FASCIAL SLING FOR THE MANAGEMENT OF URINARY-INCONTINENCE DUE TO SPHINCTER INCOMPETENCE

The surgical management of urinary incontinence due to sphincter incom petence is still a challenging issue for urologists to date. We review ed our experience with the fascial sling performed in 10 male and 3 fe male patients 3 to 72 years old (median age 13 years) with sphincter i ncompetence, including 11 with a neurogenic bladder (8 with myelodyspl asia, 2 after pelvic operation and 1 after spinal cord injury), 1 afte r transurethral. resection of the prostate and 1 after surgical injury to the bladder neck. Patient selection for a sling procedure was base d on cystography (an open bladder neck) and urodynamic findings (under active 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 th e fascial sling was placed around the bladder neck in 11 and the bulbo us urethra in 2. Augmentation cystoplasty was performed concomitantly in 9 patients with poor bladder compliance (8 ileocystoplasty and 1 ga strocystoplasty). Postoperative followup ranged from 4 to 63 months (m ean 36). Nine patients became continent and 3 improved significantly b ut remain damp. Of these 12 patients 10 with a neurogenic bladder were placed on intermittent catheterization, while the 2 without a neuroge nic bladder are able to void normally. The remaining patient with surg ical failure due to inadvertent wound infection received an indwelling urethral catheter. In all but this patient preoperative and postopera tive 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 intrauret hral pressure demonstrated a dramatic increase in intraurethral pressu re during coughing or straining because of the action of the sling. Po stoperative upper urinary tract deterioration has not been documented to date. Although various surgical options have been available, the fa scial sling seems to be promising in the management of refractory urin ary incontinence due to sphincter incompetence.