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RESEARCH ARTICLE
Year : 2003  |  Volume : 20  |  Issue : 1  |  Page : 37-39
 

Midurethral bulbocavernous muscle sling for genuine stress incontinence - an alternative to synthetic slings?


Department of Urology/Urogynaecology, Govt. Kasturba Gandhi Hospital, Madras Medical College, Chennai, India

Correspondence Address:
N Rajamaheswari
Urogynaecology Research Centre No. 18/86. C.P. Ramaswamy Road, Abiramapuram, Chennai - 600 018
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objectives: To assess the efficacy of midurethral bulbo­cavernous muscle sling (BCMS) in the treatment of genu­ine stress incontinence in women.
Methods: A prospective study comprising 25 women was carried out at the Govt. Kasturba Gandhi Hospital, Chennai. The women whose age was in the range of 30-65 years had GSI as proved by urodynamic evaluation. The bulbocavernous muscle sling implies the approximation of both the bulbocavernous muscles around the midurethra with prolene sutures. The procedure is done under regional anaesthesia.
Results: These patients were followed up for 2 years. Eighteen (72%) women reported complete cure, 4 (16%) were significantly improved and in 3 the surgery failed.
Conclusions: The bulbocavernous muscle sling is a promising new procedure for genuine stress incontinence. There is no need for intraoperative cystoscopy and the chances of bladder injury are nonexistent. Larger sample with long term follow up and randomized controlled trials comparing it with the other surgical techniques may prove its true efficacy.


Keywords: Bulbocavernous muscle, stress incontinence, sling proce-dure, minimally invasive, midurethra.


How to cite this article:
Rajamaheswari N, Gunasekaran K. Midurethral bulbocavernous muscle sling for genuine stress incontinence - an alternative to synthetic slings?. Indian J Urol 2003;20:37-9

How to cite this URL:
Rajamaheswari N, Gunasekaran K. Midurethral bulbocavernous muscle sling for genuine stress incontinence - an alternative to synthetic slings?. Indian J Urol [serial online] 2003 [cited 2019 Nov 13];20:37-9. Available from: http://www.indianjurol.com/text.asp?2003/20/1/37/37122



   Introduction Top


Sling procedures with many different modifications have been used for more than 100 years in the treatment of fe­male incontinence. Slings have been autogenous as well as man made. Goebell [1] and Stockell [2] utilized the pyramidalis muscle. Frangheim added strips of rectus fascia attached to pyramidalis. Giordano described the transposition of the gracilis wrapped around the urethra. Martius developed the use of the bulbocavernous fat pad to provide bulk around the urethra. The synthetic materials that have been used for suburethral slings include Nylon, Perlon, PTFE, Mersilene, Silastic and Polyglactin. In tension-free vaginal tape [3] (TVT) knitted prolene is used and it differs from conventional sling procedures in that, the sling is kept at the midurethral level. Similarly the bulbocavernous muscle sling is also placed at the level of the midurethra.


   Patients and Methods Top


This prospective study was conducted at Govt. Kasturba Gandhi Hospital, Chennai from January 2000 to June 2000. Twenty-five multiparous women in the age range of 30­65 years with GSI were selected and thorough clinical evaluation including gynaecological, urological and neu­rological assessment were performed. All women were subjected to urodynamic evaluation comprising of cystometrogram and pressure flow studies. Voiding disor­der and detrusor overactivity in these women were ruled out. None of these women had prior surgery for GSI. For patient details and overview of the operative procedure refer to [Table - 1]. Under regional anaesthesia the patient was placed in a lithotomy position and a vertical 1 cm sagittal vaginal incision was proximally made, 1 cm from the external urethral meatus. Minimal paraurethral dissec­tion was done. A labial incision was made and the bul­bocavernous muscle was dissected out on both sides.

Bulbocavernous muscle is represented as fibrofatty tissue in women. It covers the superficial parts of the vestibular bulbs and greater vestibular glands and passes forwards on each side of the vagina to attach to the corpora caver­nosa clitoridis. It is attached posterioly to the perineal body, where its fibres decussate with those of sphincter ani ex­ternus and the contralateral transverse perineii. Blood sup­ply (from the perineal branch of internal pudendal artery) was preserved by retaining its proximal attachment. The distal attachment of the muscle was freed. The bulbo­cavernous muscles were brought into the midurethral re­gion through a subvaginal tunnel. Both the muscles were approximated in the midline using 1 `0' prolene sutures. The bladder was filled with 250 ml of saline. The patient was then asked to cough or if unable to do so, suprapubic pressure was applied. Tension was then adjusted. The vagi­nal and labial wounds were then closed with catgut. The urethral Foley catheter was retained for 6 hours. All pa­tients went home on the 2nd or 3rd postoperative day. They were reviewed thereafter at monthly intervals for 3 months and then once in every 4 months for 2 years.


   Results Top


These patients were followed up for 2 years. All pa­tients were evaluated with history, clinical examination and urodynamic studies. Eighteen (72%) women reported com­plete cure. Four (16%) patients were significantly improved which meant that there was an occasional leakage with a very strong cough with full bladder. In 3 patients the sur­gery failed. Two patients had granulation tissue at the mid­line which was treated by fulgration. Two patients had vaginal sloughing which healed in a month. The need for postoperative analgesia was minimal.


   Discussion Top


The bulbocavernous muscle sling is a minimally inva­sive simple and short procedure. It is an absolute vaginal procedure negating all the perils of an abdominal surgery. The bulbocavernous muscle sling differs from the tradi­tional sling operation in that it is placed at the level of the midurethra. The bulbocavernous muscle sling offers aback board against which the midurethra (zone of maximum pressure transmission) gets compressed during exertion. As dissection around the bladder neck and proximal ure­thra are minimal, chances of denervation are reduced. Please refer to [Table - 2] for the advantages of this proce­dure.


   Conclusions Top


The bulbocavernous muscle sling is a simple vaginal procedure that has all the advantages of a minimally inva­sive synthetic sling like the TVT. However, bulbocaver­nous muscle sling lacks the complications and expenses of TVT. The success of any incontinence surgery in only established over time. The bulbocavernous muscle sling is still in its infancy. The long term results in a larger group will tell us whether it can replace the synthetic slings.

 
   References Top

1.Goebell RG. Zur operativen behandlung der incontinent der mannlichen harnrohre. Gynakol Urol 1910; 2: 187.  Back to cited text no. 1    
2.Stockel W. Uber di verwendung der muscli pyramidales bei der operativen behandlug der incotinentia urinae. Gynakol Urol 1917; 41: 11.  Back to cited text no. 2    
3.Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia in the treatment of fe­male urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunc­tion 1996; 7:81-5.  Back to cited text no. 3    



 
 
    Tables

  [Table - 1], [Table - 2]



 

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusions
    References
    Article Tables

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