INTRODUCTION
The banning of midurethral slings (MUS) in the United Kingdom (UK) has
removed the option of a repeat MUS and has provoked discussions about
other, more traumatic options such as Burch Colposuspension, autologous
sling, artificial sphincters [1]. The fact that these are major
operations aside, after a 20-year dominance of the stress urinary
incontinence (SUI) field by the MUS, few surgeons are skilled in such
procedures. A less traumatic option which has been discussed by experts
for failed MUS surgery [1] is Bulkamid (polyacrylamide hydrogel),
which is far inferior to the MUS. An RCT between tension-free vaginal
tape (TVT) and Bulkamid [2] gave the following 12-month results:
satisfaction score of 80 or greater on a visual analogue scale of 0 to
100 was reached in 95.0% and 59.8% of patients treated with TVT and
Bulkamid, respectively. Bulkamid often requires multiple return
treatments.
Though the initial midurethral sling surgeries published cure rates
regularly exceeding 85%,
more recently, much lower cure rates have been recorded. A Cochrane
Review in 2017 recorded a wide cure rate for MUS, between 62% and 98%
[3]. The MUS dominance for 20 years indicates most likely, that the
major group of failed incontinence operations in the UK currently derive
from midurethral slings [3].
My long experience in MUS surgery causes me to believe that most stress
urinary incontinence (SUI) failures were caused by a MUS set too
loosely. A loose PUL invalidates the distal urethral and bladder neck
closure mechanisms, fig.1 [5]. PUL laxity is easily diagnosed by a
“simulated” or “virtual operation”: a hemostat applied immediately
behind the symphysis controls SUI by preventing elongation of a weak
PUL, fig.1, VIDEO1 https://youtu.be/0UZuJtajCQU. The anatomy of
this “simulated operation” manoevre is exactly reflected in the
ultrasound section of Fig1. If the suburethral hammock is loose, please
note the VIDEO how a gentle fold of vagina helps continence control. The
“fold” in the video improves the distal closure mechanism, fig.1, and
indicates it should be repaired in addition to the “tape rescue
procedure”, VIDEO2.
The aim of this short commentary is to introduce a clinical test
(VIDEO1) which can diagnose which of the MUS failures may have been
caused by a tape applied too loosely, to introduce a “tape rescue
operation” for precise tensioning of the tape and, in addition,
reconstitution of the distal urethral closure mechanism, fig.1, which is
similar in principle to the two-incision version of the MUS [4,6].