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ORIGINAL ARTICLE
Year : 2006  |  Volume : 22  |  Issue : 1  |  Page : 53-55
 

Bladder neck broad based polypropylene sling for stress urinary incontinence


Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Rakesh Kapoor
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.24656

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   Abstract 

Objectives : Bladder neck suspension using polypropylene is an established technique for treatment of stress urinary incontinence (SUI). We report our retrospective audit of the bladder neck sling in SUI. MaterialS and Methods : Twenty-one patients with SUI operated at our institute were included in the study. The audit was performed using the case records for - patient demographics, detailed history and examination, routine hemogram, renal function tests, urine culture sensitivity, urine microscopic examination and uroflowmetery + cystometrogram(CMG). After complete evaluation, all patients underwent bladder neck suspension using polypropylene mesh. Results : Twenty-one patients with mean age of 55 years underwent bladder neck sling surgery. Mean duration of surgery was 67 minutes (50-100 minutes). Mean operative blood loss of 100ml. Mean duration of hospital stay was 2days (1-5 days). Eighteen patients had complete or significant decrease in the severity of stress urinary incontinence in immediate post-operative period. Mean duration of follow up of patients was 19 months (3-28 months). All patients were dry at the end of the follow up. Conclusions : Broad base polypropylene mesh gives good continence results in patients of SUI.


Keywords: Urinary incontinence, bladder neck sling


How to cite this article:
Kapoor R, Singh KJ, Suri A, Singh P, Mandhani A. Bladder neck broad based polypropylene sling for stress urinary incontinence. Indian J Urol 2006;22:53-5

How to cite this URL:
Kapoor R, Singh KJ, Suri A, Singh P, Mandhani A. Bladder neck broad based polypropylene sling for stress urinary incontinence. Indian J Urol [serial online] 2006 [cited 2020 Feb 23];22:53-5. Available from: http://www.indianjurol.com/text.asp?2006/22/1/53/24656


Stress urinary incontinence (SUI) is a disorder commonly affecting females of all age groups compromising their quality of life. The bothersome symptoms of SUI adversely affect the social relationships and activities, restrict physical pursuits, impair personal hygiene and lead to avoidance of sexual relationship.[1] Several risk factors have been implicated in causation of SUI: weak collagen, age, childbearing, obesity, constipation, advanced pelvic organ prolapse and chronic obstructive airway disease.[2] SUI is thought to occur as a result of bladder neck/urethral hypermobility and/or neuromuscular defects.[3] Neuromuscular defects lead to the intrinsic sphincter deficiency. Pubovaginal slings have become standard modality of treatment in last decade after work of Delancy et al who had shown that the anterior vaginal wall acts as a hammock for the vesical neck and urethra.[4] Over last few years many procedures using autologous material (rectus sheath, fascia lata) or synthetic material (polypropylene, mersilene) have been reported in literature.[5],[6] Mersilene was the first synthetic material to be used as pubovaginal sling,[7] while polypropylene has been recently described. The main advantage of the use of synthetic material is avoidance of morbidity of harvesting autologous material and avoids the risk of transmission of an infective disease of cadaveric tissue. Furthermore, they are not biodegradable and the tensile strength does not decrease with passage of time.[8] The main disadvantage of the synthetic material is the risk of erosion. We analyzed our initial results with use of polypropylene mesh as a pubovaginal sling in treatment of SUI in terms of dryness rates, erosion rates, duration of follow up and recurrence.


   Materials and Methods Top


A retrospective analysis was performed in 21 patients undergoing pubovaginal slings procedure from June 2002 to Aug 2004 for stress urinary incontinence. Preoperative evaluation included a history, physical examination, urine culture, urine microscopic examination and uroflowmetry. Urodynamic evaluation was done in patients where history was suggestive of overactive bladder. All patients were preoperatively counseled regarding the need for post operative clean intermittent catheterization (CIC). One day prior to surgery, in all patients poviodine pessary were kept in the vagina.

Surgical procedure was performed in all the patients: after prophylactic antibiotics 18 Fr Foleys was placed in urinary bladder and balloon was palpated at bladder neck. An Allis clamp was placed between bladder neck and meatus pulled anteriorly. Saline was infiltrated into the anterior vaginal wall to facilitate dissection. A 3-4 cm inverted 'U' shaped incision was made over vagina and flap was dissected from mid urethra to bladder neck area. The urethropelvic ligament was identified and preserved. Endopelvic fascia was perforated with scissors by directing the scissors towards ipsi-lateral shoulder. After sweeping the bladder medially the retropubic space was entered anteriorly from the vaginal incisions.

