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THE JOURNAL OF FEMALE
URINARY INCONTINENCE

Commented Abstracts

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  • "An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge síndrome."
    FULFORD, S.C.V.; FLYNN, R.; BARRINGTON, J.; APPANNA, T.; STEPHENSON, T.P.
    Urological Unit University Hospital of Wales, , Cardiff, Wales.J. Urol., v.162, p.135-137, 1999.

ABSTRACT

Purpose: We assessed the urodynamic changes after pubovaginal sling procedure for stress incontinence, particulary in regard to the associated symptoms of urgency, frequency, nocturia and urge incontinence, known as the urge syndrome.

Materials and Methods: A total of 85 women with proved stress incontinence underwent a pubovaginal sling procedure using rectus fascia between 1992 and August 1996. Of the women 41 (48%) had undergone previous anti-incontinence surgery and 59 (69%) had the associated urge syndrome. There was at least some degree of hypermobility in 51 cases and type III stress incontinence was diagnosed in 34. Patients were assessed with a questionnaire and video urodynamics preoperatively and 3 months postoperatively. Preoperative and postoperative ambulatory studies were performed in 25 cases.

Results: Of the 85 patients 83 (97%) were symptomatically cured of stress incontinence. The urge syndrome resolved in 32 patients (69%), almost all of whom had a closed bladder neck at rest. Overall bladder neck incompetence at rest decreased from 57 to 18% (p < 0.001). Of 27 patients with the persistent urge syndrome postoperatively 9 (41%) had an open bladder neck at rest compared to 4 of 50 (8%) without urge incontinence (p < 0.01). Despite symptomatic control of stress incontinence in 83 patientes (97%), only 66 were satisfied with the surgical result, mainly because of the persistent urge syndrome in 27. Despite care to avoid obstruction overall, there were statiscally significant obstructive changes in detrusor pressure at maximum flow rate, maximum flow rate and residual urine volumes.

Conclusions: The pubovaginal sling is effective in curing genuine stress incontinence and, when correctly placed at the right tension, the associated urge syndrome also can be managed, usually by achieving bladder neck closure at rest. However, despite careful maneuvers, obstruction occasionally persists.

EDITORIAL COMMENT

For over a century the surgical techniques based on the principal of the pubovaginal sling with the use of autologous aponevrotic strips were proposed for the correction of stress Urinary Incontinence. Since then a number of variations and different alloplast materials have been used and the frequency of the indication of those techniques have oscillated through the decades. Nowadays, after the work of McGuire and Lytton 1 there has been a popularization of the use of the fascia of the abdominal rectum a sustentation material of the vesicle urethral transition obtaining good results 2,3. One of the clinical problems presented by patients carriers of stress Urinary Incontinence (SUI) is that, very frequently is associated complaints of urination urgency, nycturia, polyuria and urge Incontinence, which characterize the urgency syndrome problem. The persistency of these symptoms or the appearance of them in the post operative of these pubovaginal sling techniques are uncomfortable for the patients and interfere in the degree of satisfaction of them with the results of surgery, even in the cases where the cure or Urinary Incontinence is complete.
The authors of this article observed that among their 85 patients, 50 presented urgency syndrome and these symptoms persisted in 27 patients in the post operative. In the pre operative evaluation the authors related the presence of urgency syndrome with 4 main factors.

  1. A great amount of patients had been submitted to a previous hysterectomy.

  2. Poor vesicle complacency.

  3. Detrusor instability registered in a urodynamic video, even though it was a small amount of cases.

  4. 2/3 of these patients showed an opening of the bladder neck in repose with the patient standing.

The authors emphasize the persistency of the opening of the bladder neck as one of the main factors of urgency syndrome, based on the fact that of the 27 patients that persisted with this syndrome, 9 (41%) presented an open neck, while only 4 patients in 50 (8%) continued with an open neck without having urgency symptoms.

Another aspect discussed by the authors is the degree of tension used in the aponevrotic sling of the abdominal rectum in which the used technique is formed by a 22 x 1.5 cm tape. To avoid tension, the authors suggest the setting of a Foley probe No 20F which must be tractioned downward forming a 30 degree angle with the vulva’s level, while the aponevrotic tape is sutured on the fascia of the abdominal rectum muscle. Even though having these operative precautions, some patients presented a post operative obstruction problem. Even though there has been made a great progress in treating stress Urinary Incontinence (SUI) and a great number of technical variations have been proposed lately, there still persist serious doubts of which is the best technique used in each case of SUI.
In truth, SUI, must be faced as a syndrome with many determinant causes and the perfecting of the pre operative propaedeutic must be stimulated to identify the main anatomical factor of Incontinence mechanisms which are under obligation to elect the most adequate surgical technique for the correction of that particular case.

José Carlos Souza Trindade


1. McGuire, E.J. e Lytton, B.: Pubovaginal sling procedure for stress incontinence. J Urol, 119:82, 1978.
2. Mason, R.C. e Roach, M.: Modified pubovaginal sling for treatment of intrinsic sphincter deficiency. J Urol, 156:1991, 1996.
3. Blaivas, J.G. e Jacobs, B.L.: Pubovaginal fascial sling for treatment of complicated stress urinay incontinence. J Urol, 145:1214,1991.

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