Pubovaginal Sling for all Types of
Stress Urinary Incontinence:
Long- Term Analisis.
CHAIKIN,D.C.; RESENTHAL,J.; E BLAIVAS, J.G.
From the Departament of Urology, New York Hospital, Cornell Medical Center,
New York, New York. J. Urol.,v.160,p.1312 – 16, 1998.
ABSTRACTS
Purpose: There is a lack of
consensus regarding indications and long-term efficacy of the many surgical techniques for
treating stress incontinence. Historically pubovaginal sling has been reserved for cases
of intrinsic sphincter deficiency or prior surgical failure. Transvaginal needle and
retropubic suspensions have been used mainly for sphincter incontinence unassociated with
intrinsic sphincter deficiency. We report the long-term results of pubovaginal sling for
all types of stress incontinence.
Materials and Methods: A total of 251 consecutive women with all types of
stress incontinence who underwent pubovaginal fascial sling by a single surgeon were
retrospectively and prospectively reviewed. Patients were evaluated prospectively with
history, physical examination, standardized symptom questionnaire, voiding diary ,pad
test, uroflow, post-void residual urinary, video-urodynamics and cystoscopy.
Postoperatively women with at least 1-year followup were assessed by an independent third
party ( J.R. ) who had no prior knowledge of them, and who recorded the parameters of the
questionnaire examinations with a full bladder, voiding diary, pad test, uroflow and
post-void residual urine.
Results: Overall stress incontinence was cured or improved in 92% of the
patients with at least 1-year followup ( median 3.1 years, range 1 to 15 ). The majority
of patients with postoperative incontinence had the novo ( 3% )or persistent ( 23% ) urge
incontinence. Permanent urinary retention developed in 4 patients ( 2% ).
Conclusions: Fascial pubovaginal sling is an effective treatment for all
types of stress incontinence with acceptable long-term efficacy.
EDITORIAL COMMENT
Traditionaly patients with types 1 and 2 of stress
urinary incontinence (SUI)1 or urethral hypermobility of the
urethravesical junction are surgicaly treated by retropubic colposuspension, transvaginal
colposuspension or anterior reparation. While in type 3 or Intrinsic Sphincter Deficiency1 (ISD) sling techniques are used or peri-urethral injections or artificial
sphincters.
The authors of this article use pubovaginal sling technique built with the fascia of the
muscle of the abdominal rectum (strips of 2X15 cm. length) in which on the extremity are
fixed long threads of unabsorbable 2 zeros. The approach is done by the abdominal way
(retropubic) and vaginal and the sling passes from the abdomen under the urethra, near to
the bladder neck and the extremity of the sling returns to the repropubic region where
both threads are tied amongst each other, over the aponevrosis of the abdominal rectum
without tension or fastening on the muscle.
The authors proposal is that this technique should be used indistinctly for all types of
urinary incontinence be it by vesical-urethro hypermobility or sphincter deficiency.
In the evaluation of the surgical results the authors do not consider the SUI
classification in types I,II or III1, and in the entirety the cases
were classified as simple or complex. They considered as complex cases the incontinent
patients that were carriers of urge-incontinence, urethral diverticulum, cystocele degree
3 or 4 or neurogenic bladder. These cases represented 188 patients (75% in total). They
were classified as simple, 63 incontinent patients (total of 25%) that did not belong in
the classification of the complex cases and also those with detrusor instability, as long
as they did not present urge-incontinence or previous surgery.
Altogether there was a cure in 73% of the cases, improvement in 19 % and failure in 8%.
The largest percentage of good results occurred among the simple cases (98%) and among the
complex cases the authors registered 93% of cure, 5% of improved cases and 2% in failures.
In the opinion of the authors most of the failures resulted from the persistency of the
urge-incontinence symptoms. Of the 165 cases that presented urge-incontinence in the
preoperative, 23% persisted with the symptoms in the 1st. year after surgery. Gradually,
other cases presented a relapse of this symptomatology, attaining after 10 years the
amount of 41% of the cases.
The complaint of urge-incontinence in the preoperative and the existence of multiple
previous surgeries seems to be one the main factors of persistance of these symptoms. The
authors emphasize that the sling must be set without any tension in all patients and that
they emphasize that the fact of not fixing it to the rectum abdominal fascia constitutes
an important factor of success in this technique.
The amplification of indication of this surgery for all types of urinary incontinence is
justified by the authors, by the fact that they believe that the abdominal leak point
pressure or urethral hypermobility have no influence in the results after using the
pubovaginal sling.
The authors proposition is tempting having in view that they proclaim one only type of
surgery for all urinary incontinence cases.
Meanwhile, some caution must be taken in the adoption of this conduct, mainly if we
consider that for many simple cases of urinary incontinence, this surgical technique is
excessive, besides that, obviously, the possibility of eventual ocurrence of postoperative
complications, such as, urinary retention and urge-incontinence.
José Carlos Souza Trindade
1. BLAIVAS,J.G.; OLSSON,C.A. Stress
incontinence classification and surgical approach. J. Urol., v.139,p.727-31,1988. |
