USE OF A PEDICLED RECTUS-ABDOMINIS MUSCLE FLAP SLING IN THE TREATMENTOF COMPLICATED STRESS URINARY-INCONTINENCE

OBJECTIVE: A pedicled rectus muscle flap sling in the treatment of com plicated stress urinary incontinence was evaluated. STUDY DESIGN: Thir ty-two women underwent a combined vaginal and abdominal sling operatio n for stress incontinence with a pedicled muscle flap developed from t he rectus abdominis muscle. All operations were performed jointly by t he same two surgeons. The procedure involved transecting one rectus ab dominis muscle just above its first tendinous intersection and isolati ng the muscle as a flap on its inferior vascular pedicle. The muscle f lap was then swung beneath the urethra and bladder neck, pulled into t he retropubic space on the contralateral side, and sewn to the obturat or internus fascia or to Cooper's ligament. All patients undergoing th e procedure had demonstrable stress incontinence on physical examinati on and underwent preoperative fluoroscopic video urodynamics. The diag nosis of complicated stress incontinence was based on the presence of one or more of the following factors: previous failed antiincontinence surgery (33 operations in 22 patients, average 1.5 operations), open vesical neck on fluoroscopy (14 patients), urethral closure pressure l ess than or equal to 30 cm H2O by the Brown-Wickham technique (16 pati ents), or massive vaginal prolapse and demonstrable stress incontinenc e with the prolapse reduced and the urethra supported in a normal posi tion (16 patients). Follow-up ranged from 2 to 13 months (average 6 mo nths). Surgical outcome was assessed by physical examination and a det ailed telephone interview conducted by a physician who was not involve d in the operations. RESULTS: Twenty-eight patients (87.5%) were satis fied with the results of the operation. There were four surgical failu res (12.5%). Stress incontinence persisted in three patients after sur gery, and one patient who had mixed incontinence before surgery was cu red of stress incontinence but continued to have significant urinary l eakage as a result of detrusor overactivity. There appears to be less voiding dysfunction with this technique than with other sling procedur es for stress incontinence. CONCLUSIONS: The sling procedure with a re ctus abdominis muscle flap appears to be a viable surgical technique i n the treatment of complicated stress incontinence. Further study is n eeded to assess the long-term results of this operation and to evaluat e its proper place in reconstructive pelvic surgery.