Surgery for Stress Incontinence
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Stress urinary incontinence—the involuntary loss of urine through the intact urethra as a result of a sudden increase in intra-abdominal pressure—creates a social problem to the patient. It is the end result of a deficient urinary control system in which the intra-abdominal pressure exceeds the resistance produced by the urethral closure mechanisms. Normal continence in the female results from the delicate balance of several forces, including closing forces of the urethra, a critical functional and anatomical urethral length, the ability of the pelvic floor and the urethra to increase urethral resistance at the time of stress, and the proper anatomical location of the sphincteric unit. We like to organize these factors in what we call the UCLA theory of female continence, in which the U signifies the urethral changes that occur during stress, the C represents the closing function of the urethra, the L is its functional and anatomical length, and A stands for anatomy. These factors are briefly described below.
KeywordsStress incontinence Slings Bladder neck suspension Fascial sling Fascia lata sling Spiral sling
Bladder neck suspension/vaginal wall sling. This video presents the technique of bladder neck suspension used in cases of mild stress incontinence. After entering the retropubic space, nonabsorbable sutures of polypropylene include the urethropelvic fascia, the periurethral, and perivesical fascia at the bladder neck. A small puncture is performed in the retropubic space, and a double-pronged passer is used to transfer the suture from the vagina to the suprapubic incision (MP4 231388 kb)
Distal urethral polypropylene sling. This video presents the use of a self-cut 10 × 1 cm segment of soft polypropylene mesh to perform a retropubic sling. At the end of the mesh, a #0 delayed absorbable suture is applied. A tunnel is made under the vaginal wall to transfer the mesh. A small puncture is made in the suprapubic area and under finger control in the vagina; a double-pronged passer is used to transfer the sutures from the vagina to the suprapubic area. The mesh is intentionally short. It will not reach the suprapubic area; instead, it will fix itself behind the pubic bone and obturator muscle. Allis clamps are used to prevent obstruction (MP4 215289 kb)
Autologous fascial sling with donor site from lower abdomen. This video shows the performance of an autologous fascial sling with a donor site from the anterior rectus fascia in the lower abdomen in a patient with recurrent severe incontinence. A segment of 8–10 cm of lower abdominal fascia is retrieved and the abdominal fascia is closed. At the end of the fascial segment, #1 figure-of-eight delayed absorbable sutures are applied. The anterior vaginal wall is exposed, two oblique incisions are made in the distal vagina, the retropubic space is entered, and a tunnel is made under the vaginal wall 2 cm from the external meatus. The fascial strip is transferred under the tunnel and fixed to the periurethral fascia to prevent displacement. A small puncture is performed in the suprapubic area, and a double-pronged passer is used to transfer the sutures from the vagina to the suprapubic area. After cystoscopy, the sutures are tied without tension (MP4 252841 kb)
Autologous fascial sling with donor site from the iliotibial band (fascia lata tendon). A 10–12-cm segment of fascia lata tendon is retrieved from the lateral aspect of the thigh 10 cm above the knee joint using the Crawford fascial stripper. At the end of the fascial strip, #1 figure-of-eight delayed absorbable sutures are placed. The anterior vaginal wall is exposed, two oblique incisions are made in the anterior vaginal wall, the retropubic space is entered, and a tunnel is made under the vaginal wall 2 cm from the external meatus. The fascial strip is transferred under the tunnel and fixed to the periurethral fascia in one side to prevent displacement. A small puncture is performed in the suprapubic area, and a double-pronged passer is used to transfer the sutures from the vagina to the suprapubic area. After cystoscopy the sutures are tied without tension (MP4 348940 kb)
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