Stress urinary incontinence surgical treatment with suburethral suprapubic SPARC sling

IntroductionStress urinary incontinence (SUI) has a high incidence and important morbidity. Multiple surgical techniques have been described to treat it, with despair results. Suburethral slings have become, in recent years, a simpler and less invasive method to treat SUI surgically.Material and methodThe purpose of this paper is to review, retrospectively, 86 patients treated at our institution, from 10/01 to 12/05 of SUI, with a suprapubic suburethral sling (SPARC).ResultsMedium (range) age is 58.7 (39-80), hospital stay was 2.43 d (1-8) and catheter was removed 1.52 d (1-10). 14.5% of patients underwent other vaginal surgeries at same time, most frequently anterior colpoperineoplasty (10.7%). Complications are not very frequent; bladder perforation (5.8%), acute urinary retention (7%), chronic urinary retention (3.5%) and UTI (15.3%). Sling release was performed in 3.5% of women with chronic urinary retention. Total continence was found in 71.4% of patients with 10.1 months medium follow up (1-32). De novo urge symptoms were found in 26.2% of women, with urge incontinence in 54.5% of them. (p < 0,002; OR 5.0 (IC 95% 1.75-14.28).ConclusionsSuprapubic suburethral SPARC sling is a simple method, with few complications and fast social recovery. Outcome can be measured soon, with a high continence rate. De novo urge symptoms are high and they worsen functional results. It is necessary longer follow-up to evaluate long term outcomes.     

Bladder neck sling for treatment of neurogenic incontinence in children with augmentation cystoplasty: long-term followup

PURPOSE: We retrospectively reviewed the outcome and long-term followup (mean 4.16 years) of bladder neck slings for the treatment of neurogenic urinary incontinence in 58 patients (15 males) who also underwent bladder augmentation. MATERIALS AND METHODS: A total of 58 patients with neurogenic bladder (43 females and 15 males, median age 11.4 years) underwent a rectus fascial sling procedure as part of the reconstructive efforts for continence between July 1991 and July 2003. Criteria for enhancement of bladder outlet resistance included a detrusor leak point pressure of less than 45 cm H2O, an open bladder neck during bladder filling at low detrusor pressures and clinical evidence of stress incontinence. RESULTS: Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). A total of 51 patients (88%) obtained good continence results. Five females and 2 males remained incontinent following the sling procedure. Four females underwent a secondary open bladder neck procedure at a mean of 18 months after the initial procedure (artificial urinary sphincter in 2, bladder neck closure in 2). Two male patients (5 and 17 years old) had daily underwear staining or dampness with exercise or transfer. CONCLUSIONS: We consider bladder neck slings the procedure of choice for the enhancement of bladder outlet resistance in the majority of patients with neurogenic bladder who need augmentation cystoplasty and whom we do not expect will be capable of voiding spontaneously. In males and females satisfactory long-term continence can be expected with the use of the rectus fascial sling.     

The surgical treatment of urinary incontinence in children]

The paper reports examination, treatment and follow-up data on 8 children aged 4-13 suffering from total enuresis, who failed previous conservative or operative treatment. Upon examination enuresis was attributed to trauma or malformations of the neck of the urinary bladder (NUB) or urethra (in 2 and 6 patients, respectively). Out of the latter, NUB congenital defect was in 4, total epispadia in 1, spina bifida in 1 patient. Urodynamic studies showed the absence of detrusor-sphincter dyssynergia and confirmed organic nature of NUB lesion. Six children underwent NUB electromyography which recorded no uniform, preformed complexes with adequate voltage. All the children were operated on: NUB reconstruction according to Davis, bilateral uretero-cystostomy according to Coen. An immediate postoperative response was seen in 7 children who were able to retain urine for 40 min-2.5 hours. Long-term response (6 months-3 years) was achieved in 7 children who recovered normal uresis. Total enuresis persisted in 1 patient with spina bifida. 2.5-3 years after the treatment the bladder capacity increased in spite of its resection by 1/3.     

Use of polydimethylsiloxane for endoscopic treatment of neurogenic urinary incontinence in children

PURPOSE: We report on the injection of polydimethylsiloxane for endoscopic treatment of urinary incontinence in children with neurogenic bladder and determine the optimal criteria for patient selection. MATERIALS AND METHODS: We have treated 17 boys and 16 girls since 1995. The etiology of incontinence was spina bifida in 24 cases. Previous surgery was performed in 18 patients, including bladder neck reconstruction in 15 and bladder augmentation in 9. Mean patient age at injection was 13 years (range 7 to 17). We administered 1, 2 and 3 injections in 21, 11 and 1 patients, respectively. Mean volume at each injection was 3.2 cc. Mean interval between injections was 6 months (range 3 to 15). In all cases injection was done transurethrally. RESULTS: Followup ranged from 6 to 41 months (median 16). A total of 11 patients (33.3%) are dry (continence for greater than 4 hours and no urinary pad use during the day) and 8 (24.2%) are improved (continence for 2 to 3 hours and minimal pad use). Results are poor in 14 cases. Overall previous bladder neck surgery or preoperative detrusor hyperactivity did not influence results. Good results were mainly associated with female gender (47.4% of girls versus 10.5% of boys achieved cure). CONCLUSIONS: Injection of polydimethylsiloxane at the bladder neck resulted in continence in 33% of neurogenic bladder cases. Better results occurred in girls and injection did not compromise other surgical procedures. Polydimethylsiloxane seems more suitable than bovine collagen due to potential problems with biological product use.     

Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence

PURPOSE: There are many alternatives for the surgical treatment of children with neurogenic sphincteric incompetence. However, there is no consensus regarding appropriate evaluation and long-term management in these patients. We critically reviewed the literature and compare the outcomes of each technique. MATERIALS AND METHODS: A MEDLINE search was performed to select all relevant peer reviewed publications since 1966. In addition, the bibliography of each article was examined for additional published resources. The results of each technique were compared in 7 objective categories, including continence (defined as complete dryness for 4 hours between voidings or catheterizations), the need for intermittent catheterization, effects on bladder compliance, the need for bladder augmentation, upper tract changes, other complications and the revision rate. RESULTS: Long-term results of artificial urinary sphincter placement were superior and reproducible in terms of continence, preservation of volitional voiding and avoidance of bladder augmentation. Revision rates of various procedures were similar but the incidence of complications was highest with the Kropp procedure. Long-term published data were limited in regard to bladder neck sling, reconstruction, injection, suspension and urethral lengthening techniques. CONCLUSIONS: Long-term published data support artificial urinary sphincter creation as first line surgical management of neurogenic sphincteric incontinence. Girls who already depend on intermittent catheterization may benefit equally from a sling procedure if successful long-term continence is demonstrated in future studies.     

Bladder neck sling and appendicovesicostomy without augmentation for neurogenic incontinence in children

PURPOSE: Most children undergoing bladder neck sling for neurogenic urinary incontinence also have undergone bladder augmentation. However, complications from enterocystoplasty and uncertainty regarding its indication during bladder outlet enhancement led us to perform slings without augmentation. Herein we report outcomes in consecutive patients. MATERIALS AND METHODS: A total of 30 patients with neurogenic bladder underwent tight 360-degree fascial sling wrap around the bladder neck and appendicovesicostomy without augmentation. Indications included detrusor leak point pressure less than 50 cm water and stress urinary incontinence. Urodynamics were obtained in all patients preoperatively, in 26 at a mean of 6 months postoperatively and in 16 at a mean of 24 months postoperatively. RESULTS: Satisfactory continence defined as 2 or fewer damp pads daily was achieved in 83% of patients with followup of 6 to 60 months (mean 22). Symptomatic hyperreflexia and/or loss of compliance developed in 8 patients postoperatively, which responded to anticholinergics in 7. The remaining patient underwent enterocystoplasty 18 months later, for an augmentation rate of 3%. No patient had hydronephrosis or reflux. CONCLUSIONS: Evaluated parameters, including bladder capacity and compliance determined during preoperative urodynamics, did not predict the need for augmentation. Satisfactory continence can be achieved for neurogenic bladder by sling without enterocystoplasty.     

Puboprostatic sling repair for treatment of urethral incompetence in adult neurogenic incontinence

PURPOSE: An incompetent urethral sphincter can be a significant factor contributing to urinary incontinence in patients with neurogenic bladders. We review our experience with 12 men who underwent a puboprostatic sling. MATERIALS AND METHODS: The study included 12 men (mean age 37.1 years) with neurogenic bladder due to spinal cord injury in 9 and spina bifida in 3. All patients were diagnosed with urethral incompetence based on fluorourodynamic evaluation. Medical therapy failed in all 12 patients and all complained of urine leakage with activity. All patients underwent placement of an autologous fascial sling distal to the prostatic urethra via an abdominal approach. Ten patients also underwent simultaneous bladder augmentation to correct high intravesical pressures. RESULTS: Followup ranged from 1 to 39 months (average 14.25). All patients manage the bladder with intermittent catheterization. Of the patients 8 are completely dry between catheterizations and 2 had significant improvement with only minimal leakage (1 pad per day), with an overall success rate of 83%. One patient improved initially but subsequently underwent placement of an artificial urinary sphincter for residual stress incontinence. In 1 patient several external sphincterotomies failed despite adequate sling placement. There were no complications related to the placement of the sling and all patients are able to perform intermittent catheterization without difficulty. CONCLUSIONS: In select male patients the puboprostatic sling can be an effective and safe method to treat urethral incompetence secondary to neurogenic voiding dysfunction.     

