Original Article
REVISTA PAULISTA DE MEDICIN AComparison of vaginal wall sling
and modifie d vaginal wall sling
for stre ss urinary incontine nce
Hospital Padre Anchieta, Faculdade de Medicina do ABC and Hospital São Paulo, Universidade
Federal de São Paulo / Escola Paulista de Medicina, São Paulo, Brazil
a b s t r a c t
CON TEX T: There are several co ntro versies abo ut which is the best fo rm o f surgical treatment fo r stress urinary inco ntinence in wo men. The vaginal wall sling in its o riginal and mo dified fo rm were pre-sented by Raz as new o ptio ns fo r treatment o f these co nditio ns, but there is a lack o f co mparative clinical trials using bo th techniques.
OBJECTIVE: To co mpare the effectiveness o f the o riginal and the mo dified vaginal wall sling.
DESIGN : A co mparative, pro spective, no n-rando mized clinical trial.
SETTIN G: Public and private health care units (Uro lo gy Divisio n, Fac-ulty o f Medicine o f the ABC Fo undatio n, and Universidade Federal de São Paulo / Esco la Paulista de Medicina).
PARTICIPAN TS: Twenty patients with anato mical and intrinsic sphinc-ter deficiency stress urinary inco ntinence were surgically treated fo r evaluating the initial results o f the vaginal wall sling, fro m February 5 , 1 9 9 4 , to June 2 7 , 1 9 9 6 .
IN TERVEN TION S: The patients were divided into two gro ups. G ro up A (n = 1 0 ) were treated with the o riginal vaginal wall sling. G ro up B (n = 1 0 ) were treated with the mo dified vaginal wall sling. Bo th gro ups were statistically similar acco rding to clinical and uro dynamic parameters.
M AIN M EASUREM EN TS: Cure and co mplicatio n rates.
RESULTS: Fo llo w-up ranged fro m 1 9 to 4 3 mo nths (median = 2 8 ) fo r gro up A. The o verall cure rate was 7 0 %. Fifty per cent o f the pa-tients had urinary retentio n o f 7 to 3 5 days. There were no majo r co mplicatio ns. Fo llo w-up ranged fro m 1 4 to 2 6 mo nths (median = 1 8 ) fo r G ro up B. The cure rate was 8 0 %. Two patients had urinary retentio n o f 7 and 5 5 days. There were no majo r co mplicatio ns.
CON CLUSION S: The vaginal wall sling is as effective as the mo di-fied vaginal wall sling but has a higher rate o f urinary retentio n.
KEY W ORDS: Urinary inco ntinence. Stress. Surgery. Vagina.
• Carlo s Alberto Bezerra • Marcus Vinicius Sadi
INTRODUCTION
There are several co ntro versies abo ut which is the best fo rm o f surgical treatment fo r wo men with stress urinary inco ntinence.1-5 The surgeo n’s cho ice is
based o n the type and severity o f inco ntinence, num-ber o f previo us anti-inco ntinence pro cedures, ho r-mo nal status, uro dynamic parameters and perso nal preferences.
Type III stress urinary inco ntinence is the invo l-untary lo ss o f urine due to an intrinsically damaged urethra (intrinsic sphincter deficiency), with o r with-o ut hypermwith-o bility.1 Patients with this type o f stress
urinary inco ntinence are best treated by slings, a pro -cedure where a sling is harvested fro m fascia, muscles, vaginal wall o r synthetic material and is transplanted to the suburethral area to co mpress and suppo rt the pro ximal urethra. Anato mical stress urinary inco nti-ne nc e is the invo luntary lo s s o f urinti-ne d ue to hypermo bility o f an intact sphincter unit. Patients with this type o f inco ntinence may be treated with slings, but traditio nally they are no t, because o f bladder emp-tying disturbances pro duced by this type o f pro cedure. In this case, Burch’s co lpo suspensio n is the pro cedure o f cho ice.
In 1994, Yo ung et al. mo dified the Raz vaginal wall sling4 fo r applicatio n in patients with anato mical
and intrinsic sphincter deficiency.6 In this technique,
there is no real sling, but two pairs o f sutures placed at the level o f the middle urethra and at the bladder neck.
pa-tients with anato mical and intrinsic sphincter defi-ciency stress inco ntinence.
