, Volume 7, Issue 2, pp 81-86

An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence

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Abstract

The object was to study prospectively the results of a modified intravaginal slingplasty for the surgical treatment of female stress incontinence, carried out under local anesthesia as a day procedure. Seventy five patients with genuine stress incontinence were operated upon and followed for a 2-year period. All patients were diagnosed urodynamically to have genuine stress incontinence. Pad tests and quality of life assessments were carried out in all patients both pre- and postoperatively. There were no intra- or postoperative complications and 63 patients (84%) were completely cured throughout the 2-year follow-up period. Six patients (8%) were significantly improved, i.e. they did not loose urine apart from an occasional leakage during severe cold etc. In the remaining 6 patients (8%) no improvement was seen. These failures were obvious at the first postoperative check-up after 2 months. Thus, there were no relapses after 2 months. All but 5 patients were able to void properly directly after surgery. These 5 needed an indwelling catheter during the night directly after the operation. All 75 patients were released from the hospital the same day or the day after surgery without catheterization. Mean sick leave was 10 days and mean operation time 22 minutes. No defect healing or rejection of the sling occurred. It is concluded that the procedure described is a promising new technique for the surgical treatment of female stress incontinence. Prospective long-term studies including more patients are in progress to establish the definitive place of this technique in the clinical routine.

EDITORIAL COMMENT: The authors present their initial results in treating female stress incontinence with a new surgical technique, the modified intravaginal slingplasty. The procedure is performed on an outpatient basis, under local anesthesia and heavy intravenous sedation. Mean operating time is less than 1 hour. There were no intraoperative or postoperative complications, including hemorrhage, requiring transfusion or lower urinary tract injury. No rejection or infection of the sling or operative site occurred. An 84% cure rate is reported at 2 years follow-up, based on subjective measures and confirmed by stress test in the office. Total leakage on pad testing was significantly improved. Unfortunately, objective measures (pre- versus postoperative urodynamic parameters) of operative success are not included in the report. This procedure is of interest for several reasons. First, a new instrument is introduced which allows placement of the sling via a vaginal route, rather than the traditional abdominal passage of a needle or packing forceps, to retrieve the sling arm. Secondly, the sling material (in this case prolene gauze) is covered by a plastic sheath to theoretically prevent contamination of the sling prior to placement. Thirdly, the surgical technique differs from the suburethral sling procedure in that the sling is placed at the level of the midurethra, is not elevated but loosely positioned, and the sling arms are not fixed to the rectus fascia or together in the midline. Finally, the entire procedure takes less than 1 hour, is performed under local anesthesia and as an outpatient — all attractive features in the new age of medicine. The modified intravaginal slingplasty is a new and interesting procedure. Only time and further experience will determine its place among anti-incontinence surgical procedures for female stress incontinence.
AUTHORS' COMMENTS: In the editorial comment it is pointed out that the procedure is performed under heavy sedation. We do not agree completely with this view. To further clarify the matter of sedation we would like to advise that in this ongoing multicenter study, we have reduced the amount of sedation. Currently only 0.05 mg fentanyl just before the injection of the local anesthetics is given. This dose of fentanyl can be repeated once during the procedure. Our experience based on >100 patients has shown that this lighter sedation gives as good pain relief as that initially described.