A 2.5 cm horizontal incision was made over the pubic symphysis. Rectus sheath incised. One eyed Stamey needle is passed twice along the retropubic space from the suprapubic incision and laterally brought out through the vaginal incision. A mesh measuring 1 x 10 cm polypropelene mesh (Johnson and Johnson, Aurangabad) soaked in antibiotic saline is taken and 2-0 prolene suture is passed at one end, while the other end of the thread is passed through the Stamey needle. Stamey needle is then withdrawn through the suprapubic incision. Before Stamey needle is passed on other side, a catgut suture is placed in the centre of the mesh along its length. This suture is basically is to ensure that mesh is placed equally on both the sides.

The urethral catheter is removed and Cystoscopy is performed to assess for any inadvertent bladder injury during the procedure. 18 Fr FOLEYS was replaced and the sling was placed against the bladder neck and proximal urethra without tension by pulling the anchoring sutures. The tension on the sling is avoided by placing a hemostat between the bladder neck and sling while tying the sutures. The prolene suture was tied in air knot fashion at the skin level without putting any undue tension on the sling. The anterior vaginal wall was closed with running 3-0 vicryl sutures. The suprapubic incision was closed with a running 3- 0 monofilament suture. Antibiotic solution soaked vaginal pack was inserted. We routinely do not place a supra pubic catheter. Antibiotic was continued for 3 days post operatively. Vaginal packs were removed after 24 hours of surgery. Voiding trial was given after 48-72 hours and check for high residual urine. If residual urine was more than 50 ml patient was asked to do CIC. CIC was discontinued when the residual urine was less than 50 ml.


   Results Top


Twenty one patients underwent surgery for stress incontinence. Preoperative urodynamic assessment was need in only 4 patients. In none of the instances the urodynamic assessment revealed presence of detrusor over activity. Mean + SD age of patient was 55 + 10 years. Mean operative blood loss was 100 ml. Mean operative time (+ SD) was 67+11 minutes (50-100 minutes). Eighteen patients had complete or significant decrease in the severity of stress urinary incontinence in immediate post operative period. Remaining three patients voiding trial failed and required CIC. In two patients CIC was discontinued after period of 3 weeks and 4 weeks respectively after post void residual urine volume on ultrasonography was less than 50 ml, while third patient required CIC till last follow up. Mean duration of hospital stay was 2 days (1-5 days). Mean duration of follow up (range) of patients was 19 months (3-28 months). Eighteen patients reported no use of pads while two patients reported use of one to two pads per day. Mean subjective satisfaction rate with surgical outcomes in all the patients were 9 on a scale of 0-10 (on a scale where 0 means- very disappointed and 10 -satisfied). Four patients complained of dull aching lower abdominal pain, which was relieved by administration of oral analgesic agents. Five of our patients complained of mild pain during intercourse, which was not presented preoperatively. None of our patients reported significant voiding dysfunction, infection, non-healing or erosion of the sling till their last follow up. There was no worsening of the posterior vaginal defects in any of the patients.


   Discussion Top


Stress urinary incontinence is a common condition affecting females of all ages. Numerous surgical procedures have been described in literature for the same, but in last decade there has been increased inclination of urologist towards use of pubovaginal slings. Numerous materials are available for use in a suburethral sling- synthetic and autologous material.[5],[6] The use of these graft substitutes have flourished in recent years. It has been shown that the females suffering from SUI have higher plasma proteolytic activity in comparison to age and sex matched controls, thus use of autologous material to treat SUI thus becomes questionable.[9]

Choosing an artificial sling simplifies the operative procedure, in that the graft is readily available and does not require harvesting from a second operative site. The readiness and ease of preparation decreases the operative time, patient discomfort and potential postoperative complications. Synthetic materials also bypass the potential problems of inadequate length and strength associated with autologous grafts. Furthermore the synthetic sling is non degradable, tensile strength does not decrease with passage of time and allows tissue in growth between the interstices of the mesh.[8]

Use of polypropylene mesh is yielding encouraging results but major concern remains erosion into the urinary tract. Tying the sutures at the end of the mesh loosely can minimize the erosion. Creation of adequate vaginal mucosal flaps prevents ischemic necrosis of the flaps. We did not encounter any such instance of mesh erosion in any of the patient till last follow up, while a recent study has shown that the erosion rate with use of the polypropylene mesh is less than 5%.[10],[11] These findings correlate well with decreased incidence of infection or urinary retention and our study correlates well with these findings. Also the urethral erosion can be minimized by loosely anchoring the sutures at the skin level. It also helps in decreasing the incidence of postoperative urinary retention and urgency.