METHODS
The pro cedures that fo llo w were in acco rdance with the ethical standards o f the co mmittee respo n-sible fo r human experimentatio n and with the Helsinki Declaratio n o f 1975, as revised in 1983.
Design
This was a co mparative study o f the effective-ness o f two surgical techniques fo r stress urinary in-co ntinence, perfo rmed pro spectively and no t rando m-ized.
Setting
Public and private health care units (Uro lo gy Divisio n, Faculty o f Medicine o f the ABC Fo undatio n and Universidade Federal de São Paulo / Esco la Paulista de Medicina).
Participants
Twenty wo men were surgically treated fo r stress urinary inco ntinence due to anato mical and intrinsic sphincter deficiency inco ntinence, between February 5, 1994, and June 27, 1996. Patients were selected acco rd-ing to the fo llo wrd-ing criteria: a) grade 3 stress urinary inco ntinence (defined as severe invo luntary lo ss o f urine, which needs continuous use of pads or someother pro tective measure); and b) lo ss o f urine fro m urethra during stress maneuver and witho ut simultaneo us de-truso r co ntractio n (defined in uro dynamic study). In this way, all patients selected had the same severity o f stress leak. Ten patients (gro up A) were submitted to the vagi-nal wall sling and ten (gro up B) were submitted to the mo dified vaginal wall sling. Patient selectio n was made witho ut the intentio n o f classifying types o f stress uri-nary inco ntinence. Bo th types o f stress inco ntinence (anato mical and intrinsic sphincter deficiency) were included in the study.
Preo perative investigatio n included co mplete histo ry with physical examinatio n and visualizatio n o f the urinary leak fro m the urethra during stress
ma-neuver and uro dynamics, acco rding to the Interna-tio nal Co ntinence So ciety,7 and perfo rmed using a
POLIMED, PL 2400 machine (Vio tti Asso ciado s, São Paulo , Brazil). The uro dynamic study was used to mea-sure the intensity o f inco ntinence, do ne using Valsalva le ak p o int p re ssure8,9 and lo o king fo r d e truso r
o veractivity that co uld affect the results o f surgery. Mean age, previo us surgery and parity is sho wn in Table 1. In gro up A, six patients had po st meno -pausal status, seven had periurethral fibro sis with a fixed urethra and no hypermo bility o f the bladder neck. In gro up B five patients were po stmeno pausal and two had a fixed urethra.
The uro dynamic results are seen in Tables 2 and 3. Patients 2, 4, 5, 12, 13, 17, 18 and 19 had a Valsalva leak po int pressure to o lo w to be exactly measured. But these patients leaked at a po int lo wer than 60 cmH2O, which means they had intrinsic sphincter de-ficiency.8,9
Interventions
Gro up A patients were submitted to the vaginal wall sling as previo usly described by Raz.4 This
tech-nique co nsists o f incisio n o f the anterio r vaginal wall in the suburethral space, delimiting a rectangular area that is to be the sling. The sutures (po lypro pylene, 0) are placed in each angle o f this rectangle to gether with periurethral tissues (urethro -pelvic ligaments) at the level o f the bladder neck and with periurethral tissues and fibers o f the levato r ani muscle, at the middle ure-thra. Next, they are passed with the 0º Stamey-Pereyra needle to the supra-pubic area thro ugh the periure-thral space. After suspensio n, the anterio r vaginal wall is clo sed o ver the sling and finally, the sutures are tied. Cysto sco py was perfo rmed ro utinely fo r check-ing the exact po sitio ncheck-ing o f the sutures, the integrity o f the urethral meatus and fo r the presence o f sutures inside the bladder. A co mpressive pad was left inside the vaginal vault fo r 24 ho urs and a Fo ley catheter fo r 48 ho urs. Fo r the patients with urinary retentio n the catheter was reintro duced fo r a week and then clean intermittent catheterizatio n was instituted if no rmal vo iding had no t been resumed.
