Fascial sling for the management of urinary incontinence due to sphincter incompetence

Abstract

The surgical management of urinary incontinence due to sphincter incompetence is still a challenging issue for urologists to date. We reviewed our experience with the fascial sling performed in 10 male and 3 female patients 3 to 72 years old (median age 13 years) with sphincter incompetence, including 11 with a neurogenic bladder (8 with myelodysplasia, 2 after pelvic operation and 1 after spinal cord injury), 1 after transurethral resection of the prostate and 1 after surgical injury to the bladder neck. Patient selection for a sling procedure was based on cystography (an open bladder neck) and urodynamic findings (underactive external urethral sphincter on electromyography and low maximum urethral closure pressure). A free graft of fascia was harvested from the rectus fascia in 8 patients and from the fascia lata in 5, and the fascial sling was placed around the bladder neck in 11 and the bulbous urethra in 2. Augmentation cystoplasty was performed concomitantly in 9 patients with poor bladder compliance (8 ileocystoplasty and 1 gastrocystoplasty). Postoperative followup ranged from 4 to 63 months (mean 36). Nine patients became continent and 3 improved significantly but remain damp. Of these 12 patients 10 with a neurogenic bladder were placed on intermittent catheterization, while the 2 without a neurogenic bladder are able to void normally. The remaining patient with surgical failure due to inadvertent wound infection received an indwelling urethral catheter. In all but this patient preoperative and postoperative maximum urethral closure pressures were 34.3 +/- 5.7 and 37.2 +/- 3.8 cm. water, respectively, without a significant increase. However, postoperative simultaneous measurements of intravesical and intraurethral pressure demonstrated a dramatic increase in intraurethral pressure during coughing or straining because of the action of the sling. Postoperative upper urinary tract deterioration has not been documented to date. Although various surgical options have been available, the fascial sling seems to be promising in the management of refractory urinary incontinence due to sphincter incompetence.