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.     

The inside-out trans-obturator sling: a novel surgical technique for the treatment of male urinary incontinence

Objectives

To describe a new sling procedure for treating stress urinary incontinence (SUI) after radical prostatectomy (RP) and prospectively evaluate its short-term safety and efficacy.

Methods

The sling technique uses specific instruments and a polypropylene mesh with two arms that are passed inside to outside through the obturator foramens, pulled for compressing the bulbar urethra upward, and tied to each other across the midline. Patients with detrusor overactivity were excluded. Baseline and follow-up evaluations included uroflowmetry and continence and quality of life (QoL) questionnaires. Cure was defined by no pad use and improvement by a number of pads/d ≤2 and reduced by at least 50%. Complications were recorded.

Results

From April 2006 through February 2007, 20 consecutive patients suffering from post-RP SUI underwent the sling procedure using the same operative protocol. Preoperatively, 3 (15%), 11 (55%), and 6 (25%) patients were using 2, 3–5, and >5 pads/d, respectively. The procedure was preceded by an endoscopic urethrotomy in four patients. No perioperative complication was noted; three patients required suprapubic catheterization. At 6 mo, nine (45%) patients were cured and eight others (40%) were improved (1 pad/d). QoL was significantly enhanced and 80% of patients were moderately to completely satisfied with the procedure. Preoperative and postoperative maximum flow rate and postvoid residual values were not statistically different. No sling infection, urethra erosion, persistent pain, or neurologic complications were observed.

Conclusions

The inside-out trans-obturator sling procedure appears to be safe and efficient at short term. Further studies are warranted to determine long-term outcome.     

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.     

Experimental evaluation of suture support in bladder-neck suspension for the treatment of female stress urinary incontinence

BACKGROUND AND PURPOSE: Bladder-neck suspension has been used widely for the management of female stress incontinence. Despite high early success rates, the long-term results are poor. This in-vitro model was designed to simulate the tear forces affecting the sutures under standardized laboratory conditions. MATERIALS AND METHODS: First, we determined the ultimate strength of various tissues (porcine vagina [PV], human vagina [HV], porcine colon, and chicken skin) in resisting standardized traction force and expansion. Subsequently, different types of suture fixation (U stitch, Z stitch, patch suspension) and button techniques (titanium 2 mm and buttons with various diameters) on PV were exposed to standardized stress impulses generated by the horizontal movement of a metal sledge and the traction force of a 0.5-kg weight pulling on the suture. Amplitude, frequency of the sine movement, traction force on the suture, and tissue thickness were modified; and the tear-out time of the fixation (suture, button) was measured. RESULTS: The PV and HV revealed similar ultimate strengths (49.04 N and 32.08 N, respectively, for traction force; 58.25% and 58.20%, respectively, for expansion). Increasing the frequency (110-160/min), amplitude (8-24 cm), or traction force (0.3-1.2 N) shortened the tear-out time. Tissue thickness had a nearly linear correlation with the tear-out time. The conventional suture technique was almost equal to the smaller buttons (8 and 12 mm) in tear-out resistance, but the 20-mm button was superior (2.6-fold increase in tear-out time). Further improvement of the button technique could be achieved by use of round silicone-coated buttons with medium hardness (shore 40). CONCLUSION: A button-like support is promising, being superior to conventional suturing. Compared with tension-free vaginal tape, it provides the advantage that paraurethral suspension prevents erosion of a foreign body through the urethra. Further technical improvements may include adjustment devices for postoperative fine-tuning of the bladder-neck suspension.     

Management of neurogenic urinary incontinence with AMS artificial urinary sphincter

The AMS artificial urinary sphincter was implanted in 33 patients with neurogenic urinary incontinence during a 10-year period. All sphincter types were employed, from the earliest AS 721 model to the latest AS 800. The mechanically unstable AS 721 and 761 types have all been removed and, when possible, replaced by later models. In 27 of the 33 patients the device is still in situ, and in 6 (18%) it was removed, mainly because of urethral erosion. Increasingly favourable sphincter survival rats have been obtained. The overall survival rate for model AS 742 was 55% (7 years) for first implant, while the 4-year survival rate for AS 791/792 was 90%. Successful control of voiding function, defined as complete continence or slight but not socially inconvenient incontinence, was obtained in 25 patients (76% of the series).     

Ventral hernia of the urinary bladder with mixed urinary incontinence: treatment with herniorrhaphy and allograft fascial sling

Abdominal hernias are not rare in women with urinary incontinence, but incisional bladder hernia is uncommon. The presenting symptoms in the rare cases reported included suprapubic discomfort, irritative voiding symptoms, and urinary incontinence. We present a patient with bladder herniation and severe mixed urinary incontinence. The pathophysiology of the urinary symptoms and the surgical alternatives for the correction of this condition are discussed.