|Year : 2004 | Volume
| Issue : 2 | Page : 106-108
Modified anterior vaginal wall sling for SUI
AS Sawant1, VD Trivedi1, SA Salve1, V Upadhaye2, P Dangle1
1 Department of Urology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, India
2 Department of Gynecology and Obstetrics, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, India
V D Trivedi
Department of Urology, Lokmanya Tilak Municipal Medical College and Hospital, Sion, Mumbai - 22
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : Bladder neck suspension using autologous tissue is an established technique for SUI. We report 12 cases of anterior vaginal wall sling for patients with anatomical incontinence and modification of standard procedure by anchoring the sling to Cooper's ligament.
Methods : Twelve patients with anatomical incontinence were operated by our technique. Detailed preoperative evaluation was done and patients with only anatomical incontinence were selected, patients with intrinsic sphincter deficiency (ISD) were excluded. The surgical technique included suspension of rectangular strip of anterior vaginal wall overlying proximal urethra and bladder neck with number 1 polypropylene to Cooper's ligament.
Results : The follow-up period ranged from 6 months to 3 years and all patients were continent.
Conclusions : Cooper's ligament provides a good anchoring system and avoids the use of expensive bone anchoring systems.
Keywords: Anatomical incontinence, anterior vaginal wall sling, Cooper′s ligament.
|How to cite this article:|
Sawant A S, Trivedi V D, Salve S A, Upadhaye V, Dangle P. Modified anterior vaginal wall sling for SUI. Indian J Urol 2004;20:106-8
| Introduction|| |
Pubovaginal slings have been performed using fascial grafts and anterior vaginal wall. Kaplan et al have reported on the technical ease, decreased morbidity, and comparable efficacy of fascial and anterior vaginal wall slings. , Several modifications have been described where the sling has been fixed to the anterior abdominal wall or the pubic bone with various bone anchoring systems. ,, We propose a modification in anchoring the edges of the sling to the Cooper's ligament. It offers a strong anchor for the sling and avoids the use of expensive bone anchoring systems.
| Patients and Methods|| |
Twelve patients with anatomical SUI were operated from January 1999 to January 2002. The mean age of these patients was 51 years.
Pre-operative evaluation included detailed medical history, voiding diary, gynecological evaluation, urodynamic study and cystoscopy.
Anatomical incontinence was defined as stress urinary incontinence with Valsalva leak point pressure (VLPP) of 60 cm of water or more. Patients with VLPP less than 60 cm of water were suggestive of ISD and hence were excluded.
The standard surgical technique described by Kaplan  was followed with a few modifications. With the patient in lithotomy position, cystoscopy is performed and 16 Fr perurethral Foley's catheter is inserted and balloon inflated to 20 cc to identify bladder neck. A transverse rectangular incision 2 cm in breadth and 4-5 cm in length is marked on the anterior vagina overlying the proximal urethra and bladder neck [Figure - 1]. The marked incision is infiltrated with 1 in 100,000 saline adrenaline solution. The full thickness of the marked sling is dissected from rest of vagina but kept attached to urethra and bladder neck. The vaginal wall (lower flap) is dissected sufficiently so as to cover the defect created by suspension of the sling. Laterally the urethropelvic ligament is dissected from the pelvic wall and retropubic space is developed with blunt and sharp dissection on either side. A 4 cm transverse skin crease suprapubic incision is made and the retropubic space is dissected lateral to the rectus muscle and the Cooper's ligament is identified bilaterally. The transverse ends of the vaginal wall sling along with the urethropelvic ligament are sutured with no. I prolene continuous suture with ends locked. A long curved artery forceps is guided into the vaginal wall incision with the help of finger placed in the retropubic space from below and the sutures are transferred into the suprapubic incision bilaterally. Cystoscopy is then performed to rule out bladder injury. The sutures are taken through the Cooper's ligament, and the bladder neck is simultaneously visualized cystoscopically. The sutures are tied when the bladder neck assumes half-moon shape. Suprapubic catheter is inserted and suprapubic incision is closed. Perurethral Foley's is reinserted, and anterior vaginal wall is closed with 2-0 vicryl, and vagina is lightly packed for 24 hours. Intravenous antibiotics like ciprofloxacin, metrogyl, amikacin were given for 48 firs and then converted to oral antibiotics which are given for 5-7 days. The perurethral catheter is removed after 48 hours and voiding trial is given. Suprapubic catheter is removed when the residual volume is less than 30-50 ml.
| Results|| |
Patients were evaluated at 1. 6 and 12 months and then yearly. Assessment of the patient's satisfaction was done as follows: 1- fully satisfied, 2 - satisfied, 3 - no change, 4 - disappointed, 5 - very unsatisfactory. 
Complications which can be encountered are: severe blood loss, bladder injury, chronic retention over a month, wound infection, pelvic wall prolapse, and vaginal wall infection. In our series, blood loss was less than 200 ml and the average operative time was 90 minutes. Bladder injury due to Stamey's needle occurred in case no. I which was diagnosed intraoperatively, and the sutures were repositioned. Thereafter we preferred using blunt artery forceps for suture transfer. Eleven patients voided normally within 3-5 days. One patient had prolonged retention for 1 month after which she voided normally. None of the patients had pelvic organ prolapse. One patient had severe vaginal infection that necessitated excision of part of the sling on the postoperative day 8, but the patient was continent postoperatively.
Follow-up period was from 6 months to 3 years, none of the patients had recurrence of SUI and all were satisfied.
| Discussion|| |
The rationale for using anterior vaginal sling for SUI is its ability to provide support for proper cooptation of urethra during increased intra-abdominal pressure. It also suspends and fixes the proximal urethra and bladder neck in proper position so as to limit its hypermobility. We decided to anchor the anterior vaginal wall sling to the Cooper's ligament, as it is a strong ligament, in proximity to the vagina and fixation to it acts as a proper anchorage for the hammock provided by anterior vaginal wall. In Raz sling  only the ends of the sling are tagged, we sutured complete breadth of the sling which decreases the chance of suture cutting through. In Raz's sling the sutures are anchored to the anterior abdominal wall which is mobile structure, we anchor our sling to Cooper's ligament which is strong static structure, hence support to the hammock is better. In comparison bone anchor's  are very costly, not easily available and there is chance of foreign body reaction causing ostetis pubis. As we anchor the sling to the Cooper's ligament we avoid the use of expensive bone anchoring systems. The initial outcome and 3 year follow-up of this procedure shows satisfactory results.
| Conclusions|| |
Anchoring the anterior vaginal sling to the Cooper's ligament provides a strong static anchorage for the hammock provided by the anterior vaginal sling. The procedure also gives good results.
| References|| |
|1.||Kaplan SA, Santorosa RP et al. Comparison of fascial and vaginal slings in the management of intrinsic sphincter deficiency. Urology 1996; 47: 885-9. |
|2.||Kaplan SA, Young GP et al. Prospective analysis of 373 consecutive women with stress urinary incontinence treated with vaginal sling. The Columbia-Cornell University experience. J Urol 2000; 164: 1623-9. |
|3.||Raz S, Sussman EM, Erickson DB et al. The Raz bladder neck suspension: Results in 206 patients. J Urol 1992; 148: 845-50. |
|4.||Desantel MG, Lumerman JH et al. Pubovaginal sling using polypropylene mesh and vesica bone anchors. Urology 1998; 51: 708-11. |
|5.||Charkin DC, Rosenthal JG et al. Pubovaginal fascial sling for all types of urinary incontinence: Long-term analysis. J Urol 1998; 160: 1312-4. |
[Figure - 1]