The Urology Center Newsletters

Physician Newsletter

The Raconteur

Note from the author:

According to Webster's Dictionary “raconteur” is derived from the Old French words "re-" plus "aconter", meaning to recount. The newsletter is intended to provide practical information for non-urologist physicians, physicians assistants and nurses caring for patients with urology-related problems. I hope you agree that this forum for sharing information can be helpful to keep abreast of new developments. This newsletter has long been a personal project and I am happy that the first issue is complete and available on the web at www.theUrologyCenter.org.

Topics of discussion will be based primarily upon your interests. Your suggestions for future articles are welcomed and encouraged. Articles henceforth presented will represent a summary of current literature, with commentary by local physicians. Every effort will be made to concisely edit all articles, considering the time constraints under which we all work.

For additional information concerning this or any other urology topic please visit www.theUrologyCenter.org or contact me at (985) 370-0911, (800) 346-3837, (985) 370-9110 (fax), PO Box 2932, Hammond, LA 70404 or Steve@DoctorWatson.org (e-mail). If you prefer to receive future volumes of The Raconteur by e-mail please forward your e-mail address to Steve@DoctorWatson.org.

Sincerely,

H. Stephen Watson, M.D.

Outpatient Sling Procedure Revolutionizes Female Incontinence Surgery at North Oaks

by H. Stephen Watson, M.D.

Two advances now allow urologists to perform pubovaginal sling procedures on a strictly outpatient basis. A Precision Tack device made by Microvasive allows precise placement of bone anchors with attached permanent suture material into the posterior portion of the pubic bone. The sutures are used to suspend a small piece of xenograft tissue (porcine dermis) or allograft tissue (cadaveric rectus fascia) beneath the proximal urethra, providing needed support in women with stress urinary incontinence.

I have been performing sling procedures since 1994, performing the first urological sling procedure at North Oaks Hospital in 1997. The classic sling procedure, popularized by Dr. Ed McGuire, required two separate skin incisions — one incision (abdominally) for harvesting autologous rectus fascia to be used as sling material and another incision (vaginally) to place the sling beneath the proximal urethra near the bladder neck. For over two years now, I have performed numerous sling procedures with the more advanced equipment which allows the procedure to be performed with only a single small intravaginal incision. The very small vaginal incision allows immediate hospital discharge and almost zero postoperative discomfort.

Results have been excellent with greater than 95 percent of patients totally dry. Again, women undergoing the sling procedure alone are generally discharged home several hours after the procedure, without a catheter, voiding normally and dry! Patients typically report little, if any postoperative pain and often use no narcotic analgesics whatsoever.

It should be noted that these comments apply to women undergoing the sling procedure alone. I commonly work with the gynecologists by performing sling procedures in patients undergoing simultaneous hysterectomy or AP repair. Obviously, these cases require hospitalization catheterization times are significantly longer. Nonetheless, the results are ultimately the same.

Results from the current sling procedure have been durable with no known early or late postoperative stress incontinence failures in patients having undergone this procedure as primary surgical treatment. A single patient who had only recently undergone a sling procedure elsewhere was also shown to have stress urinary incontinence after sling performed here. In contrast another severely incontinent patient patient who had undergone four prior surgeries elsewhere underwent a successful sling procedure here. That patient had been nearly home-bound by continuous large volume incontinence, but she is now completely dry and urinating normally about two years after her removal of her old sling, dissection of the scarring about the urethra (urethrolysis) and redo sling procedure here. This lady is the delighted with her results. She is the most grateful patient with whom, I have ever had the pleasure to assist. Obviously, the risk of failure is increased with the number of prior failed procedures and I am happy to have achieved these lasting results.

Generally, if a patient is dry when she leaves the hospital, she remains dry. Of course no surgery is without potential complications. Some of the possible untoward effects include temporary urinary retention and temporary exacerbation of urge type urinary incontinence in a minority of cases. Other potential complications such as injury to the bladder, ureters or urethra, largely depend upon the experience of the operating surgeon.

While the classic indication for sling surgery is intrinsic sphincter deficiency in women with atrophic vaginitis or prior bladder surgery, current candidates for this procedure include women with any form of stress urinary incontinence. Additionally, patients with mixed urinary incontinence (combined stress and urge incontinence) also do well with the sling procedure. Patients with pure urge incontinence are very poor candidates for this approach. These patients are best managed with behavioral techniques, anticholinergic therapy, biofeedback and neuromodulation (subjects of future reports).

In summary, the management of women with stress urinary incontinence and mixed urinary incontinence is radically different than it was just several years ago. Specialized equipment and xenograft and allograft sling materials now allow even less experienced urologists to successfully perform pubovaginal sling procedures by a simplified method. The indications for the procedure have expanded appropriately, resulting in improved long-term results of surgery as compared to older anti-incontinence procedures such as bladder neck suspension procedures and simple anterior repair. The current sling procedure which incorporates sutures secured by pubic bone tacks appears to be as successful and durable as the classic sling procedure. However, the current sling procedure may be performed in half the operating time and with half the number of surgical incisions resulting in the ability to perform the procedure strictly on an outpatient basis with minimal postoperative discomfort.

(Additional information concerning the Precision Tack device is available at www.bostonscientific.com).