Surgical treatment of the incontinent female patient with myelomeningocele

Surgical therapy was required for 42 incontinent female patients with myelomeningocele who had urodynamically documented high pressure bladders. Conservative treatment consisting of cholinolytic and alpha-adrenergic agents, and intermittent self-catheterization had failed. The surgical approach consisted of perivesical denervation (for hyperreflexia), Burch bladder neck suspension, enlargement cystoplasty and ureteral reimplantation when required. Among 33 patients (79 per cent) there was no incontinence on intermittent self-catheterization and 6 (14 per cent) had improvement with rare urgency or stress incontinence. In 3 patients (7 per cent) sphincteric incompetence required a transvaginal sling procedure.     

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.     

Transvaginal urethrolysis after obstructive urethral suspension procedures

Obstructive uropathy after an operation for stress incontinence was treated by transvaginal urethrolysis in 13 women. Bladder outlet obstruction developed after retropubic urethropexy in 6 patients, after needle suspension in 4 and after a pubovaginal sling operation in 3. Transvaginal urethrolysis was accompanied by a needle suspension in 2 patients, an Inglemann-Sundberg denervation in 1 and a pubovaginal sling in 1. Of 13 patients 10 are voiding and none has stress incontinence but 3 continue to perform intermittent self-catheterization.     

Surgical treatment of stress urinary incontinence after radical hysterectomy

Stress urinary incontinence is not infrequent after radical hysterectomy for cervical cancer. Eight women who underwent surgery for correction of stress incontinence after radical hysterectomy were studied with urodynamic techniques before and 1 year after incontinence surgery. Five patients underwent a Marshall-Marchetti-Krantz (MMK) operation, 1 a Burch colposuspension, 1 a sling procedure and 1 an anterior repair. Two patients remained incontinent after an MMK operation, as did the patient who had an anterior repair. The patient who underwent a sling procedure had to practice intermittent selfcatheterization. We conclude that an appropriate operation can cure stress incontinence after radical hysterectomy, but that patients should be selected carefully.     

Gore-tex sling urethral suspension in type III female urinary incontinence: Clinical results and urodynamic changes

The authors prospectively evaluated 24 consecutive female patients with type III stress urinary incontinence, ranging in age from 36 to 70 years (mean 55 years). All patients were operated upon and had a vesicourethral suspension by a Gore-Tex suburethral sling. All were evaluated urodynamically 6 and 30 months after surgery. In this group of patients clinical cure of incontinence was observed in 83.3% (20) and in the remaining 4 patients it was significantly improved. In 2 patients there was an erosion of the urethra and the sling had to be removed 3.5 years later. Five other women remained dry but complained of occasional irritative symptoms, and several urinary tract infections were recorded (2–3 per year), which were documented by positive urine cultures. In the remaining 17 patients no erosion was observed and no irritative symptoms were reported. The urodynamic evaluation revealed an excellent postoperative result both 6 months and 30 months after surgery. EDITORIAL COMMENTS: This study reports the author’s experience with the use of the Gore-Tex suburethral sling procedure in women with type III stress incontinence, excluding patients with urethrovesical junction hypermobility. Diagnosis is based on videourodynamic criteria, as is postoperative follow-up and the definition of cure/failure. It is interesting that the technique used specifically refrains from placing extensive tension on the sling, although extra sutures are placed attaching the sling to ‘fascial tissue in the vicinity of the puboiliac bone’, even including the periosteum. Typically the use of a sling procedure in patients with a fixed drainpipe urethra has been based on the obstructive characteristics of the sling, rather than giving support to an already well supported urethrovesical junction. Previous reports have described postoperative voiding dysfunction requiring intermittent self-catheterization, recurrent urinary tract infections, elevated postvoid residuals and detrusor instability as possible consequences of ‘tight’ slings. Hints that these sequelae did occur in the study population include the high incidence of urinary tract infections and detrusor instability (persistent and de novo), and the fact that 2 patients required removal of the sling because of erosion into the urethra. Although the authors report a significant cure rate (84%) of stress incontinence, clearly this report again cautions against the use of slings in patients with ISD and a well supported bladder neck.     

