Comparison of video urodynamic results after the pubovaginal sling procedure using rectus fascia and polypropylene mesh for stress urinary incontinence

PURPOSE: Video urodynamic changes were compared after the pubovaginal sling procedure using rectus fascia or polypropylene mesh in women with stress urinary incontinence. MATERIALS AND METHODS: A total of 50 women with various types of stress urinary incontinence were treated with the pubovaginal sling procedure using randomly abdominal rectus fascia in 24 or polypropylene mesh in 26. The sling was placed at the level of the bladder neck and tied with sufficient tension to prevent urinary leakage without obstructing the bladder outlet. Video urodynamics were performed preoperatively, and 7 to 14 days and 3 to 6 months postoperatively in all cases. Surgical results and urodynamic changes after the pubovaginal sling procedure were compared in the 2 groups. Long-term results were evaluated at a mean followup of 2 years. RESULTS: Complete continence was achieved in 23 patients (95.8%) in the rectus fascia group and 26 (100%) in the polypropylene mesh group, including 1 initial failure with reoperation, at a median followup of 24 and 23 months, respectively. The subjective success rate was 91.6% for rectus fascia and 92.3% for polypropylene mesh. The main cause of dissatisfaction was persistent urge incontinence and dysuria in 2 cases each. In each group video urodynamics revealed a mild but nonsignificant decrease in maximum urinary flow and a significant increase in bladder neck opening time at 7 to 14 days versus baseline. However, these parameters returned to baseline within 3 to 6 months postoperatively. Voiding pressure, cystometric capacity and post-void residual urine also showed no significant change in either group after the pubovaginal sling procedure. Patients treated with a polypropylene mesh sling had a shorter operative time and hospital stay, a higher spontaneous voiding rate after catheter removal and a lower incidence of wound pain after surgery. One patient treated with polypropylene mesh had sling margin extrusion. The incidence of new onset detrusor instability and persistent dysuria was similar in the 2 groups. Transrectal sonography of the sling showed that it was located beneath the bladder neck and proximal urethra in all patients in each group. CONCLUSIONS: The results of this study show that the pubovaginal sling procedure using rectus fascia or polypropylene mesh as the sling material had similar effectiveness for treating female stress incontinence but the polypropylene group had more rapid recovery. Postoperatively video urodynamics demonstrated that the pubovaginal sling using either sling material did not cause bladder outlet obstruction with proper surgical technique.     

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

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

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

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

Long-term surgical results of pubovaginal sling procedure using polypropylene mesh in the treatment of stress urinary incontinence

INTRODUCTION: Surgery for stress urinary incontinence (SUI) in women might cure incontinence symptom but develop new problems. This study assessed the long-term outcome of pubovaginal sling procedure using polypropylene mesh in patients with SUI. MATERIALS AND METHODS: A total of 108 patients with various types of SUI received pubovaginal sling procedure using polypropylene mesh. A surgical technique that did not create bladder outlet obstruction after operation was used in all the patients. Video urodynamic study was performed at baseline, 2 weeks and 3 months after operation. The long-term surgical results and patients' satisfaction were assessed. RESULTS: The age of patients ranged from 33 to 94 years (mean 62.6 +/- 12.0 years). The follow-up period ranged from 24 to 72 months (median 46 months). Among the 108 patients, a successful result was noted in 92 (85.2%), including a continence rate of 65.7% and mild SUI in 19.4% of patients. Treatment failure was noted in 16 patients (14.8%), including 13 (12%) with urge incontinence and 3 (2.8%) with severe SUI that was cured by a second sling. There were 104 patients (96.3%) who could void volitionally with little residual urine, whereas 4 (3.7%) needed transvaginal urethrolysis. Urodynamic study revealed no significant changes in the mean values of parameters at 3 months after operation. However, 22 (20%) patients had an increase in voiding pressure by 50% at 3 months postoperatively. The reported satisfactory rate was 89.8%. CONCLUSIONS: Pubovaginal sling procedure using polypropylene mesh had a high success rate in all types of SUI. The continence rate was suboptimal, indicating that the absence of bladder outlet obstruction might result in inadequate urethral compression after pubovaginal sling procedure.     

