THE JOURNAL OF FEMALE
URINARY INCONTINENCE

Commented Abstracts

• A simple objetive method of adjusting sling tension.
  NGUYEN, A.; MAHONEY, S. ; MINOR, L.; G. GHONIEM, G.
  Department of the Urology of the Tulane University School of Medicine, New Orleans, Louisiana. J. Urol., v.162, p.1674-1676, 1999 .

ABSTRACT

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 beperformed 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 na 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.

There exist several proposed methods to adjust the tension of the pubovaginal sling, among others we may cite the measurement of the urethral pressure during the procedure, the use of intra operative ultra sound to verify the position of the bladder neck before and after applying traction to the sling and the endoscopic observation of the effect of the sling to make sure of the coaptation of the anterior and posterior walls of the urethra when tension is applied.
In all these procedures the surgeon must have the help of na assistant. The authors of this work propose a method that may be done by one surgeon using a cotton swab that introduced in the bladder and left at the level of the urethrovesicle junction which is mobilized getting it near the symphysis pubis (the authors preconize that the position of the cotton swab should stay, in relation to the horizontal plane, between 0 and 10 degrees) they concluded by the results obtained, that with this method they would avoid problems related to the excessive tension applied to the sling and which may result in Urinary obstruction in the post operative.
This work has as its biggest merit to contain a simple proposal, to standardize the pubo vaginal sling.

Luiz Antonio Corrêa