When the sling is too proximal: a specific mechanism of persistent stress incontinence after pubovaginal sling placement.
OBJECTIVE
To review a series of patients with persistent stress urinary incontinence (SUI) after pubovaginal sling (PVS) placement because of an excessively proximal position of the graft on the bladder neck.


METHODS
Four women, who had previously undergone PVS placement for SUI, presented for evaluation of persistent SUI. All underwent investigations, including history, symptom questionnaire, quality-of-life assessment, physical examination, voiding cystourethrography, and multichannel urodynamic studies. Subsequently, takedown of the primary PVS and placement of an autologous fascial PVS were performed on all patients. A detailed case review of one of the patients is presented.


RESULTS
All patients had persistent severe SUI confirmed by a positive supine stress test and Valsalva leak point pressure determination. Malposition of the graft was diagnosed preoperatively on the basis of severe distortion of the bladder base and a wide-open bladder neck at rest on the lateral standing voiding cystourethrography images. The diagnosis was confirmed on operative exploration. All patients were continent after takedown of the prior PVS and placement of an autologous fascial sling.


CONCLUSIONS
Persistent SUI after PVS placement may occur secondary to positioning of the graft excessively proximally on the bladder neck. True lateral voiding cystourethrography views are essential for the precise diagnosis. In our experience, optimal management involves takedown of the primary PVS and placement of an autologous fascial PVS.
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA.
Christina
C
Poon
Philippe
P
Zimmern
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020878:Device Removal; D005205:Fascia / Q000637:transplantation; D005260:Female; D006801:Humans; D008875:Middle Aged; D011312:Pressure / Q000009:adverse effects; D019736:Prostheses and Implants / Q000009:adverse effects*; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D014182:Transplantation, Autologous; D001748:Urinary Bladder Neck Obstruction / Q000209:etiology*; D014550:Urinary Incontinence, Stress / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D014563:Urodynamics; D014567:Urography; D014636:Valsalva Maneuver