Gro up B patients were o perated as described by Yo ung et al.6 The majo r mo dificatio n is that the
vaginal wall is no t harvested as a sling. Two pairs o f sutures are placed thro ugh two lateral incisio ns at the anterio r vaginal wall, excluding the epithelium. They are placed to gether with the periurethral tissues, at the level o f the bladder neck and the periurethral tis-sues and levato r ani muscle fibers, at the level o f the middle urethra. After the suspensio n is do ne, the in-Table 1 - Comparison of parame te rs:
age , pre vious surge ry and parity
Pa ra meters M EAN *
Group A Group B P-va lue
Age 5 3 .7 (4 3 to 6 0 ) 5 1 .8 (4 1 to 6 2 ) > 0 .0 5 Previo us Surgery 2 .9 (2 to 3 ) 5 .7 (3 to 8 ) > 0 .0 5 Parity 1 .8 (1 to 2 ) 1 .3 (1 to 2 ) > 0 .0 5
cisio ns are clo sed witho ut epithelial superpo sitio ning. The o ther steps o f the pro cedure are identical.
All patients received antibio tic pro phylaxis with cephalo spo rins befo re surgery, which was maintained until the urethral catheter was remo ved.
Main measurements
At fo llo w-up patients were co nsidered cured, if co mpletely dry; impro ved, if they had leakage at a lo wer grade (meaning leakage that did no t need co ntinuo us use o f pads o r any o ther pro tective measure); o r failed, if equal o r wo rse. Po sto perative examinatio n included interview with o ne o f the autho rs (CAB) fo r urinary sympto ms, physical examinatio n and tro uble with sexual activity. No specific questio nnaires o r third party analysis were do ne. Patients were systematically evaluated at 1, 3, 6 ,12, 18 and 24 mo nths after the pro cedure. Uro dynamics were do ne o nly if the patient had failure o r co mplicatio n, and accepted this.
Statistical methods
The Mann-Whitney test was applied fo r co mpari-so n o f the gro ups, with the limit o f 5% (P < 0.05) fo r
the null hypo thesis. The variables studied were effec-tiveness, defined in terms o f number o f patients cured o r impro ved, and co mplicatio n rates, defined in terms
o f vo iding disturbances and sexual impairments.
RESULTS
Baseline comparisons
The two gro ups were co mparable since they were statistically similar (Table 4).
Main outcomes
Fo r the patients in gro up A, fo llo w-up ranged fro m 19 to 43 mo nths (median 28); seven patients were cured o r impro ved and 3 failed. Amo ng the 3 failures (patients 1, 7 and 9 – Table 2), o ne o ccurred in the immediate po sto perative perio d (patient 9), o ne at thirty days (patient 1) and o ne at 11 mo nths (patient 7) after the pro cedure. Two o f them (patients 1, 7) were uro dynamically evaluated, co nfirming the persistence o f stress urinary inco ntinence with a stable bladder. Bo th were reo perated and remained cured after 12 mo nths o f fo llo w-up. The third patient (patient 9), who failed immediately, refused evaluatio n and treatment. She was reo perated at ano ther institutio n and is still inco ntinent.
Of the patients with surgical success, five were cured and two were impro ved (patients 2 and 5) and demanded no further treatment. One o f the latter
(pa-Table 3 - Characte ristics of group B patie nts
Pa tients Age Previous Pea k flow Lea k point End filling Voiding pressure
Surgeries (ml/ s) pressure (cm H2O) pressure (cmH2O) (cm H2O)
1 1 4 3 1 - G 2 5 1 0 0 0 2 3 4
1 2 2 9 1 - B 2 3 - 0 7 1 0
1 3 6 1 - 3 5 - 1 6 1 2
1 4 6 3 2 - KK-R 1 4 1 1 0 1 8 1 4
1 5 7 8 1 - B - 4 0 2 2 0 2
1 6 5 3 - 3 0 1 0 0 1 0 0 5
1 7 5 7 1 - KK 1 5 - 1 2 1 2
1 8 4 6 2 - KK-R - - 1 2 0 2
1 9 3 3 1 - KK 1 7 - 0 5 3 5
2 0 5 5 2 - KK-B 1 6 9 0 1 8 1 5
Legend: names o f previo us pro cedures: KK = Kelly-Kennedy; B = Burch; R = Raz; G = G ittes.
