**10. Conclusion**

Traditional first-line therapies for stress urinary incontinence are not successful in all women and management of recurrent incontinence can be quite difficult. Options for these patients include conservative management, endoscopic management with periurethral bulking, a repeat sling procedure, spiral slings, the artificial urinary sphincter and adjustable continence therapy devices or new technologies such as autologous stem cell injection. Variable success rates for all of these methods have been reported in the literature depending on the length of follow up and the definition of cure.

#### **11. References**

238 Urinary Incontinence

requiring transvaginal urethrolysis. On patient driven subjective assessment, 49% of patients reported never experiencing SUI, and 72% experienced no or rare episodes of SUI. Overall patients reported a mean improvement of 84% with a decrease in daily pads from 5.5 to 1.0. Most patients were highly satisfied with their urinary symptoms after surgery (mean QoL of 1.4). In addition, there was no statistically significant difference between pre and postoperative

A review of the literature for alternatives to bladder neck closure revealed no existing circumferential sling procedure in the adult population. Mingin and colleagues described a transabdominal technique of a urethral sling using rectus muscle wrapped around the urethra for pediatric patients with congenital urethral incompetence. (Mingin et al. 2002) Of the 37 patients reported, 92% remained dry between catheterizations. The pediatric population is unlike this population since these patients had roughly three anti-incontinence surgeries with subsequent scarring and more difficult coaptation. The mechanism of cure of the transvaginal spiral sling is not completely understood. It likely supports the midurethral segment while preventing urethral descent and improving pressure transmission to the urethra. In addition, unlike a routine sling procedure, the spiral sling also provides circumferential coaptation to the urethra at the time of increases in intrabdominal pressure. Raz and colleagues concluded that the spiral sling is an effective salvage transvaginal procedure that may be considered for a small subset of female patients with non-functional urethras as a last resort prior to urethral closure procedures. This includes patients with urethral incompetence caused by neurologic disease, congenital anomalies or iatrogenic injury from multiple failed anti-incontinence surgeries. The most comparable surgical alternative is the AUS which requires manual dexterity to operate the device and a more extensive dissection to implant all components. The initial outcomes look promising but longer follow-up will better define its role in refractory female incontinence and

Efficacy, safety & technical feasibility of intrasphincteric injections of autologous muscle derived stem cells have been shown by several groups in both animal models and humans. (Mitterberger et al. 2008; Sebe et al. 2011) In the human studies, myoblasts and fibroblasts were obtained from muscle biopsies of the patient. Cells are then grown in a culture facility to yield more myoblasts. After amplification, the cells are collected and frozen in a pellet, which is transferred to the urologist and thawed immediately prior to endourethral injection under endoscopic control. A recent review of stem cells for the treatment of urinary incontinence nicely describes the theory behind the use of stem cells for the treatment of urinary incontinence. (Staack & Rodriguez 2011) Ideally, these autologous cells provide additional mucosal coaptation in order to restore resting urethral closing pressures. These studies are in their infancy and no data has been reported on women with refractory stress urinary incontinence, however this might provide a more effective means of endoscopic

Traditional first-line therapies for stress urinary incontinence are not successful in all women and management of recurrent incontinence can be quite difficult. Options for these

symptoms of incomplete bladder emptying (P>0.05).

demonstrate the durability of the spiral sling.

bulking without the use of collagen and other synthetic materials.

**9. New technologies** 

**10. Conclusion** 


**15** 

*México D.F. México* 

**Surgical Complications with Synthetic Materials** 

Many factors are involved in the pathogenesis of stress urinary incontinence (SUI) and for several decades attempts have been made to design the best device for its treatment. Experience and research have led to important breakthroughs, but there is currently no 100% effective treatment devoid of complications. As treatments have changed, the materials and access routes have given way to complications not previously reported that have sometimes been fatal. ObGyns, urologists and urogynecologists that perform surgical procedures for urinary incontinence would like to have the best kit and none of the reported complications, but in actuality, everyone has such complications. Every surgeon wonders: What was the cause of this complication? How will it be resolved? How is it classified? For future patients, how can such a complication be prevented? There have been reports of erosion and/or extrusion of material in new kits or devices for urinary incontinence in the urethra, bladder, vagina and ureter; as well as bleedings during the surgical procedure with injury to the pelvic or vaginal vessels, suburethral hematomas, intestinal perforation, voiding dysfunction, nerve lesions, bladder perforation, infections and abscesses, de novo

For decades, different types of materials have been used, such as monofilament or multifilament mesh, micropore, macropore, silicone, polyester, polypropylene and gore-tex,

This chapter is an overview of the complications reported according to the device or kit used, the type of mesh, with reference to the classification of complications of the International Continence Society (ICS) and the International Urogynecological Association (IUGA) and the treatments used to resolve these complications. It is necessary to adequately follow the technical procedure, check the correct position of the patient´s legs, know the

The first to use synthetic material for a female urethral sling were Williams and Te Linde in 1962, followed by Ridley in 1966 and Morgan in 1970, using a polypropylene Marlex mesh for recurrent stress urinary incontinence. Subsequently, Morgan and colleagues (1985) reported at least a 5 year follow-up of patients with a 77.4% success rate. The complications

overactive bladder, pelvic pain, necrotizing fasciitis and even death.

and none of them is free of complications.

anatomy and receive periodical training.

**2. History** 

**1. Introduction** 

Verónica Ma. De J. Ortega-Castillo1 and Eduardo S. Neri-Ruz2

*1Instituto Nacional de Perinatología, SSA* 

*2Clínica de Especialidades de la Mujer, SEDENA* 

