Botulinum Toxin Urethral Sphincter Injection Resolves Urinary Retention after Pubovaginal Sling Operation

The management of prolonged urinary retention following pubovaginal sling surgery typically involves transvaginal urethrolysis for anatomical urethral obstruction. Brubaker [1] recently reported on urethral sphincter abnormalities as a cause of postoperative urinary retention following either Burch suspension or pubovaginal sling procedure. We report a case of functional urethral obstruction and detrusor acontractility following pubovaginal sling surgery that was successfully treated by botulinum A toxin urethral sphincter injection.     

Colposuspension or Sling for Low Urethral Pressure Stress Incontinence?

The aim of this study was to compare Burch colposuspension with the pubovaginal sling in the management of low urethral pressure urinary stress incontinence. Forty-five women with low urethral pressure stress incontinence were retrospectively reviewed: 21 underwent colposuspension and 24 a pubovaginal sling. The subjective success rate of the Burch colposuspension and the pubovaginal sling was 90% and 71% (P= 0.12), respectively; the objective success rate was 67% and 50% (P= 0.26), respectively. The incidence of postoperative complications, including de novo detrusor instability and symptomatic voiding dysfunction following the colposuspension, was 5% compared to 25% following the pubovaginal sling (P= 0.06). Colposuspension should be considered in the management of women undergoing surgical correction of low urethral pressure stress incontinence. In a clinically similar group of women, the Burch colposuspension had a superior subjective and objective success rate with a lower incidence of complications than did the pubovaginal sling. Although these differences failed to reach statistical significance, colposuspension can be safely considered in the management of women with low urethral pressure GSI.     

Pubovaginal or Vicryl Mesh Rectus Fascia Sling in Intrinsic Sphincter Deficiency

The aim of this study was to compare the pubovaginal sling with a new Vicryl mesh rectus fascia (VMRF) sling in the surgical treatment of low urethral pressure genuine stress incontinence. Fifty-one consecutive women who had a VMRF (n= 27) or a pubovaginal sling (n= 24) procedure between March 1995 and December 1997 were evaluated. The patient-determined subjective success rate of the VMRF sling (85%) was significantly higher than that of the pubovaginal sling (58%) in women with low urethral pressure stress incontinence (P=0.03). The objective success rates following the VMRF and the pubovaginal sling were 52% and 50%, respectively. The prevalence of postoperative symptomatic voiding dysfunction and de novo detrusor instability was 7% after the VMRF sling and 25% following the pubovaginal sling (P=0.08). The VMRF sling had a higher patient-determined success rate and a lower complication rate than the pubovaginal sling, and should be considered in the surgical management of women with low urethral pressure stress incontinence.     

Repeat Tension-Free Transvaginal Tape (TVT) Sling for the Treatment of Recurrent Stress Urinary Incontinence

The pubovaginal sling is one of the preferred procedures for the treatment of female stress urinary incontinence because of its improved long-term cure rates. Recently a modified technique of the pubovaginal sling, known as the tension-free transvaginal tape (TVT), has gained popularity. We present the first reported cases of repeat TVT pubovaginal sling for the treatment of patients with recurrent stress urinary incontinence. Both patients had repeat TVT slings performed between 6 and 9 months following the initial procedure without revision or removal of the previous TVT sling. Both patients reported surgical cure without significant intraoperative or postoperative complications. It appears that reapplication of the TVT polypropolene sling may be a viable option in the event of initial TVT sling failure.     

Pregnancy Complicated by a Suburethral Sling: A Case Report

Incontinence surgery is rarely performed prior to the completion of a woman’s childbearing. The literature is sparse in regard to women with prior incontinence surgery. There are no reports of pregnancy complicated by a sling procedure. A 26-year-old gravida 3, para 2-0-0-2 with prior surgical history of a Pereyra urethropexy followed by a Vesica suburethral sling, was referred at 18 weeks’ gestation for assessment of the sling. Her antenatal course was complicated by pyelonephritis and intermittent urethral obstruction requiring Foley catheter placement. She delivered by scheduled cesarean section at 37 weeks’ gestation. Three months following delivery she presented with pyelonephritis and recurrence of her incontinence. Pregnancy complicated by prior suburethral sling procedure may result in urinary outlet obstruction, pyelonephritis and disruption of the surgical repair.     

Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome

PURPOSE: We present a series of urethral erosion following a pubovaginal sling procedure due to synthetic and nonsynthetic materials and discuss their management and continence outcome. MATERIALS AND METHODS: During a 3-year period 57 patients underwent urethrolysis for urethral obstruction after receiving a pubovaginal sling. Urethral erosion, defined as sling material entering the urethral lumen, was present in 9 patients and this cohort comprises the focus of our review. In 3 patients the eroded material was synthetic, that is ProteGen (Boston Scientific, Natick, Massachusetts) in 2 and polypropylene in 1. This condition was treated with removal of the whole sling, multilayer closure of the erosion and selective use of a Martius flap. In 6 patients the eroded material was nonsynthetic, that is allograft fascia in 5 and autograft fascia in 1. This condition was treated with sling incision and multilayer closure of the urethra. Preoperative assessment included a urogynecologic questionnaire, measurement of pad use, a voiding diary, cystourethroscopy and videourodynamics. Postoperatively similar parameters were used to assess continence outcomes and the need for subsequent procedures. RESULTS: Nine patients were followed 30 months after urethrolysis. All 9 women had some manifestation of voiding dysfunction following the pubovaginal sling procedure, including urinary retention in 4, urge incontinence in 3 and mixed incontinence in 2. Urinary retention resolved in 3 patients and urge incontinence resolved in 4. Stress urinary incontinence (SUI) persisted in 2 of the 3 patients in the synthetic group, while no patient in the nonsynthetic group had recurrent SUI. There were no recurrent urethral erosions or fistulas in either group. CONCLUSIONS: Urethral erosion after a pubovaginal sling procedure can occur irrespective of the sling material. However, recurrent SUI is not an invariable outcome of the management of urethral erosion following the pubovaginal sling procedure.     

Preventing Urethral Obstruction Using the 6-Point Fixation and Weight-Adjusted Spacing Nomogram During Sling Surgery

The aim of the study was to assess the outcome of a 6-point fixation technique and weight-adjusted spacing nomogram for performing sling surgery. Fifty women with stress incontinence underwent implantation of a Gore-tex patch sling. Sling tension was gauged based on the patient’s body weight. Postoperative analysis was performed using cough stress tests, Q-tip tests, pelvic examinations and patient satisfaction questionnaires. Urodynamics were performed for women with persistent incontinence. Mean follow-up was 24 months (range 7–28). Mean age was 58 years (range 29–87). Stress incontinence was cured in 47/50 patients (94.0%). De novo urge incontinence occurred in 1/23 (4.3%) patients. Mean time to suprapubic tube removal was 7 days (range 1–21). No patients experienced urinary retention or urethral obstruction. Mean satisfaction score was 9/10 (range 7–10) and all patients said they would undergo surgery again. The combination of a 6-point fixation technique and a weight-adjusted spacing nomogram allows for a successful sling outcome without obstruction.     

Grades of Intrinsic Sphincteric Deficiency (ISD) Associated with Female Stress Urinary Incontinence

Intrinsic urethral sphincter deficiency (ISD) is a clinical entity that should be suspected in women with stress urinary incontinence. If it is not diagnosed prior to surgery, it poses a significant risk factor for repair failure. We propose a classification of ISD based on videofluorourodynamic (VFUD) and abdominal leak-point pressures. One hundred female patients with stress urinary incontinence due to ISD were included in this study. History and physical examination were performed on all patients. Each patient underwent a standard VFUD study with abdominal leak-point pressure (ALPP) measurement. ISD is classified into subtypes according to VFUDS and ALPP. The findings were then correlated with the clinical presentation, etiology and proposed management. Three types of ISD/SUI were identified. ISD-A, subtle/urodynamic, was present in 32 patients (32%). It is most difficult to diagnose because radiologically the bladder neck is not open at rest, and it is only diagnosed by VFUD. The abdominal leak-point pressure was less than 12 cmH₂O. ISD-B was present in 45 patients (45%). This is characterized by a beak-shaped open bladder neck at rest. The abdominal leak-point pressure was less than 90 cmH₂O. ISD-C was present in 14 patients (14%). It is characterized by an open, fixed non-functioning urethra (pipe-stem) with high position of the bladder neck. The abdominal leak-point pressure was less than 70 cmH₂O. All the three subtypes had proximal urethral closure pressure (PCUP) less than 10 cmH₂O. Based on these data, the treatment options may vary from one subtype to another. For ISD-A, initial treatment was medical, with collagen injection being used for the failed cases. For ISD-B a modified pubovaginal sling was used, as it corrects the ISD and the urethral hypermobility at the same time. For ISD-C, urethrolysis and takedown of the previous suspension was required before using a sling. Collagen injections were used in selected cases. This classification identifies different subgroups of ISD, which is important in the diagnosis and management of this condition.     