Silastic slings for female incontinence

Between September 1985 and June 1988, 67 patients with stress urinary incontinence were treated with reinforced Silastic slings using an abdominovaginal approach. Of these patients, 54 were cured, 2 were improved and 10 were the same or worse (1 patient was not followed up). Six patients who are now continent require periodic intermittent self-catheterization; 3 patients had to have the sling removed, due to a persistent sinus or pain; and 16 patients had to have the sling adjusted.     

Pubovaginal slings for stress urinary incontinence following radical cystectomy and orthotopic neobladder reconstruction in women

PURPOSE: We evaluated the clinical efficacy of pubovaginal slings for new onset stress urinary incontinence following radical cystectomy and orthotopic lower urinary tract reconstruction in women. MATERIALS AND METHODS: Between June 1990 and July 2002, 101 female patients with primary transitional cell carcinoma of the bladder were treated with radical cystectomy and orthotopic ileal neobladder reconstruction. Four patients 61 to 73 years old underwent pubovaginal slings (autologous rectus fascia in 2 and dermal graft in 2) for stress urinary incontinence persisting 9 to 20 months following reconstruction with a Studer (2) or T pouch (2) ileal neobladder. Pre-cystectomy continence was excellent in 3 patients, while 1 had mild stress incontinence. All patients had high grade, muscle invasive transitional cell carcinoma and/or carcinoma in situ with negative urethral margins and 3 of the 4 had lymph node negative disease on pathological examination. Two patients were treated with transurethral bulking material 4 to 5 months prior to the sling procedure without noticeable improvement. RESULTS: Two patients who underwent autologous pubovaginal slings had significant complications arising from dissection in the retropubic space, including 1 entero-pouch fistula and 1 enterotomy resulting in an enterocutaneous fistula, sepsis and subsequent death. These 2 patients had persistent stress incontinence despite the sling procedures and they ultimately underwent conversion to continent cutaneous urinary diversions. Two patients were treated with a dermal graft sling using infrapubic bone anchors through a transvaginal approach, obviating the need to enter the pelvis. These patients had uneventful postoperative courses and they are currently hypercontinent, performing intermittent catheterization with complete daytime continence and only occasional nighttime leakage 3 and 9 months following sling surgery. CONCLUSIONS: Pubovaginal sling procedures for incontinence following orthotopic neobladder reconstruction in women may be complicated due to extensive pelvic surgery. Dissection in the retropubic space should be avoided because potentially fatal complications may occur. Slings using infrapubic bone anchors may provide the best option in such patients in whom conservative management has failed because the pelvis need not be violated.     

Vaginal wall sling: four years later.

Since December 1985, we have treated 65 patients with urinary stress incontinence due to intrinsic sphincter dysfunction with the vaginal wall sling procedure. Of the 54 patients who were available for follow-up, intrinsic sphincter dysfunction was related to multiple prior bladder neck suspension procedures in 48 patients. In the remaining 6 patients, 2 had pelvic trauma, 2 had neurogenic urethral dysfunction, 1 had urethral diverticulectomy, and 1 had pelvic radiation. The success rate of the vaginal wall sling procedure for correcting stress incontinence was 94.4 percent at a mean follow-up of 23.9 months. Postoperative complications were minimal. Although 83 percent were temporarily in urinary retention, in the absence of neurogenic bladder and augmentation cystoplasty, only 5.5 percent needed intermittent self-catheterization on a long-term basis. De novo detrusor instability developed postoperatively in 14.8 percent of the cases. In no patient did a vaginal inclusion cyst develop. The vaginal wall sling is a simple procedure with excellent success rate and minimal morbidity. We recommend it for patients with stress urinary incontinence due to intrinsic sphincter dysfunction.     