Suprapubic sling adjustment: minimally invasive method of curing recurrent stress incontinence after sling surgery

PURPOSE: Recurrent stress urinary incontinence after sling surgery is a complex problem. A minimally invasive method of correcting recurrent stress urinary incontinence after pubovaginal sling surgery is described. MATERIALS AND METHODS: We performed suprapubic sling adjustment in 10 women with recurrent stress urinary incontinence after sling surgery. Of these 10 women 4 had received antibacterial polytetrafluoroethylene patch sling, 3 an autologous dermis patch sling and 3 an autologous rectus fascia patch sling but stress incontinence recurred. To correct recurrent incontinence, a pubovaginal sling was revised by adjusting the sling tension suprapubically with the aid of a cotton swab test and bladder leak test. RESULTS: Mean followup was 13 months (range 8 to 28). Of the 10 women 9 became completely dry and 1 was greatly improved. One patient who had persistent stress incontinence generated an abdominal leak point pressure of 189 cm. H(2)O compared to a preoperative pressure of 120 cm. H(2)O. The incidence of de novo urge incontinence was 2% (2 of 10 cases). Mean resting cotton swab angle was (+) 20 and (+) 5 degrees, and mean Valsalva cotton swab angle was (+) 40 and (+) 5 preoperatively and postoperatively. Mean pad use decreased from 3 pads to less than 1 pad a day. Mean self-reported satisfaction score was 9 (range 8 to 10) on a visual analog scale. CONCLUSIONS: Pubovaginal slings may be revised safely with excellent results. Adjusting the sling tension suprapubically is a minimally invasive technique. Suprapubic sling adjustment may be performed as an intermediary step before resorting to a complete sling takedown/revision.     

Stress incontinence: classification and surgical approach

We present a modified classification for stress urinary incontinence based on the nature of vesical neck descent and the integrity of the intrinsic sphinteric mechanism. Surgical treatment was undertaken in 72 patients with this classification. With a minimum followup of 18 months there was a 94 per cent cure rate with respect to stress incontinence. However, in 14 patients significant frequency and urgency developed, which persisted for at least 6 months postoperatively. Of these patients 13 had undergone a pubovaginal sling procedure, 3 of whom had refractory symptoms, including urge incontinence, which resulted in augmentation cystoplasty in 2 and supravesical urinary diversion in 1.     

ANATOMICAL AND FUNCTIONAL RESULTS OF PUBOVAGINAL SLING PROCEDURE USING POLYPROPYLENE MESH FOR THE TREATMENT OF STRESS URINARY INCONTINENCE

PURPOSE: The anatomical and functional results of pubovaginal sling procedure using polypropylene mesh were investigated. MATERIALS AND METHODS: A total of 50 women with stress urinary incontinence, including 26 with type 2, 7 with mixed type 2/3 and 17 with type 3 disease, underwent the pubovaginal sling procedure using polypropylene mesh. A self-fashioned 2 cm. polypropylene mesh sling was used in all cases. The slings were fixed without tension at each side of the bladder neck. The sling was further suspended to elevate the bladder neck in patients with type 2 disease and those with a hypermobile bladder base, while it was placed without further tension in those with type 3 disease and those with a nonmobile bladder base. After the operation video urodynamics and transrectal sonography were done to evaluate functional and anatomical results. RESULTS: At a median followup of 24 months 42 women were cured, 6 had improvement and treatment had failed in 2. Although the maximum flow rate increased, no changes were noted in detrusor pressure, post-void residual urine or cystometric capacity at month 3. Transrectal sonography revealed that mean sling width plus or minus standard deviation had decreased to 13.5 +/- 3.3 mm. at 3 months. The endopelvic fascia was thicker in women with type 2 than in those with types 2/3 or 3 disease (mean 5.3 +/- 1.5 versus 3.5 +/- 1.3 mm., p = 0.001). The position of bladder neck on video urodynamics was elevated a mean of 2.01 +/- 2.01 and 3.07 +/- 2.07 cm. compared to baseline elevation during resting and straining, respectively (p = 0). No hypermobility was noted while the patients coughed and no kinking of the urethra was observed while they performed the Valsalva maneuver. Detrusor instability resolved in 6 of 8 women (75%) and new onset detrusor instability was noted in 7 (14%). In 2 women with persistent stress urinary incontinence a repeat sling procedure was necessary to treat type 3 disease and cure incontinence. The overall success rate was 96%. One patient with sling erosion into the vaginal wall was treated with simple revision. CONCLUSIONS: Fixation of a polypropylene mesh sling at the bladder neck and adequate suspension may effectively achieve a hammock effect without creating bladder outlet obstruction in patients with types 2 and 2/3 stress urinary incontinence. The anatomical and functional results of this study show that a well suspended bladder neck did not create bladder outlet obstruction after a pubovaginal sling procedure using polypropylene mesh.     

