An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome

Purpose: We assessed the urodynamic changes after pubovaginal sling procedu re for stress incontinence, particularly in regard to the associated sympto ms of urgency, frequency, nocturia and urge incontinence, known as the urge syndrome. Materials and Methods: A total of 85 women with proved stress incontinence underwent a pubovaginal sling procedure using rectus fascia between 1992 an d August 1996. Of the women 41 (48%) had undergone previous anti-incontinen ce surgery and 59 (69%) had the associated urge syndrome. There was at leas t some degree of hypermobility in 51 cases and type III stress incontinence was diagnosed in 34. Patients were assessed with a questionnaire and video urodynamics preoperatively and 3 months postoperatively. Preoperative and postoperative ambulatory studies were performed in 25 cases. Results: Of the 85 patients 83 (97%) were symptomatically cured of stress i ncontinence. The urge syndrome resolved in 32 patients (69%), almost all of whom had a closed bladder neck at rest. Overall bladder neck incompetence at rest decreased from 57 to 18% (p <0.001). Of 27 patients with the persis tent urge syndrome postoperatively 9 (41%) had an open bladder neck at rest compared to 4 of 50 (8%) without urge incontinence (p <0.01). Despite symp tomatic control of stress incontinence in 83 patients (97%), only 66 were s atisfied with the surgical result, mainly because of the persistent urge sy ndrome in 27. Despite care to avoid obstruction overall, there were statist ically significant obstructive changes in detrusor pressure at maximum flow rate, maximum flow rate and residual urine volumes. Conclusions: The pubovaginal sling is effective in curing genuine stress in continence and, when correctly placed at the right tension, the associated urge syndrome also can be managed, usually by achieving bladder neck closur e at rest. However, despite careful maneuvers, obstruction occasionally per sists.