Management of functional bladder neck obstruction in women: use of alpha-blockers and pediatric resectoscope for bladder neck incision

PURPOSE: Functional bladder neck obstruction has been definitively diagnosed in the last few years due to detailed synchronous pressure flow, electromyography and video urodynamics. Clean intermittent self-catheterization and bladder neck incision are the modalities of treatment. To our knowledge the role of alpha-blockers is not yet defined in women. A new technique was developed to perform bladder neck incision using a pediatric resectoscope. MATERIALS AND METHODS: A total of 24 women with obstructive voiding symptoms or retention were evaluated with video pressure flow electromyography, and diagnosed with functional bladder neck obstruction due to high pressure and low flow on silent electromyography and bladder neck appearance on fluoroscopy. Patients were initially treated with clean intermittent self-catheterization and alpha-blockers. Catheterization was stopped when post-void residual was less than 50 ml. and only alpha-blocker therapy was continued. Bladder neck incision was performed in patients who had a poor response to or side effects of alpha-blocker therapy, or when therapy was discontinued due to economic reasons. Clean intermittent self-catheterization was continued in patients who had a poor response to alpha-blockers or refused to undergo bladder neck incision. Bladder neck incision was performed in the initial 2 cases with an adult resectoscope using a Collin's knife and subsequently a pediatric resectoscope (13F). Uroflow and post-void residual measurements were performed in all cases. RESULTS: Of the 24 patients 12 (50%) showed improvement in symptoms, peak flow and post-void residual (p <0.01) with alpha-blocker therapy only. Of the 12 patients who had a poor response to alpha-blockers 6 underwent bladder neck incision subsequently and 6 remained on clean intermittent self-catheterization. All 8 patients treated with bladder neck incision, including 2 who had a good response but discontinued alpha-blocker therapy, had sustained improvement in post-void residual and peak flow (p <0.01) after a mean followup of 3.8 +/- 2.4 years. Grade 1 stress incontinence in 2 adult resectoscope cases responded to conservative treatment. None of the pediatric resectoscope cases had stress incontinence. CONCLUSIONS: Clean intermittent self-catheterization and alpha-blockers are the initial treatment options for functional bladder neck obstruction. The alpha-blockers were successful in 50% of our patients. Bladder neck incision should be offered judiciously with minimal risk of curable stress incontinence. The pediatric resectoscope is useful to make a well controlled incision safely in the female urethra.     

Modified urethral sling for the treatment of genuine stress incontinence and latent incontinence

The results of 143 women who underwent a modified urethral sling using Marlex mesh for the correction of stress urinary incontinence and latent stress incontinence, as diagnosed by clinical and urodynamic testing, are examined. The overall success rate for the surgical correction of genuine stress urinary incontinence was 99% during a median follow-up time of 1 year (range 0.12–4 years). There was a 12% postoperative incidence of varying degrees of genital prolapse. Difficulty with voiding resulting in the need for self-catheterization occurred in 17% of patients in the first 6 weeks, but only 2.8% were needing self-catheterizing after 1 year. There was a difference in peak flow preoperatively compared with 1 year postoperatively (20.5 ml/s v 15.7 ml/s, P=0.0003). Patients with a normal peak flow preoperatively (>20 ml/s) were more compromised at 1 year postoperatively (28 ml/s preoperatively, 18.4 ml/s postoperatively, P=0.00001), than women with an abnormal preoperative flow (<20 ml/s), (13.2 ml/s preoperatively, 13.5 ml/s postoperatively). Whether the operation was done for overt or latent stress incontinence did not affect postoperative flow results. It was not possible to predict by preoperative uroflow testing which patients were likely to need intermittent self-catheterization postoperatively. One year after surgery there were no significant alterations in bladder capacity (CMG) or urethral pressure profile measurements. There were no statistically significant changes in uroflow patterns when comparing primary and secondary surgical groups.     

Initial experience with the modified vaginal wall sling in the treatment of female stress urinary incontinence

From March 1995 to March 1996 24 women aged 29–73 years with stress urinary incontinence underwent a modified vaginal wall sling procedure following videourodynamic evaluation. Of these 24, 2 had stress urinary loss due to urethral hypermobility (UH), 3 had intrinsic sphincter deficiency (ISD) and 19 had both UH and ISD. Thirteen (54%) had preoperative urge incontinence, 13 (54%) had associated pelvic floor weakness, including cystocele, and 12 (50%) had had previous pelvic surgery and bladder neck suspension. Twenty-two patients were evaluable for a mean follow-up of 14 months (range 9–21 months). Stress urinary incontinence was resolved in all patients (100%). Of the patients with preoperative urge symptoms, 58% reported resolution but in 42% the urge symptoms remained unresolved. One new patient developed urge and occasional urge incontinence. Out of 22 patients 20 (90.9%) are totally continent; 2 (9.1%) are incontinent and both have documented detrusor instability and occasionally wear pads. The vaginal wall sling is an ideal procedure for the treatment of the various forms of stress urinary incontinence in women. In our series the early results indicate excellent patient acceptability and continence. Long-term follow-up will determine the durability of the procedure. EDITORIAL COMMENT: This is an observational study of a technique that is only slightly different from that previously described by Raz. The authors appear to have fairly good success, but the study is limited by the lack of uniform follow-up evaluations and the relatively short follow-up time. Further studies with longer follow-up and more comprehensive postoperative testing will be necessary before this procedure can be recommended.     