Non braided suture material helps in avoiding infection. In our series we used monofilaments sutures (polypropylene suture) to secure the mesh. Shah et al have described similar use of sutures in their series.[12] There were few steps taken to reduce the infection like - removing vaginal pack within 24 hours, soaking the mesh with antibiotic saline and intra-operatively wound was repeatedly washed with antibiotic saline.

Assessment of the outcome of the sling procedure basically depends upon the patient subjective assessment. Our preoperative work up of the patient did not include routine urodynamic testing. Urodynamic assessment of the patient was done in cases were there was history suggestive of detrusor over activity. Our assessment regarding outcome of the procedure was subjective. In immediate postoperative period subjective cure rates was 91%, which increased to 96% at the end of mean, follow up of 19.4 months. Jarvis et al had reported a subjective cure rate of 82.4% in their study on use of synthetic slings in treatment of SUI.[13] Synthetic slings have been shown to produce durable results both objective and subjective-81.63% and 81.2% respectively in patients with SUI.[12] Thus, we did not find any need to do urodynamics in these patients. One patient who failed to void following surgery had hypocontractile bladder on cystometrogram, but patient was fully satisfied with complete dryness and CIC.

Although the midurethral slings are giving same results as the bladder neck slings, the role of the latter remains in combined pelvic floor repair. In present study we found bladder neck sling as durable treatment modality for treatment of stress urinary incontinence and are comparable to the existing literature. Longer follow up studies are required to establish the role of the bladder neck sling in SUI.


   Conclusions Top


Use of polypropylene sling for bladder neck suspension in patients with stress urinary incontinence produces good continence results. It is a simple, efficacious and durable procedure.

 
   References Top

1.Futz NH, Burgio K, Diokno AC, Kinchen KS, Obenchain R, Bump RC. Burden of stress incontinence for community dwelling women. Am J Obstet Gynecol 2003;189:1275-82.  Back to cited text no. 1    
2.Viktrup L. Female stress and urge incontinence in family practice: insight into lower urinary tract. Int J Clin Pract 2002;56:694-700.  Back to cited text no. 2  [PUBMED]  
3.Koeble H, Mostwin J, Boiteux JP. Pathophysiology. In : Abrams P, Cardozo L, Khoury S, Weins A, editors. Incontinence, 2nd ed. Health Publication Ltd: Plymouth UK; 2000. p. 165-201.  Back to cited text no. 3    
4.Delancy JO. Structural support of the urethra as it relates to stress urinary incontinence: The Hammock Hypothesis. Am J Obastet Gynaecol 1994;170:1713-23.  Back to cited text no. 4    
5.McGuire EI, Lytton B. Pubovaginal sling procedure for stress incontinence. J Urol 1978;119:82-6.  Back to cited text no. 5    
6.Leach GE, Dmochowski RR, Appell RA, Blaivas JG, Hadley HR, Luber KM, et al . Female stress incontinence clinical guidelines panel summary report on surgical management of female stress incontinence. J Urol 1997;158:875-80.  Back to cited text no. 6    
7.Moir JC. The gauze-hammock operation. J Obstet Gynaecol Br Commonw 1968;75:1-9.  Back to cited text no. 7  [PUBMED]  
8.Law NW, Ellis H. A comparison of polypropylene mesh and expanded polypropylene mesh and polypropylene mesh for repair of contaminated abdominal wall defect- an experimental study. Surgery 1991;109:652-5.  Back to cited text no. 8  [PUBMED]  
9.Corujo M, Badlani G. The use of synthetic material in the treatment of women with SUI lends strength anddisability. Contemp Urol 1999;11:76-80.  Back to cited text no. 9    
10.Young SD, Howard AE, Baker SP. Mersilene mesh sling: Short and long term clinical and urodynamic outcomes. Am J Obstet Gynecol 2001;185:32-7.  Back to cited text no. 10    
11.Hom D, Desautel MG, Lumerman JH, Feraren RE, Badlani G. Pubovaginal sling using polypropylene mesh and vesica bone anchors. Urology 198;51:708-12.  Back to cited text no. 11    
12.Shah DK, Paul EL, Amukele S, Eisenberg ER, Badlani G. Broad based tension free synthetic sling for stress urinary incontinence: 5 year outcome. J Urol 2003;179:849-51.  Back to cited text no. 12    
13.Jarvis GJ. Stress urinary incontinence. In : Urodynamics Principles, Practice and Application, 2nd ed. Edited by AR Mundy, TP Stephenson and AJ Wein. Churchill Livingstone: New York; 1994. p. 299-326.  Back to cited text no. 13    




 

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