Pubovaginal sling using polypropylene mesh and Vesica bone anchors.

OBJECTIVES: To report preliminary results from a modified pubovaginal sling procedure using polypropylene mesh as the sling suspended by nonabsorbable sutures anchored to the pubic tubercle with Vesica bone anchors. METHODS: Thirty-five women with type III stress urinary incontinence (SUI) (with or without associated urethral hypermobility) or type II SUI with additional risk factors such as obesity, chronic obstructive pulmonary disease, or failed prior incontinence-correcting procedures underwent this modified pubovaginal sling procedure. Postoperative voiding status was evaluated during office follow-up visits and telephone surveys. RESULTS: With a mean follow-up of 8.4 months (range 2 to 18), 32 women (91.4%) were dry, 1 improved, and 2 remained incontinent. The pubovaginal sling procedure was the only operation performed in 46% of patients, with a mean operative time of 72 minutes, a mean estimated blood loss of 137 mL, and a mean hospital period of 2.3 days. Patients on whom concomitant gynecologic procedures were performed had a mean duration of surgery of 122 minutes, a mean estimated blood loss of 202 mL, and a mean hospitalization period of 2.9 days. Thirteen women had preoperative urgency that persisted in 31% of patients. De novo urgency developed in 3 patients. Seven women required prolonged suprapubic tube drainage but no patient remained in permanent retention. There has been no infection or erosion. CONCLUSIONS: Our experience with this modified pubovaginal sling procedure using polypropylene mesh and Vesica bone anchors showed excellent results with greater technical ease, minimal morbidity, and decreased hospitalization period when compared to a traditional pubovaginal sling performed in our hands. Additional follow-up will be needed to assess long-term efficacy.

Role of permanent stents.

The application of permanent stents in the urinary tract followed their success in the vascular system. Permanent metal stents have been used in the treatment of urethral stenosis, bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), and detrusor-sphincter dyssynergia. In addition, stents are used in the ureter for ureteroileal strictures and malignant obstruction. Despite the favorable early results, concerns have been raised about their biocompatibility, hyperplastic tissue response, encrustation, and carcinogenicity. This paper reviews the long-term data on permanent stents, primarily the Urolume device, which has been studied extensively in multicenter trials in North America and was recently approved for use in the urethra and for the treatment of bladder outlet obstruction secondary to BPH.

Rationale and treatment results with bioinjectables.

Management of intrinsic sphincter deficiency (ISD) can be achieved by many techniques. Those patients suffering from urinary incontinence secondary to ISD have often undergone multiple prior procedures for management of incontinence; therefore, an ideal form of treatment would be one that is minimally invasive and safe without compromising efficacy. The bioinjectables have proved to be safe and effective for the management of ISD and offer a minimally invasive alternative that can be performed under local anesthesia. This form of therapy is especially advantageous for properly selected patients suffering from urinary incontinence caused by ISD. We review the properties, indications for use, and results of the bioinjectables used in the treatment of ISD.

Uncommon complications of permanent stents.

The UroLume endoprosthesis has been used for recurrent bulbar urethral strictures, benign prostatic hyperplasia, and detrusor-external sphincter dyssynergia. Complications of the UroLume have been described by the North American Multicenter Trial as migration, encrustation, hyperplastic tissue growth, in addition to pain and irritative voiding symptoms. Generally, complications have been minimal, and few of the stents required removal. Patients with bulbar strictures were felt to be at relatively greater risk of hyperplastic tissue reaction if their stricture was secondary to trauma or if they had a prior urethroplasty. On the other hand, patients with benign prostatic hyperplasia were at risk of developing complications if they had median lobe enlargement or a short (<2.5 cm) prostatic urethra. We describe two cases in which off-label compassionate use of UroLumes in the anterior urethra and in an irradiated urethra led to adverse reactions such as stent separation, poor epithelialization, hyperplastic tissue growth, encrustation, or obstruction necessitating removal.