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.     

Polytetrafluoroethylene sling for failure in female stress incontinence surgery

Summary Surgery for stress urinary incontinence (SUI) in women with previous interventions is often difficult and yields poor results. A total of 33 women with recurrent SUI underwent placement of a polytetrafluoroethylene (PTFE) sling after a mean of 1.5 (range, 1–3) unsuccessful operations. Preoperative bladder instability (BI) was ruled out in all cases. The patients' mean age was 54 (range, 34–79) years. In all, 64% had SUI and 36% had SUI and incontinence at rest. The Aldrige-Stoeckel technique is used with insertion of a 2×30 cm sling instead of fascia lata. Mean operating time was reduced in 40 minutes. After a mean follow-up period of 13 months, 72% of the patients achieved continence without retention (complete success). Altogether, 16 patients (48%) required self-catheterization after discharge, with the voiding imbalance lasting for more than 3 months in only 4 cases (12% of the total). Three patients underwent surgery for outlet obstruction. There were five abdominal wound infections but no vaginal wound infection. Two slings have since been removed (one partially), but none has eroded through the urethra. The PTFE sling is a reasonable option for this group of patients. Retention is usually self-limited, and most complications can be managed successfully.     

Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra

Vaginal flap urethral reconstruction was done in 10 women who sustained total or partial loss of the urethra, and extensive damage to the vesical neck and trigone due to operative complications. In all patients a neourethra was constructed by rolling a vaginal flap into a tube and covering the anastomosis with a labial pedicle fat pad graft and vaginal flap. Five patients underwent a concomitant pubovaginal sling procedure, 3 had a modified Pereyra operation and 1 had a modified Kelly plication. Postoperatively, 9 of the 10 patients had a satisfactory neourethra but 3 required a generous meatotomy to facilitate micturition. Two patients required temporary intermittent self-catheterization. Of the 10 patients 6 were completely continent after a single reconstruction, which included an anti-incontinence repair. Of the patients with postoperative incontinence 2 subsequently were cured with a pubovaginal sling and 1 had a vesicovaginal fistula that was successfully repaired transvaginally. These results support our contention that a vaginal flap urethral reconstruction combined with an appropriate anti-incontinence operation offers a viable and simple alternative to bladder flap urethral reconstruction.     

Results in 32 women operated for genuine stress incontinence with the pubovaginal sling procedure ad modum Ed McGuire

OBJECTIVE: To determine the efficacy of the sling procedure in curing genuine stress incontinence in women. PATIENTS AND METHODS: Thirty-two women underwent the pubovaginal fascial sling procedure because of genuine stress incontinence. Currently, the patients are still monitored in order to check the efficiency of the treatment. RESULTS: The patients have been followed for a period of 5 years, and 30 patients are cured from stress urinary incontinence. One patient is improved, one is lost to follow up. Five patients experience intermittent minor degree of urge incontinence. Two patients have to perform clean intermittent catheterization (CIC) from time to time; one also did this before the operation. CONCLUSION: The sling procedure is a superior operation for patients that suffer from genuine stress incontinence, and should be the first choice of treatment.     

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.     