Table 2 - Characte ristics of group A patie nts
Pa tients Age Previous Pea k flow Lea k point End filling Voiding pressure
Surgeries (ml/ s) pressure (cm H2O) pressure (cmH2O) (cm H2O)
1 4 6 1 - KK 1 6 4 9 1 4 0 8
2 5 9 1 - KK - - 0 5 0 2
3 5 7 2 - KK-B 2 5 5 0 0 8 0 3
4 5 7 3 - KK-KK-B 3 7 - 0 5 0 2
5 5 0 2 - KK-B - - 0 8 0 2
6 5 7 2 - KK-G 2 5 9 0 0 5 0 2
7 3 3 2 - KK-R 2 5 9 0 0 9 1 2
8 5 3 1 - KK - 1 0 0 0 8 0 2
9 6 3 2 - KK-B 3 5 7 0 1 2 0 5
1 0 6 2 2 - B-R 3 7 1 0 0 0 4 1 2
tient 5) had recurrent urinary tract infectio n fo r 8 mo nths. Uro dynamic evaluatio n revealed persistent stress urinary inco ntinence, a stable bladder and go o d emptying functio n, witho ut residual vo lume. She has no w been free fro m infectio ns fo r 14 mo nths.
Five patients had urinary retentio n after the cath-eter withdrawal. This co nditio n lasted 7 to 35 days (median 14). The seven sexually active patients had no pro blems with interco urse after the pro cedure. There were no majo r co mplicatio ns except fo r o ne (pa-tient 4), who had vaginal bleeding in the surgery, and the hemo glo bin dro pped fro m 13.4 g/dl to 9.8 g/dl. But blo o d transfusio n was no t necessary.
Fo r the patients in gro up B, fo llo w-up ranged fro m 14 to 26 mo nths (median 18). Eight patients were cured (seven) o r impro ved (o ne) and two patients failed. One o f the pro cedure failures (patient 14 – Table 3) had detruso r instability, which wo rsened after sur-gery and is receiving anti-cho linergic agents. She still uses several pads a day fo r urge and stress inco nence. Uro dynamics revealed stress urinary inco nti-nence, no rmal vo iding pressure, residual vo lume o f 230 ml and reduced functio nal capacity due to invo l-untary and uninhibited co ntractio ns. The o ther inco n-tinent (patient 18) had o ne o f the sutures ruptured at surgery. Because it was felt that the o ther three su-tures were go o d, it was no t redo ne. The uro dynamic evaluatio n revealed stress urinary inco ntinence with a stable bladder. She was treated by the Raz vaginal wall sling and is no w co ntinent after 11 mo nths. Two patients had urinary retentio n o f 7 days (patient 13) and 55 days (patient 19), respectively. Bo th patients resumed vo iding but the seco nd persisted with o b-structive urinary sympto ms, recurrent urinary infec-tio ns and elevated po st-vo iding residual vo lume. Af-ter 12 mo nths she was o perated fo r urethro lysis and bo vine pericardium sling. She is no w co ntinent but still has o bstructive pro blems.
DISCUSSION
Patients with stress urinary inco ntinence due to intrinsic sphincter deficiency may be treated by
peri-urethral injectio ns, artificial urinary sphincters o r slings.1,5,10-13 After Raz described the vaginal wall sling,
so me autho rs evaluated it with pro mising success rates,4,10,14 no ne o f which were in patients with anato
mi-cal stress urinary inco ntinence The o riginal descrip-tio n o f the pro cedure in 32 patients with intrinsic sphincter deficiency sho wed a cure rate o f 88%. Fo ur years later, the fo llo w-up with 54 patients presented the same excellent results (91%). Two po ssible co m-plicatio ns were expected with this pro cedure: cyst fo r-matio n and vaginal sho rtening.1,4 The first is due to
the superpo sitio ning o f the vaginal epithelium; the seco nd, due to the resected vaginal wall, which co uld cause sexual disturbances during interco urse. Never-theless, these two co mplicatio ns have no t been de-scribed by any autho r so far, including o urselves.