Resolution of urge symptoms following sling cystourethropexy

PURPOSE: Persistence of urinary urge symptoms in women after pubovaginal sling cystourethropexy is a distressing problem. We assess the ability of preoperative video urodynamics to identify patients in whom urinary urge symptoms failed to resolve postoperatively. MATERIALS AND METHODS: The records of 84 consecutive women who had undergone pubovaginal sling cystourethropexy were reviewed. Preoperative video urodynamics revealed stress urinary incontinence in all cases and concomitant detrusor instability in some. Cases of motor urge, defined as urge symptoms plus detrusor instability, were divided into low and high pressure categories. Patients with urge symptoms but no demonstrable detrusor instability on video urodynamics were diagnosed with sensory urge. Postoperatively complete urge resolution was defined as total absence of symptoms without pharmacological therapy. Mean followup was 26.7 months (range 2 to 62). RESULTS: Of the 84 patients 41 with motor urge and 28 with sensory urge had preoperative urge symptoms. Complete resolution or improvement in urge symptoms occurred in 24 (58.5%) and 7 (17.1%) of the motor urge, and 11 (39.3%) and 9 (32.1%) of sensory urge cases, respectively. Of the 41 patients with motor urge 23 had low pressure instability, which completely resolved in 21 (91.3%) and improved in 2 (8.7%). Of the 18 remaining patients with high pressure motor urge only 5 (27. 8%) had complete resolution of urge and 5 (27.8%) had improvement. CONCLUSIONS: Our results suggest that patients with low pressure motor urge are significantly more likely to experience resolution of urinary urge symptoms after pubovaginal sling cystourethropexy than those with high pressure motor urge or sensory urge.     

The surgical results of the pubovaginal sling procedure using polypropylene mesh for stress urinary incontinence

OBJECTIVE: To investigate the surgical results after a pubovaginal sling procedure using polypropylene mesh in women with stress urinary incontinence (SUI). PATIENTS AND METHODS: Sixty-four women with different types of SUI underwent a pubovaginal sling procedure, using polypropylene mesh. The sling was placed at the level of the proximal half of the urethra and tied with adequate tension, but not obstructing the bladder outlet. A video-urodynamic study and transrectal ultrasonography were undertaken before and after surgery. The surgical results were assessed and the urodynamic changes compared at different stages. RESULTS: At a median follow-up of 24 months, 52 patients (81%) were completely continent, 10 (16%) had an improvement but with mild SUI, and two had persistent SUI requiring a second sling procedure. The treatment result was considered satisfactory by 55 patients (86%). The video-urodynamic study showed no significant change in voiding pressure, cystometric capacity and residual urine volume after surgery. The bladder neck opening time was increased at 7 days and the maximum flow rate increased at 3 months after surgery. Transrectal ultrasonography showed that all the polypropylene mesh slings were located beneath the bladder neck and proximal urethra, with no notable granuloma formation around the sling. CONCLUSION: The pubovaginal sling procedure is effective in treating female SUI, using polypropylene mesh as the sling material. The video-urodynamic results showed that a pubovaginal sling of polypropylene mesh causes no bladder outlet obstruction when the correct surgical technique is used.     

Pubovaginal fascial sling for the treatment of complicated stress urinary incontinence

We reviewed retrospectively 67 consecutive women with complicated stress incontinence who underwent a pubovaginal fascial sling procedure by a single surgeon. A detailed micturition questionnaire was completed at the last followup, which ranged from 1 to 8 years, with a mean of 3.5 years. Postoperatively, 82% of the women claimed that they were never incontinent and never wore pads, while 9% were incontinent less often than once per 2 weeks and 9% 9% continued to have troublesome incontinence on a daily basis. Only 2 of these women had persistent stress incontinence; the remainder (5) had urge incontinence. In 6 patients with a neurogenic bladder postoperative urinary retention was expected and they were treated with intermittent self-catheterization. Two patients had urethral obstruction by the sling and required prolonged (probably permanent) intermittent self-catheterization.     