Clinical and urodynamic outcomes of pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence

AIM: We report the clinical and urodynamic outcomes of the pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence (SUI) and determined the urodynamic parameters that could predict the occurrence of postoperative voiding difficulty. METHODS: Between 1998 and 2005, a total of 29 consecutive women with SUI underwent pubovaginal sling surgery with autologous rectus fascia. Patients were preoperatively and postoperatively evaluated with regard to symptoms and urodynamic findings including uroflowmetry (UFM), postvoid residual urine volume (PVR), filling cystometry (CMG) and pressure flow study (PFS). RESULTS: Overall SUI was cured in 23 patients (80%) and improved in 3 patients (10%). Three patients (10%) who developed persistent urinary retention or severe voiding difficulty after surgery underwent urethrolysis. Of 17 patients who had urgency before the pubovaginal sling, urgency was cured postoperatively in seven, while de novo urgency appeared in one patient. Maximum flow rate (Qmax) in UFM was significantly decreased (P < 0.05) and PVR was increased (P = 0.08) after surgery. PFS showed a significant increase in detrusor opening pressure and detrusor pressure at Qmax (P < 0.01) after surgery. Eight patients (28%) needed prolonged intermittent self-catheterization. Patients who had PVR >100 mL (P < 0.05) or Qmax < or = 20 mL/s (P = 0.09) in preoperative UFM were more likely to require prolonged intermittent catheterization after surgery. CONCLUSIONS: The pubovaginal sling procedure with autologous rectus fascia is an effective treatment for SUI. A comparison of preoperative and postoperative urodynamic parameters indicates an increase in urethral resistance after pubovaginal sling surgery. PVR >100 mL and Qmax < or = 20 mL/s before surgery are risk factors for postoperative voiding difficulty.     

Suburethral sling procedure for genuine stress incontinence and low urethral closure pressure. A continued experience

Forty-eight patients with genuine stress incontinence and low urethral closure pressure have undergone a suburethral sling procedure using polytetrafluoroethylene. Forty-five of the 48 patients have been followed up beyond 3 months, allowing assessment of postoperative complications. Ten patients required intermittent self-catheterization, 6 continuing beyond 3 months secondary to obstructed voiding or vesical dysfunction. Six slings were removed due to graft infection and/or vaginal mucosa erosion. All patients who were continent prior to removal remained so afterwards. Two slings were loosened secondary to obstructed voiding (1 patient experienced improved voiding, the other continued intermittent catheterization). Sixty-two per cent (28/45) of the patients followed, developed at least one documented urinary tract infection. Thirty-four of the 45 patients followed, underwent postoperative multichannel urodynamic testing. Ten patients (29%) demonstrated postoperative detrusor instability (5 were new onset, 5 were persistent). Six improved with medication and bladder retraining drills. Twenty-eight of the 34 patients tested (82.4%) were objectively cured of genuine stress incontinence. In spite of the complications noted, this suburethral sling procedure offers a high success rate and is a viable alternative in treating patients with genuine stress incontinence and low urethral closure pressure. Modifications in surgical technique have been made to reduce postoperative complications in the future.     

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.     

Long-term 5-year followup of the results of the vesica procedure

PURPOSE: We evaluated the long-term results of Vesica (Boston Scientific Corp., Watertown, Massachusetts) percutaneous bladder neck suspension for stress urinary incontinence. MATERIALS AND METHODS: A total of 40 women with urodynamically proven stress urinary incontinence (SUI) underwent Vesica percutaneous bladder neck suspension between 1994 and 1997. Patients were assessed at 6 months, 12 months and 5 years with a simple questionnaire to elicit whether they had experienced any adverse effects, whether they were dry and whether further investigation or a surgical incontinence procedure was offered. RESULTS: Only 1 of the 40 women was lost to long-term followup. Initial results were excellent with 85% of women reporting complete dryness at 6 months. However, wound infections developed in 16% of patients secondary to hematomas in the suprapubic incisions and 10% required a period of intermittent self-catheterization. By 12 months only 46% of women remained dry, although most only reported occasional leakage. At 5 years 69% of patients had recurrent SUI and more than two-thirds of this group (70%) had symptoms severe enough to be offered a further surgical procedure. Patients undergoing subsequent secondary procedures were found to have fraying of the suspensory sutures at the bone anchor. CONCLUSIONS: Initial results of this minimally invasive procedure were excellent and despite the lack of long-term data the technique rapidly came into widespread use. The 5-year outcome shows a 31% continence rate. We no longer advocate this particular form of bladder neck suspension for SUI.