The mo dificatio n intro duced by Yo ung elimi-nates these two po tential co mplicatio ns, since there is neither epithelium superpo sitio ning no r vaginal sho rtening. But this new style o f sling do es have no t a sub stantial am o unt o f tissue p o sitio ne d in the suburethral space, to co mpress and suppo rt the ure-thra. This fact may decrease the success rate o f the pro cedure, especially in patients with intrinsic sphinc-ter deficiency, because it is no t certain that the valve mechanism, where the urethra is co mpressed between the sling and the pubis during stress, is maintained.15
Altho ugh the results were extremely favo rable in Yo ung’s series, there is a lack o f a single clinical trial fo r co mpariso n o f the vaginal wall sling with the mo dified vaginal wall sling in patients with bo th types o f stress urinary inco ntinence.
This study pro po sed to co mpare these two pro -cedures perfo rmed in patients with bo th types o f stress urinary inco ntinence (intrinsic and anato mical sphinc-ter deficiency). The number o f patients enro lled was to o sho rt and the fo llo w-up was do ne witho ut specific questio nnaires. Altho ugh we kno w that higher num-ber o f patients were needed and a mo re o bjective, third party, analysis sho uld be do ne, so me o bservatio ns were po ssible at this initial fo llo w-up.
In o ur patients, the success rate with the o rigi-nal Raz pro cedure was 70%, after a minimum fo llo w up o f 19 mo nths (mean 28 mo nths). With the mo di-fied pro cedure, an 80% success rate was o btained af-ter 14 mo nths (minimum) and 18 mo nths (mean) o f fo llo w-up. Despite this lo wer fo llo w-up, it is estimated that, in needle suspensio n pro cedures, and also in slings, the failures o ccur in the first 12 mo nths. The initial results fro m slings are o ver 80%5,10-14,16 and tend
to be maintained fo r at least a co uple o f years. All the failures, in gro up A, o ccurred in the first year o f fo l-Table 4 - Statistical comparison
of urodynamic parame te rs
Pa ra meters M EAN *
Group A Group B P-va lue
Peak flo w 2 8 .5 (2 1 to 3 6 ) 2 1 .8 (1 5 to 2 8 ) > 0 .0 5 Leak po int 7 8 .4 (5 8 to 9 9 ) 8 8 (5 4 to 1 2 2 ) > 0 .0 5 PMCC 7 .8 (5 to 1 0 ) 1 2 .2 (8 to 1 7 ) > 0 .0 5 Vo iding Pressure 5 (2 to 8 ) 1 4 (6 to 2 2 ) > 0 .0 4
1. Blaivas JG, Olsso n CA. Stress inco ntinence: classificatio n and surgical appro ach. J Uro l 1988;139:727-31.
2. Jarvis GF. Stress inco ntinence. In: Mundy AR, Stephenso n TP, Wein AJ. Uro dynamics: principles, practice and applicatio n. 2nd ed. Edinburgh: Churchill Livingsto ne; 1994:299-326.
3. Raz S, Sto thers L, Yo ung GPH, et al. Vaginal wall sling fo r anato mical inco ntinence and intrinsic sphincter dysfunctio n: efficacy and o utco me analysis. J Uro l 1996;156:166-70.
4. Raz S, Siegel AL, Sho rt JL, Synder JA. Vaginal wall sling. J Uro l 1989;41:43-6.
5. Blaivas JG. Pubo vaginal sling. In: Kursh ED, McGuire EJ. Female Uro lo gy. Philadelphia: Lippinco tt; 1994:239-49.
6. Yo ung GP, Wahle GR, Raz S. Mo dified vaginal wall sling. J Uro l 1994;151:514A.
7. Bates P, Bradley WE, Glen E, et al. Standardizatio n o f termino lo gy o f lo wer urinary tract functio n: first and seco nd repo rts: Internatio nal Co ntinence So ciety. Uro lo gy 1977;9:237-41.
8. McGuire EJ, Fitzpatrick CC, Wan J, et al. Clinical assessment o f urethral sphincter functio n. J Uro l 1993;150:1452-54.
9. So ng JT, Ro zanski TA, Belville WD. Stress leak po int pressure: a simple and repro ducible metho d utilizing a fibero ptic micro transducer. Uro lo gy 1995;46(1):81-4.
