, other vaginal procedures were done at that time.

Results

A total of 36 patients (86%) was available for postoperative pelvic examinations performed at 3-month intervals, for a mean followup of 20.4 months (range 12 to 39). Only 3 patients had symptomatic grade III cystoceles and 2 had enteroceles. Two patients required collagen injections and 2 underwent a repeat pubovaginal sling. Therefore, all patients were continent at the time of followup.

Conclusions

This study confirms that in patients with large cystoceles and stress urinary incontinence a pubovaginal sling and anterior colporrhaphy effectively treat the incontinence and reduce the cystocele. In addition, the fascial sling appears to provide additional support to the bladder base, improving the durability of the anterior colporrhaphy.     

The Effect of Urethral Introducer Tip Catheters on the Incidence of Urinary Tract Infection Outcomes in Spinal Cord Injured Patients

Purpose

We attempted to determine whether an introducer tip catheter reduces urinary tract infection in spinal cord injured patients on intermittent catheterization.

Materials and Methods

The introducer tip catheter bypasses the colonized 1.5 cm. of the distal urethra. Enrolled patients were prospectively entered into the study in alternate groups depending on whether they reflex voided: group 1-on intermittent catheterization with the introducer tip catheter but not voiding spontaneously or wearing an external urinary catheter, group 2-same as group 1 but using a nonintroducer tip catheter; group 3-on intermittent catheterization with the introducer tip catheter, voiding by reflex and wearing an external urinary catheter, and group 4-same as group 3 but using a nonintroducer tip catheter.

Results

Statistical significance was shown when comparing patients using versus not using the introducer tip catheter regardless of whether an external urinary catheter was worn (p = 0.0121). A greater difference was noted between patients using and not using the introducer tip catheter in the intermittent catheterization only group (p = 0.0093).

Conclusions

The introducer tip catheter decreased urinary tract infections in hospitalized men with spinal cord injury on intermittent catheterization.     

Urinary continence and erectile function after bladder neck sling suspension in male patients with spinal dysraphism.

OBJECTIVE: To assess the outcome of using sling suspensions combined with clean intermittent catheterization (CIC) in patients with spina bifida, of whom a third are incontinent through pelvic floor paralysis. PATIENTS AND METHODS: Between March 1992 and April 1997, 14 male patients (mean age at surgery 11.7 years, range 6.5-15.2) with spina bifida and neurogenic sphincter incontinence underwent a puboprostatic sling suspension as a primary treatment. The procedure, via an abdominoperineal approach, consists of suspending the bladder neck by placing a simple U-shaped rectus abdominus fascial sling. The perineal approach is used to develop the plane between the rectum and Denonvillier's fascia, and to prepare the passage of the sling alongside the prostate. Apart from the sling procedure, eight of the 14 patients underwent autoaugmentation of the bladder and two underwent ileocystoplasty during the same operation. All patients used CIC daily. Erectile function was assessed by reports from the patients and their parents, and continence by report and urodynamic studies. RESULTS: Of the 14 patients, 13 achieved urinary continence with no additional procedures; one required a subsequent submucosal injection at the suspension site with silicone particles in povidone (Macroplastique(R)) to become continent. Two patients reported slight leakage at night. Before surgery, all but one patient reported having spontaneous or mechanically manipulated erections; none had erections on psychological stimulation. After surgery, erectile function was preserved in 13 of the 14 patients; in one there were problems establishing the right dissection plane between the rectum and prostate, but spontaneous erections returned a year after surgery. CONCLUSION: In males, the abdominoperineal puboprostatic sling suspension using rectus abdominis fascia appears to be a successful treatment for sphincter incontinence in patients with spina bifida, and safely maintains erectile function.     