Pubovaginal sling procedure for stress incontinence

Urinary stress incontinence associated with poor urethral sphincter function and indicated by a urethral pressure of less than 10 cm. water was treated in 52 cases with a pubovaginal autogenous fascial sling. No urethral sphincter function could be measured in 7 patients. Of these 52 patients 42 had undergone a previous operation for stress incontinence. The uninhibited detrusor dysfunction that accompanied the stress incontinence in 29 cases ceased after operation in 20 but persisted in 9. Postoperative urethral pressure measurements indicated that while the sling increased urethral pressure it did not cause an obstruction during voiding, since there was a measurable decrease in urethral pressure during a detrusor contraction. Urodynamic determination were useful in patient selection, in the adjustment of sling tension at operation and in the assessment of reasons for failure. A satisfactory result with good urinary control was obtained in 50 cases and the procedure was a failure in 2.     

Poor Surgical Outcomes after Fascia Lata Allograft Slings

The objective of this retrospective case control study was to determine whether our poor surgical outcomes were associated with the material used to construct our pubovaginal slings. Autologous rectus fascia was used in 33 patients and cadaveric fascia lata was used in 12 patients who underwent pubovaginal sling placement for intrinsic urethral sphincter deficiency (ISD). Treatment was successful in 78.8% and 33.3% of patients who underwent rectus fascia and fascia lata allograft slings, respectively (P=0.006). Based on regression analysis, the sling material was found to be strongly associated with surgical outcome after controlling for all confounding variables (β coefficient = 1204.6, P<0.00005). We conclude that fascia lata allografts are a poor choice for pubovaginal slings.     

Urodynamic Assessment of Voiding Dysfunction and Dysfunctional Voiding in Girls and Women

Voiding dysfunction is defined as impaired bladder emptying, and presents with a mixture of lower urinary tract symptoms. Dysfunctional voiding is a condition in which there is a lack of coordination between the sphincter and detrusor during emptying in a patient without overt uropathy or neuropathy. Assessment of voiding dysfunction is important in women and girls in the prevention and treatment of urinary incontinence, retention, urinary tract infection and subsequent kidney damage. Accurate diagnosis is essential in order to select the correct treatment. Screening can be done by history-taking: symptom scores can help to guide the screening. More objective measures are uroflowmetry, ultrasonography and videourodynamics. The latter is the gold standard for the diagnosis of voiding dysfunction and consists of simultaneous registration of pressure in the bladder and rectum and external sphincter behavior, either by electromyographic recording of pelvic floor activity or by pressure recording at the external sphincter, during the whole bladder cycle of filling and emptying. On fluoroscopy the bladder can be visualized throughout the filling and emptying phase. In dysfunctional voiding, hypertonicity and instability of the external urethral sphincter during filling cystometry and impaired external sphincter relaxation during emptying are pathognomonic findings. Pressure–flow analysis reveals no obstruction and the detrusor contractility is low.     

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.     

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.     

Surgery insight: management of failed sling surgery for female stress urinary incontinence

Sling surgery has replaced Burch colposuspension as the most common surgery for women with stress urinary incontinence (SUI). While incontinence surgery has become a routine part of urologic care, the management of surgical complications and recurrent incontinence can be quite difficult. It is important that the urologic surgeon is well informed about the most common complications that are associated with sling surgery, and how to best manage them. In addition, the management of recurrent incontinence following sling surgery should follow a stepwise approach, with appropriate diagnostic studies, conservative treatment if possible, and surgery if necessary. While sling surgery in the patient with urethral hypermobility is often straightforward, reoperation for recurrent incontinence can be more technically challenging. In the patient with a fixed and incompetent urethra, periurethral bulking agents, pubovaginal sling, spiral sling, or artificial urinary sphincter placement may be indicated.     

Percutaneous Bone Anchor Sling Using Synthetic Mesh Associated with Urethral Overcorrection and Erosion

Percutaneous bone anchor bladder neck suspension has been recommended as a less morbid alternative to traditional anti-incontinence procedures. Specifically, it has reported to be associated with shorter duration of hospitalization, catheterization and urinary retention, and equivalent short-term cure rates. Recently, there have been reports of pubic osteomyelitis associated with bone anchor placement, and high incidences of recurrent incontinence. To improve the effectiveness of the procedure the placement of a suburethral synthetic collagen-impregnated mesh without tension was recommended. A specific device is included with the kit (Suture Spacer (Microvasive/Boston Scientific Corp., Natick, MA)) to prevent overcorrection of the urethrovesical junction. We present a case of urethral erosion and complete urinary retention secondary to use of a percutaneous bone anchor sling using a ProteGen mesh (Microvasive/Boston Scientific Corp., Natick, MA). Significant postoperative urethral overcorrection was noted despite intraoperative use of the Suture Spacer.     

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.     