REFERENCES
10. Co uillard DR, Deckard-Janatpo ur KA, Sto ne AR. The vaginal wall sling: a co mpressive suspensio n pro cedure fo r recurrent inco ntinence in elderly patients. Uro lo gy 1994;43:203-8.
11. McGuire EJ, Lytto n B. Pub o vaginal sling pro ce dure fo r stre ss inco ntinence. J Uro l 1978;119:82-4.
12. Mo rgan JE, Heritz DM, Stewart FE, Co nno lly JC, Farro w GA. The po lypro pylene pubo vaginal sling fo r the treatment o f recurrent stress urinary inco ntinence. J Uro l 1995;154:1013-5.
13. O’Co nnell HE, McGuire EJ, Abo seif S, Usui A. Transurethral co llagen therapy in wo men. J Uro l 1995;154:1463-5.
14. Juma S, Little NA, Raz S. Vaginal wall sling: fo ur years later. Uro lo gy 1992;39:424-8.
15. Stanto n SL. Why and ho w o pe ratio ns wo rk. Uro l Clin N Am e r 1985;12:279-84.
16. McGuire EJ, Bennett CJ, Ko nnak JA, So nda LP, Savastano JA. Experience with pubo vaginal slings fo r urinary inco ntinence at the University o f Michigan. J Uro l 1987;138:525-6.
17. Awad AS, Gajewski MD, Katz NO, Acker-Ro y K. Final diagno sis and therapeutic implicatio ns o f mixed sympto ms o f urinary inco ntinence in wo men. Uro lo gy 1992;39:352-7.
18. Chamo rro MV, Casado JS, Fernandez JCR, et al. Repercusió n de lo s sínto mas irritatívo s vesicales e inestabilidad del detruso r en lo s
lo w-up. Two o f them were due to inco rrect applicatio n o f the o perative technique, since when they have been reo perated, o ne with the same technique and the o ther with the fascial sling and bo th are no w co ntinent. The third patient was reo perated in ano ther institutio n and is still inco ntinent, suggesting she has a severe in-co ntinence pro blem that is difficult to treat with any surgical technique.
In gro up B o ne failure o ccurred in a patient with detruso r instability, and it is kno wn that the results are bad when mixed inco ntinence is present.8,9 The
seco nd failure was a technical pro blem, since o ne o f the sutures bro ke during surgery.
There were no majo r co mplicatio ns in either gro up, except fo r urinary retentio n, with a higher grade in gro up A (50% versus 20%). Despite this, o nly o ne o f the twenty patients has a persistent bladder-empty-ing pro blem (patient 19, gro up B).
At present, the surgical treatment o f stress urinary inco ntinence has several po ints o f co ntro versy. In large reviews o f this theme,19,20 it is suggested that the best
p ro c e d ure fo r anato m ic al inc o ntine nc e is co lpo suspensio n (Burch pro cedure) and fo r intrinsic sphincter deficiency is slings. In spite o f this, we need to ask which type o f sling is the best (rectus fascia, cadav-eric fascia lata, vaginal wall), and whether bo th types o f stress inco ntinence must be treated with slings. So me
recent publicatio ns refer to slings as the best cho ice fo r all types o f stress urinary inco ntinence.21 Others
ques-tio n this suggesques-tio n.22 To co rrectly answer these
ques-tio ns, mo re clinical trials targeting this issue are needed. This study is an initial pro to co l to co mpare two varia-tio ns o f vaginal wall slings, used in bo th types o f stress urinary inco ntinence. Other autho rs have published ar-ticles with the mo dified vaginal wall sling, but no t with a co mparative trial.3,23 At this time, o ur sample and fo llo
w-up are to o small to adequately answer the do ubts. But it is the first co mparative study with these two variatio ns o f vaginal wall sling and we are still wo rking o n it.
In patients with stress urinary inco ntinence, the mo dificatio n suggested by Yo ung has the advantage o f eliminating the risk o f cyst fo rmatio n and vaginal sho rtening but has the disadvantage o f no t harvest-ing a substantial amo unt o f vaginal tissue in the suburethral space. This, in o ur series, did no t affect the initial results.