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.     

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.     

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

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

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.     

Pubovaginal sling and pelvic prolapse repair in women with occult stress urinary incontinence: effect on postoperative emptying and voiding symptoms

Objectives. To determine the perioperative morbidity of performing a concurrent pubovaginal sling with prolapse repair in women with occult (or potential) stress incontinence, particularly on voiding dysfunction and emptying.Methods. We reviewed the charts of 38 women with grade 3-4 pelvic prolapse and occult stress incontinence. All patients underwent video urodynamic testing with the prolapse unreduced and again with the prolapse reduced with a pessary or packing. The abdominal leak point pressure was determined. Appropriate surgical repair of all components of the prolapse was performed concurrently with pubovaginal sling placement. The outcomes were measured with respect to the time to spontaneous voiding, permanent urinary retention, development of stress incontinence or de novo urge incontinence, resolution of urge incontinence, and perioperative complications.Results. The mean age was 72 years, and the mean follow-up was 15 months (range 6 to 39). The mean time required before spontaneous voiding resumed without the need for catheterization was 11.8 days (range 2 to 46). No patient developed permanent urinary retention. Two (9.5%) of 21 women without preoperative urge incontinence developed de novo urge incontinence. However, existing urge incontinence resolved in 45%. One woman developed a suprapubic wound infection, which resolved with conservative management. Stress incontinence occurred in 2 women (7%) at 4 and 19 months postoperatively. Clinically significant prolapse (uterine) developed in 1 patient 2 years after surgery.Conclusions. Simultaneous pubovaginal sling placement for women with occult stress incontinence undergoing repair of a large pelvic prolapse is effective in preventing postoperative stress incontinence and has little negative effect on postoperative bladder emptying. It should be considered in all women with occult stress incontinence undergoing prolapse repair.     

OUR EXPERIENCE WITH PUBOVAGINAL SLINGS IN PATIENTS WITH STRESS URINARY INCONTINENCE

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

A prospective evaluation of the efficiency of early postoperative bladder emptying after the Stamey procedure or pubovaginal sling for stress urinary incontinence

PURPOSE: The pubovaginal sling has been criticized as having a higher incidence of postoperative voiding dysfunction than other surgical approaches for the management of stress urinary incontinence. In 2 similar patient groups we prospectively compared the rates of early postoperative voiding dysfunction after the pubovaginal sling or Stamey procedure. MATERIALS AND METHODS: Between June 1995 and January 1997, 50 consecutive patients underwent the pubovaginal sling or Stamey procedure. Emptying efficiency was measured 48 hours postoperatively by suprapubic catheter in the Stamey group and intermittent catheterization in the pubovaginal sling group. When emptying efficiency was greater than 75%, intermittent catheterization was stopped or the suprapubic catheter was removed. RESULTS: There was no statistically significant difference in emptying efficiency for the first 3 voids using the Dunn multiple comparison method. Median voiding efficiencies were 37%, 43% and 61% with the Stamey procedure in group 1 (mean 43%, 45% and 54%), and 60%, 75% and 75% with the pubovaginal sling in group 2 (mean 49%, 68% and 69%), respectively. The mean number of intermittent catheterizations performed in patients with the pubovaginal sling was 5.7 in less than 1 day. In the Stamey group the suprapubic catheter was removed an average of 6 days postoperatively. The mean duration of hospital stay was similar for the sling and Stamey groups (5.4 versus 6 days, respectively). There were 2 patients in each group who were voiding inefficiently after day 7. Voiding efficiency was restored at 53 and 86 days in the 2 patients with slings and at 18 days in 1 of the 2 who underwent the Stamey procedure, respectively. The second patient who underwent the Stamey procedure was able to void without using the catheter at all, and it was removed 30 days postoperatively when emptying efficiency was confirmed greater than 75%. CONCLUSIONS: These data show that early postoperative voiding dysfunction, measured using bladder emptying efficiency, after the pubovaginal sling is no more common than after the Stamey procedure and help justify the broadened indications for pubovaginal sling for treatment of stress urinary incontinence.     

Favorable Outcome of Pubovaginal Slings for Geriatric Women With Stress Incontinence

Purpose

Traditionally pubovaginal slings have been associated with a greater risk of immediate morbidity and prolonged voiding dysfunction compared to other stress incontinence repairs. Because elderly patients already have inherently greater perioperative risk and prevalence of innate voiding dysfunction, there is some reluctance to construct slings in this age group. We examined the outcome of pubovaginal sling in elderly women versus younger controls to determine whether this concern is justified.