The Gore-tex sling procedure for female sphincteric incontinence: indications, technique, and results

We constructed a pubovaginal sling using the Gore-tex Soft Tissue Patch and 2-0 polytetrafluoroethlene (PTFE) suspension suture and placed it in 122 consecutive incontinent women with urethral hypermobility and/or intrinsic sphincter deficiency. We performed a retrospective outcome analysis using a questionnaire-based telephone survey. The mean follow-up period was 24.4 months. Stress incontinence was cured in 88% of patients (equally effective in type II and type III incontinence), de novo postoperative urinary frequency occurred in 32% of cases, and preoperative urinary frequency resolved postoperatively in 51% of patients. Significant urinary obstruction occurred in 5% of patients. Vaginal granulation tissue with exposed sling occurred in 4% of patients. There was no urethral or bladder erosion. The treatment of female stress incontinence with a PTFE sling is effective and durable with minimal complications. Furthermore, this technique addresses many of the presumed technical shortcomings of endoscopic needle suspensions.     

A SIMPLE OBJECTIVE METHOD OF ADJUSTING SLING TENSION

PURPOSE: Pubovaginal sling is gaining widespread acceptance as a primary form of treatment for types II and III stress urinary incontinence. However, a major drawback is postoperative obstructed voiding due to excessive force placed on the suspension suture. We describe a simple objective method for intraoperative adjustment of sling tension that can be performed by a single surgeon during pubovaginal sling surgery. MATERIALS AND METHODS: A cotton swab is inserted into the urethra and placed at the urethrovesical junction after the sling is fixed suburethrally and the vaginal mucosa is closed. The suspension sutures are tied down directly onto the rectus fascia with enough tension to keep the cotton swab angle between 0 and 10 degrees to the horizontal plane. A total of 29 patients with an average age of 62 years underwent pubovaginal sling surgery with rectus and cadaveric fascia using this technique for tension adjustment. Of the patients 21 were diagnosed with types II and III, 5 had type II only and 3 had type III only incontinence. Preoperative evaluation revealed detrusor instability in 5 patients. Mean postoperative indwelling catheterization period was 6.2 days. Average followup was 15.6 months. RESULTS: To date no permanent urinary retention has occurred. Of the patients 15 voided without difficulty after catheter removal, 13 had urinary difficulty requiring intermittent catheterization for 1 week or less and 1 had retention requiring intermittent catheterization for 10 weeks. Preoperative symptoms of detrusor instability resolved in all cases. De novo detrusor instability in 3 cases was controlled with anticholinergics. CONCLUSIONS: Overzealous sling tension adjustment has been recognized as a cause of treatment failure leading to urethral obstruction. Our technique is effective in preventing over adjustment of tension, is reproducible and can be performed by 1 surgeon.     

Management of intrinsic sphincter deficiency in adolescent females with normal bladder emptying function

PURPOSE: Intrinsic sphincter deficiency is rare in adolescent females with normal bladder emptying function. Information regarding the long-term outcome of therapy in this group of patients is sparse. We report our long-term experience with 3 adolescent females with intrinsic sphincter deficiency and normal bladder function who were treated with an artificial urinary sphincter. We critically reviewed the literature regarding experience with anti-incontinence surgery in adolescent females, not only regarding the outcome of the surgical technique, but also issues not usually considered in older adults, including the impact of physical development and future childbearing. MATERIALS AND METHODS: The charts of 3 adolescent females with intrinsic sphincter deficiency were reviewed. In addition, relevant peer reviewed articles were selected by a MEDLINE search. The results of the artificial urinary sphincter, pubovaginal sling and periurethral injection of bulking agents were reviewed. Long-term efficacy, the complication rate, impact of pregnancy and physical development were assessed. RESULTS: The 3 patients had an excellent long-term outcome with the artificial urinary sphincter, including 1 with 2 pregnancies that ended in a normal vaginal delivery. The literature showed that a good long-term outcome was consistently achieved with the artificial urinary sphincter. An equally good outcome was achieved with the pubovaginal sling but long-term data are lacking. While periurethral injection of a bulking agent provides good initial results, they do not appear to be durable. In addition, the artificial urinary sphincter does not appear to impact pregnancy or physical development negatively. CONCLUSION: Data support the artificial urinary sphincter and pubovaginal sling as effective therapies in adolescent females with intrinsic sphincter deficiency. However, long-term data on the pubovaginal sling are not available. When considering the impact on future childbearing and physical development, the artificial urinary sphincter is a favorable option.     

Erosion of a fascial sling into the urethra

When synthetic materials are used for the construction of pubovaginal slings, urethral erosions may occur. This complication has not been reported with fascial slings. We present a case of a 34-year-old woman who underwent a pubovaginal sling procedure using rectus fascia. After 10 weeks of urinary retention, urethroscopy identified an erosion of the sling at the midurethra. Surgical revision restored normal voiding without recurrent stress incontinence. Although urethral erosions have been reported with synthetic suburethral slings, this case suggests that erosions can also occur with fascial slings. Careful positioning and minimal tension on the sling arms may minimize this risk.