Nov 15, 1987 -
British Journal of Obstetrics and Gynaecology February 1989, Vol. 96, pp. 213-220
A clinical and urodynamic study comparing the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence PAUL HILTON Summary. Twenty women with urodynamically proven genuine stress incontinence were randomly allocated to treatment by suburethral sling or Stamey endoscopic bladder neck suspension. Urodynamic assessment was performed before and 3 months after surgery; clinical follow-up is reported up to 2 years. Blood loss was greater, and there were significantly more postoperative complications associated with the sling procedures. The subjective and objective cure rates at 3 months and 2 years were not significantly different between the two procedures. No significant changes in the resting urethral pressure profile were evident, although with both procedures, cure was associated with an enhancement in pressure transmission ratios in the proximal urethra. Detrusor instability occurring for the first time after operation was associated with both procedures; the sling, in addition, induced a significant degree of outflow obstruction, although this was not evident after the Stamey procedure.
The suburethral sling procedure has been widely advocated for the management of recurrent stress incontinence following unsuccessful primary surgical treatment; it may also be appropriate in patients in whom vaginal narrowing makes simpler primary procedures such as the anterior colporrhaphy or colposuspension technically difficult. Numerous sling procedures have been described, with cure rates between 61 and 98%, although the associated morbidity may be considerable (Hohenfellner & Petri
1986). The Stamey endoscopic bladder neck suspension procedure (Stamey 1973) may offer an alternative with fewer complications (Stamey 2980). This procedure has been compared with the colposuspension (Mundy 1983), although not with the sling, which would seem a more appropriate comparison. This paper seeks to compare these two operations in terms of success rates, operative and postoperative complications, and their urodynamic effects. Patients and methods
Department of Obstetrics and Gynaecology, University of Newcastle-upon-Tyne PAUL HILTON Senior Lecturer
Corrcspondencc: Mr P. Hilton, Department of Obstetrics and Gynaecology, Princess Mary Maternity Hospital, Great North Road, Newcastle-upon-Tyne NE2 3BD
Twenty women complaining of stress incontinence, with or without other urinary symptoms, were studied. All underwent a preliminary clinical and urodynamic assessment which included a full medical history, physical examination, bacterial culture of midstream urine specimen, videocystourethrography (Bates et al. 1970) or 213
214
P.llilton
Table 1. Age, parity and previous incontinence surgery distribution for the two groups of patients
Numbcr of womcn Agc (years) Mean Rangc Parity Mean Range Previou\ in~ontinencesurgery No. of operations No of patients
Sling
Stamcy
10
10
53.7 44-62
57 1 42-75
3.8+0.5 3.3+0 S I + M + 5 1+0-7+2
12 6
11 6
subtracted dual-channel cystometry with simultaneous pressurctflow voiding studies, cystourethroscopy and estimation of urinc loss using a short perineal pad test with standard exercise programme (Mayne & Hilton 1987). Urethral pressure measurements at rest and on stress wcrc made using a microtransducer technique described previously (Hilton & Stanton 1983~).The diagnosis of pure genuine stress incontincnce was confirmed in all patients, and all were considered to be unsuitable for treatmcnt by colposuspension, the author’s preferred primary surgical approach. because of post-surgical scarring, or marked atrophic narrowing of the vagina. Patients were randomized into two groups by means of a random numbcr chart; thosc drawing odd numbers underwent an abdomino-vaginal suburethral sling procedure using porcine dermis similar to that described by Jarvis & Fowlie (1985); those with even numbers underwent thc endoscopic bladder neck suspension operation
described by Stamey (1973) and modificd by Hilton (1987). All patients received prophylactic subcutaneous heparin, 5000 i.u. every 12 h, and antibiotic cover with ampicillin and metronidazole. All had continuous bladder drainage via a suprapubic catheter for at least 3 days after operation. All patients were reviewed clinically at 2, 6, 12, and 24 months after operation; urodynamic assessment, including subtracted dual-channel cystometry with simultaneous pressure/flow voiding studies, perineal pad testing, and urethral pressure measurements were repeated at 3 months after operation; perineal pad tcsting was also repeated at 12 and 24 months after operation. Because of the small numbers and the wide differences in standard deviations seen bctwcen groups for some variables, the data were analysed with non-parametric statistics. For categorical data, McNcmar’s test or Fisher’s exact test was used and for ordinal data Wilcoxon’s signed rank test or Mann-Whitney U-test was uscd for paired and unpaired comparisons, respectively. The mcthods, definitions, and units conform, where appropriate, to the standards proposed by the International Continence Society (Bates et al. 1976. 1977, 1980, 1981). Results
Thc mean age of the 20 patients was 56 years (range 42-75) and thcir mean parity was 3.6+0.6 (range 1+0 to 8+5); the age and parity distribution between the two groups was not significantly different (Table 1).Twelve of the patients
Table 2. Distribulion of previous pelvic surgery betwccn the two group\ Patient no.
1
2 3 4 5 6 7
8 9 10
Sling Ant. repair Marshall-Marchetti-Krantz Ant. repair X 2 Ant. repair X 2 Vag. hyst. and repair; ant. rcpair; Marshall-Marchetti-Krant7 Ant. repair X 2; sling Radical hysterectomy Abdominal hysterectorny -
__
Patient no. 11
12 13 15
15 16
17 18 19 20
Ant rip.tir hntcnoi ieparr, Vag hyst , vaginal hystcrcctomy
Stanley Ant. rcpair Ant. rcpair Ant. rcpair Ant. repair; colposuspcnsion and TAH Ant. repair; vag. hyst. and repair; colposuspcnsion Ant. rcpair x 2; colposuspension Radical hystcrectoiny+radiothcrapy --
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Stamey vs sling procedure in treatment of GSI
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Table 3. Urinary symptoms before and at 3 months after surgery in the two groups Sling (n=lO)
Frequency (mean no. voids/day) Nocturia (incan no. voidshight) Stress incontinence ( n ) Sanitary protection (mean no. o f pads/day) Urgency ( n ) Urge incontinence ( n ) Voiding difficulty ( n )
Stamey (n=10)
Pre-op.
Post-op.
Pre-op.
Post-op.
14.3 (7.4)* 1.3 (1.4) 10** 5.2 (3.4)* 8
6.2 (2.6) 0.8 (0.7)
12.3 (5.6)* 1.9 (1.6)* 10** 4.3 (3.0)“ 8 6 5
7.1 (5.3) 0-5 (0.7) 1 0 5 4 2
1 0 5 3 4
S 2
Rcsults arc mean (SD) values or numbers of patients as appropriate. Significance of difference bctwccn prc- and postoperative findings in each group *P
