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Commented Abstracts

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  • Pubovaginal Sling for all Types of Stress Urinary Incontinence:
    Long- Term Analisis.

    From the Departament of Urology, New York Hospital, Cornell Medical Center, New York, New York. J. Urol.,v.160,p.1312 – 16, 1998.


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.


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 III
1, 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.

Josť Carlos Souza Trindade

1. BLAIVAS,J.G.; OLSSON,C.A. Stress incontinence classification and surgical approach. J. Urol., v.139,p.727-31,1988.

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