UROLOGICAL SURVEY   ( Download pdf )

 

FEMALE UROLOGY

Suprapubic sling adjustment: minimally invasive method of curing recurrent stress incontinence after sling surgery
Choe JM
Urodynamics and Continence Center, Division of Urology, University of Cincinnati, Ohio, USA
J Urol. 2002; 168:2059-62

  • Purpose: Recurrent stress urinary incontinence after sling surgery is a complex problem. A minimally invasive method of correcting recurrent stress urinary incontinence after pubovaginal sling surgery is described.
  • Materials and Method: We performed suprapubic sling adjustment in 10 women with recurrent stress urinary incontinence after sling surgery. Of these 10 women, 4 had received an antibacterial polytetrafluoroethylene patch sling, 3 an autologous dermis patch sling and 3 an autologous rectus fascia patch sling but stress incontinence recurred. To correct recurrent incontinence, a pubovaginal sling was revised by adjusting the sling tension suprapubically with the aid of a cotton swab test and bladder leak test.
  • Results: Mean followup was 13 months (range 8 to 28). Of the 10 women, 9 became completely dry and 1 was greatly improved. One patient who had persistent stress incontinence generated an abdominal leak point pressure of 189 cm H2O compared to a preoperative pressure was 120 cm H2O. The incidence of de novo urge incontinence was 2% (2 of 10 cases). Mean resting cotton swab angle was (+) 20 and (+) 5 degrees, and mean Valsalva cotton swab angle was (+) 40 and (+) 5 preoperatively and postoperatively. Mean pad use decreased from 3 pads to less than 1 pad a day. Mean self-reported satisfaction score was 9 (range 8 to 10) on a visual analog scale.
  • Conclusions: Pubovaginal slings may be revised safely with excellent results. Adjusting the sling tension suprapubically is a minimally invasive technique. Suprapubic sling adjustment may be performed as an intermediary step before resorting to a complete sling takedown/revision.

  • Editorial Comment
    The author, Dr. Jong M. Choe, describes his technique of suprapubic sling adjustment after failed suburethral sling. The initial slings performed were strut slings with the endopelvic fascia not being perforated, but instead the sutures of the supporting sling passing through the endopelvic fascia traversing the retropubic space and then being anchored above the anterior rectus fascia. The technique involved the dissection and identification of the sling non-absorbable suspension sutures. The sutures were then retied in a tighter fashion with the utilization of a cotton swab test and supine bladder leak test. Dr. Choe’s technique of correction as reported was very efficient with the mean operating time of 45 minutes, and mean estimated blood loss of 9 cc. The salvage success rate was equally impressive, with 9 of 10 patients being completely dry, and 1 patient greatly improved. Despite the reported objective cure rate of 90% (9 of 10 cases), and subjective cure rate of 100% (10 of 10 cases), the author also reports that 2 of 10 patients (20%) had de novo urge incontinence, and 1 of 4 patients presenting preoperative urge incontinence had persistence of same.
    Dr. Choe should be complimented for reporting on a minimally invasive method of addressing a very difficult subpopulation of patients in our practice: the woman who has failed a previous suburethral sling. This paper is distinctly different than a prior paper on repeat pubovaginal sling procedures for recurrent stress incontinence after pubovaginal sling (1). Though the author does compare the 2 studies, the studies differ in that the series reported by Dr. Frank and me dealt with patients who had previous classic pubovaginal slings with endopelvic fascia perforation, with a variable degree of inactive retropubic fibrosis encasing the urethra. Dr. Choe’s original slings were strut slings with a stated no perforation of the endopelvic fascia in addition to the sutures traversing this retropubic space. One of the interesting side points Dr. Choe raises, is that if does one really need to perforate the endopelvic fasica to a great degree in order to obtain a satisfactory and long term management of female urinary incontinence. Anecdotal experience states that when a sling fails, it usually fails right away, and when it does not fail, it lasts a long time. This is somewhat different than the time frame reported by Dr. Choe, in view that his mean time to recurrent stress incontinence was approximately 4 months (range 3-9 months). It would have been an interesting addition to this paper to explore Dr. Choe’s thoughts on why his initial slings failed. Rovner et al. has cited reasons for early failures, such as suture breakage, incorrect sling placement, and tying the sling too loosely (2). Most of these early failures though are manifested immediately, as opposed to having a period of good results that gradually degrade into operative failure. I compliment Dr. Choe on the use of the Blaivas-Groutz anti-incontinence surgery response score (3). I find this incontinence score to be an excellent, simplified way of evaluating patient outcomes (see Appendix). Of note is that the mean reported Blaivas-Groutz anti-incontinence surgery score was 1, with a range of 0-2, but Dr. Choe does not make any mention of the 24-hour pad test, which is an integral part of the anti-incontinence surgery response score. In addition, I would have found of great value to find out which patient failed among the various pubovaginal sling types, and which patients were plagued with de novo or persistent urge incontinence. This would have potentially helped our understanding of female outlet obstruction and secondary voiding dysfunction.
    This is a very valuable paper to review, especially when discussing potential options for a patient plagued with recurrent stress urinary incontinence after a pubovaginal sling. It will be of great interest to find if the reported technique has the same degree of efficacy in patients who have had a classic pubovaginal sling with perforation of the endopelvic fascia and retropubic fibrosis. I wager not.
    Appendix - Anti-incontinence surgery response score
    Postoperative 24-hour voiding diary
    0          Nor urge or stress urinary incontinence episodes
    1          1 to 2 Incontinence episodes
    2          3 or more incontinence episodes
    Postoperative 24-hour pad test
    0          Total pad weight gain 8 g or less
    1          Total pad weight gain 9 to 20 g
    2          Total pad weight gain greater than 20 g
    Patient questionnaire
    0          The patient considers herself cured
    1          The patient considers herself improved
    2          The patient considers the operation to have failed
    Total outcome score
    0          Cure
    1 to 2    Good response
    3 to 4    Fair response
    5          Poor response
    6          Failure

References
1. Petrou S, Frank I: Complications and initial continence rates after a repeat pubovaginal sling procedure for recurrent stress urinary incontinence. J Urol. 2001; 165: 1979-81.
2. Rovner ES, Ginsberg DA, Raz S: Why anti-incontinence surgery succeeds or fails. Clin Obstet Gynecol. 1998; 41: 719-34.
3. Groutz A, Blaivas JP, Rosenthal JE: A simplified urinary incontinence score for the evaluation of treatment outcomes. Neurourol Urodyn. 2000; 19: 127-35

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA