A simple objective method of adjusting sling tension

Purpose: Pubovaginal sling is gaining widespread acceptance as a primary fo rm of treatment for types II and III stress urinary incontinence. However, a major drawback is postoperative obstructed voiding due to excessive force placed on the suspension suture. We describe a simple objective method for intraoperative adjustment of sling tension that can be performed by a sing le surgeon during pubovaginal sling surgery. Materials and Methods: A cotton swab is inserted into the urethra and place d at the urethrovesical junction after the sling is fixed suburethrally and the vaginal mucosa is closed. The suspension sutures are tied down directl y onto the rectus fascia with enough tension to keep the cotton swab angle between 0 and 10 degrees to the horizontal plane. A total of 29 patients wi th an average age of 62 years underwent pubovaginal sling surgery with rect us and cadaveric fascia using this technique for tension adjustment. Of the patients 21 were diagnosed with types II and III, 5 had type II only and 3 had type III only incontinence. Preoperative evaluation revealed detrusor instability in 5 patients. Mean postoperative indwelling catheterization pe riod was 6.2 days. Average followup was 15.6 months. Results: To date no permanent urinary retention has occurred. Of the patien ts 15 voided without difficulty after catheter removal, 13 had urinary diff iculty requiring intermittent catheterization for I week or less and 1 had retention requiring intermittent catheterization for 10 weeks. Preoperative symptoms of detrusor instability resolved in all cases. De novo detrusor i nstability in 3 cases was controlled with anticholinergics. Conclusions: Overzealous sling tension adjustment has been recognized as a cause of treatment failure leading to urethral obstruction. Our technique i s effective in preventing over adjustment of tension, is reproducible and c an be performed by 1 surgeon.