Materials and Methods

We retrospectively analyzed the outcome of 19 geriatric women older than 70 years who underwent a pubovaginal sling procedure between 1992 and 1995, and compared the findings to those of 77 younger control women with a mean followup of 22 months. All women had video urodynamically proved stress incontinence due to intrinsic sphincter deficiency and many had coexistent bladder instability symptoms. Women with neurogenic causes for incontinence were excluded from the study.

Results

Stress incontinence resolved in 100% of geriatric and 97% of control women. Preoperative instability symptoms, including urge incontinence, improved in more than 50% of patients in both groups. De novo instability symptoms arose in 10% of women in each group but were generally controlled with anticholinergics. Efficient voiding resumed within a mean of 16 days in both groups.

Conclusions

The morbidity and success rates of pubovaginal sling surgery in the elderly compare favorably to those in younger women. Advanced age alone would not dissuade us from constructing a pubovaginal sling when indicated.     

Management of vaginal erosion of polypropylene mesh slings

PURPOSE: The SPARC (American Medical Systems, Minneapolis, Minnesota) polypropylene sling has recently been introduced as an alternative delivery system to TVT (Ethicon, New Brunswick, New Jersey) tension-free vaginal tape for placement of a tension-free mid urethral sling. Erosion must always be considered a risk of synthetic materials. We present 4 cases of vaginal erosion of polypropylene mesh placed with this system and the successful conservative management done. MATERIALS AND METHODS: A total of 90 patients received a SPARC polypropylene pubovaginal sling at our institution between October 1, 2001 and October 1, 2002. During followup 3 of our patients and 1 patient with tension-free vaginal tape who was referred from elsewhere presented with vaginal exposure of the mesh. RESULTS: Two patients described persistent vaginal discharge 6 weeks postoperatively, including 1 who complained primarily of partner discomfort during sexual intercourse. Two patients were completely asymptomatic and mesh erosion was discovered at routine physical examination 6 weeks postoperatively. Pelvic examination demonstrated vaginal exposure of the mesh in all cases. Each patient was observed conservatively and 3 months postoperatively all 4 had complete spontaneous epithelialization over the mesh. None had stress incontinence, urgency or urge incontinence, all emptied the bladder to completion and all patients were completely satisfied with the procedure. CONCLUSIONS: The recent literature suggests that polypropylene mesh erosion should be treated with complete removal of the sling material. We present 4 cases of vaginal erosion of polypropylene slings that were managed conservatively with observation and resulted in complete spontaneous healing. Sling preservation with continued patient continence and satisfaction is a feasible option in those with vaginal exposure of polypropylene mesh.     

Long-term results of surgical treatment for female stress urinary incontinence

OBJECTIVE: To compare the long-term success rates of bladder neck suspension (BNS) and pubovaginal sling procedure in different types of female stress urinary incontinence (SUI) in order to identify appropriate treatment strategies for SUI. METHODS: A total of 157 women who received anti-incontinence surgery were followed-up for a mean period of 58.1 +/- 33.9 months. The surgical outcome was analyzed and was compared among the different types of SUI and among BNS and pubovaginal sling procedures. RESULTS: SUI was classified as type I in 16 patients, type II in 111 patients, and type III in 34 patients. Surgical procedures included Gittes BNS (n = 62), Raz BNS (n = 53), and pubovaginal sling procedure (n = 42). The total success rate was 77.1%, including a 38.2% cure rate and a 38.9% significantly improved rate. Analysis of the results revealed that type III SUI had the lowest success rate (67.6%), while the pubovaginal sling procedure had the best success (93.9%) and cure rates (54.8%). The success rates of BNS were significantly lower than that of pubovaginal sling in type III SUI, less favorable in type II SUI, but remained high in type I SUI. 75% of patients with treatment failure had recurrence within the fist postoperative year. CONCLUSIONS: In this series of patients, the long-term cure rates of anti-incontinence surgeries are not satisfactory. BNS procedures had satisfactory results only in type I SUI while the pubovaginal sling procedure had better results in both types II and III SUI. The pubovaginal sling procedure might have better long-term results in the treatment of all types of SUI.