Defining the role of the bladder-neck sling in the surgical treatment of urinary incontinence in children with neurogenic incontinence

Patient selection for the creation of a fascial sling procedure to increase outlet resistance has been somewhat controversial. We review our experience with the fascial sling technique and report our patient selection process. Since 1991, 30 patients, including 6 males and 24 females aged 4–20 years (mean 10 years), underwent a rectus fascial sling procedure as part of their reconstructive efforts for continence. The underlying cause of incontinence was neurogenic in 28 patients. All males were prepubertal. Videourodynamics were performed in all patients preoperatively. Criteria for enhancement of bladder-outlet resistance included a detrusor leak-point pressure (LPPd) of <50 cmH₂O; a stress leak-point pressure (LPPs) of <100 cmH₂O; an open bladder neck, irrespective of LPP; and clinical evidence of stress incontinence, irrespective of videourodynamic parameters. Technical aspects of the procedure are discussed. Augmentation cystoplasty was performed in 29 patients with poor bladder compliance. In 18 patients a catheterizable stoma was also created. The period of follow-up currently ranges from 2 to 70 (mean 37) months. In all, 28 patients (93%) became continent and 2 female patients remain incontinent with a low LPP. All patients are on clean intermittent catheterization (CIC); 12 patients (40%) are catheterizing per urethra without difficulty. All prepubertal males are completely dry. The fascial sling repair has many advantages over other methods for increasing outlet resistance, including simplicity of technique, effectiveness, minimal likelihood of erosion, and low cost.     

Surgical management of lower urinary mesh perforation after mid-urethral polypropylene mesh sling: mesh excision, urinary tract reconstruction and concomitant pubovaginal sling with autologous rectus fascia

Introduction and hypothesis

We present our management of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling using a novel combination of surgical techniques including total or near total mesh excision, urinary tract reconstruction, and concomitant pubovaginal sling with autologous rectus fascia in a single operation.

Methods

We retrospectively reviewed the medical records of 189 patients undergoing transvaginal removal of polypropylene mesh from the lower urinary tract or vagina. The focus of this study is 21 patients with LUT mesh perforation after mid-urethral polypropylene mesh sling. We excluded patients with LUT mesh perforation from prolapse kits (n?=?4) or sutures (n?=?11), or mesh that was removed because of isolated vaginal wall exposure without concomitant LUT perforation (n?=?164).

Results

Twenty-one patients underwent surgical removal of mesh through a transvaginal approach or combined transvaginal/abdominal approaches. The location of the perforation was the urethra in 14 and the bladder in 7. The mean follow-up was 22 months. There were no major intraoperative complications. All patients had complete resolution of the mesh complication and the primary symptom. Of the patients with urethral perforation, continence was achieved in 10 out of 14 (71.5 %). Of the patients with bladder perforation, continence was achieved in all 7.

Conclusions

Total or near total removal of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling can completely resolve LUT mesh perforation in a single operation. A concomitant pubovaginal sling can be safely performed in efforts to treat existing SUI or avoid future surgery for SUI.     

PUBOVAGINAL FASCIAL SLING FOR ALL TYPES OF STRESS URINARY INCONTINENCE: LONG-TERM ANALYSIS

Purpose

There is a lack of consensus regarding indications and long-term efficacy of the many surgical techniques for treating stress incontinence. Historically pubovaginal sling has been reserved for cases of intrinsic sphincter deficiency or prior surgical failure. Transvaginal needle and retropubic suspensions have been used mainly for sphincteric incontinence unassociated with intrinsic sphincter deficiency. We report the long-term results of pubovaginal sling for all types of stress incontinence.

Materials and Methods

A total of 251 consecutive women with all types of stress incontinence who underwent pubovaginal fascial sling by a single surgeon were retrospectively and prospectively reviewed. Patients were evaluated preoperatively with history, physical examination, standardized symptom questionnaire, voiding diary, pad test, uroflow, post-void residual urine, video urodynamics and cystoscopy. Postoperatively women with at least 1-year followup were assessed by an independent third party (J. R.) who had no prior knowledge of them, and who recorded the parameters of the questionnaire, examination with a full bladder, voiding diary, pad test, uroflow and post-void residual urine.

Results

Overall stress incontinence was cured or improved in 92% of the patients with at least 1-year followup (median 3.1 years, range 1 to 15). The majority of patients with postoperative incontinence had de novo (3%) or persistent (23%) urge incontinence. Permanent urinary retention developed in 4 patients (2%).

Conclusions

Fascial pubovaginal sling is an effective treatment for all types of stress incontinence with acceptable long-term efficacy.