THE JOURNAL OF FEMALEURINARY INCONTINENCE

Technique of combined pubovaginal sling and cystocele repair using a single piece of cadaveric dermal graft.
Chung SY, Franks M, Smith CP, Lee JY, Lu SH, Chancellor M.
Urology 2002 Apr;59(4):538-41

ABSTRACT

OBJECTIVES: To investigate the feasibility of using a single piece of cadaveric dermal graft for the repair of stress urinary incontinence (SUI) with concurrent cystocele. METHODS: Nineteen patients with combined SUI and symptomatic grade III cystoceles were treated. Eleven of 19 patients had undergone prior repairs for SUI. All patients underwent a combined pubovaginal sling procedure and cystocele repair using a single piece of cadaveric dermal graft (3 x 7 cm). The single strip of dermal graft was placed in a longitudinal direction along the anterior vagina. The distal segment of the graft supported the urethra, and the proximal portion supported the central cystocele defect and was sutured to the pubocervical fascia. The mean follow-up was 28 +/- 4 months and patients were monitored by physical examination, videourodynamic studies, and completion of the bladder bothersome visual analog scale.

RESULTS: Of the 19 patients, 1 developed an acute infection and failure of the graft after presenting with fever, discharge, dysuria, and incontinence. The autolysed graft was removed, and she subsequently underwent successful autologous fascial repair. Of the remaining 18 patients, 17 were cured of their SUI, including 10 who had had prior repairs, and 16 had no recurrence of cystocele and 2 had asymptomatic grade I and II cystoceles. One patient developed de novo detrusor instability that was successfully treated with anticholinergic medication. No cases of urethral obstruction occurred.

CONCLUSIONS: Although the follow-up was short, the use of a single piece of cadaveric dermal graft slings for concomitant pubovaginal sling and cystocele repair is feasible and simple to perform. At more than 2 years of follow-up, documented by videourodynamic studies, neither urethral obstruction nor symptomatic cystocele recurrence was found.

EDITORIAL COMMENT

The treatment of a stress urinary incontinent patient must be global and, necessarily embody the corrections of concomitant dystopias. It is not uncommon to find a cystocele of large dimensions with the need of correction. For the correction of these problems the authors used a 3 by 7 cm tape (with a dermic graft obtained from cadavers), which was placed at the length of the axis of the anterior vaginal wall, giving support to the urethra and the base of the bladder. The graft was sutured in the complex of the uterosacral/cardinal ligament (proximal) and, with the use of prolene thread, the distal was set in place, with no tension, in the supra pubic region (with a Stamley needle). Patients with a central defect may be treated, successfully with this technique that permits the support of the urethra and the bladder body. Even in a group that is predominantly composed of patients with a history of previous surgical failures, there was success in the correction of SUI and the prolapse in 94% and 89% of the cases, respectively.

Aparecido Donizeti Agostinho