CONCLUSION
r e s u m o
CON TEX TO: Existem diversas co ntro vérsias so bre qual é a melho r fo rma de tratamento cirúrgico da inco ntinência urinária de esfo rço em mulheres. O sling de parede vaginal, em suas fo rmas o riginal e mo dificada, fo i apresentado co mo no va o pção no tratamento dessa co ndição , mas um estudo co mparativo co m ambas as técnicas ainda não fo i publicado .
O BJETIVO : Avaliar a eficácia do s sling s de parede vag inal e mo dificado .
DESEN H O : Ensa io c línic o c o mp a ra tivo , p ro sp e c tivo , nã o rando mizado .
LO CAL: Serviço s das Disciplinas de Uro lo g ia da Faculdade de Medicina do ABC e da Universidade Federal de São Paulo .
PARTICIPAN TES: Vinte pacientes com incontinência urinária de esforço tipos anatômica e por deficiência esfincterina intrínseca foram tratadas cirurgicamente para avaliação dos resultados iniciais do sling de parede vaginal, de 0 5 de fevereiro de 1 9 9 4 a 2 7 de junho de 1 9 9 6 .
IN TERVEN ÇÃO: As pacientes foram divididas em dois grupos. G rupo A (n = 1 0 ) tratadas co m o sling de parede vaginal o riginal. G rupo B (n = 1 0 ) tratadas co m o sling mo dificado . Ambo s o s grupo s fo ram estatisticamente similares de aco rdo co m parâmetro s clínico s e uro dinâmico s.
VARIÁVEIS ESTUDADAS: Índices de cura e de co mplicaçõ es.
RESULTADOS: O seguimento vario u de 1 9 a 4 3 meses (mediana = 2 8 ) para o grupo A. O índice geral de sucesso fo i 7 0 %. 5 0 % das pacientes tiveram retenção urinária que duro u de 7 a 3 5 dias. Não ho uve co mplicaçõ es maio res. O seguimento vario u de 1 4 a 2 6 meses (mediana = 1 8 ) para o grupo B. O índice de sucesso fo i 8 0 %. Duas pacientes tiveram retenção urinária durante 7 e 5 5 dias. Não ho uve co mplicaçõ es maio res.
CON CLUSÕES: O sling de parede vaginal mo dificado tem eficácia similar ao o riginal, que, po r sua vez, tem maio r índice de retenção urinária.
PALAVRAS-CHAVE: Incontinência Urinária. Estresse. Cirurgia. Vagina
Carlos Albe rto Be ze rra, MD, MChir. Assistant Pro fesso r, Uro lo gy Divisio n, Faculty o f Medicine o f the ABC Fo undatio n, São Paulo , Brazil.
Marcus Vinicius Sadi, MD, PhD. Pro fesso r - Livre Do cente, Uro lo gy Divisio n, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Source s of funding: No t declared
Conflict of inte re st: No t declared
Last re ce ive d: 22 Octo ber 1999
Acce pte d: 29 No vember 1999
Addre ss for corre sponde nce :
Carlo s Alberto Bezerra Rua Afo nso Pena, 229 - Apt. 72
São Caetano do Sul/SP - Brasil - CEP 09541-400 E-mail: bezerrac@ uo l.co m.br
p u b lis hin g in fo r m a t io n resultado s de la uretro pexia. Arch Esp Uro l 1995;48(6):595-601.
19. Black NA, Do wns SH. The effectiveness o f surgery fo r stress inco ntinence in wo men: a systematic review. Br J Uro l 1996;78:497-510.
20. Leach GE, Dmo cho wski RR, Appell RA, et al. Female stress urinary inco ntinence guidelines panel summary repo rt o n surgical management o f female stress urinary inco ntinence. J Uro l 1997;158:875-80. 21. Chaikin DC, Ro senthal J, Blaivas JG. Pubo vaginal fascial sling fo r all
types o f stress urinary inco ntinence: lo ng-term analysis. J Uro l 1998;160(4):1312-6.
22. Wahle G. Durable co ntinence pro cedures fo r wo men [Edito rial]: J Uro l 1998;160:377.
