[Anterior vaginal wall and pelvic floor sling for stress incontinence]

There is considerable doubt as to whether the intra-abdominal position of the urethra is the critical factor in maintenance of continence. Recent studies have suggested that a firm, supportive, suburethral layer is required for urethral closure during effort. The surgical procedure we describe is performed by vaginal approach and involves creation of a sling from the vaginal wall and underlying musculofascial layer, that provides compression and support for the urethra and resuspends the bladder neck. 20 women (37-70 years, mean 48.4) with severe stress incontinence (average of 5 wet pads per day) underwent the sling procedure between October 1994 and July 1995. 10/20 had had previous pelvic surgery (6 anti-incontinence procedures and 4 hysterectomies). 3/20 had intrinsic sphincter dysfunction and the rest a hypermobile urethra. The surgical technique was easily performed. Postoperative complications were minimal, and included blood transfusion in 3 and in 5 suprapubic pain which subsided spontaneously or after oral diclofenac. The cystostomy was closed after 10.5 days (range 3-49) when voiding resumed and urine residual became less than 60 ml. The median follow-up was 9.4 months (range 3-12). All patients were cured and satisfied. 2/20 reported onset of urge incontinence which was found urodynamically to be de-novo detrusor instability due to urethral obstruction. On the other hand, all 3 patients with associated urge incontinence reported its disappearance postoperatively. These results are encouraging and this surgical procedure seems to provide a good solution for all types and grades of stress incontinence. Long-term follow-up is required to determine persistence of the good results.