ࡱ> 8:567` ~jbjb 6|c|cxttttttt,')8xxxxxxx(((((((,_+R-`(txxxxx((ttxx((((xtxtx((L|ttttx(((tt( j%4(((0')(.(.((tD  Red M. Alinsod, M.D., FACOG, ACGE South Coast Urogynecology The Women's Center 31852 Coast Highway, Suite 200 Laguna Beach, California 92651 949-499-5311 Main 949-499-5312 Fax www.urogyn.org Walsh: Campbell's Urology, 8th ed., Copyright 2002 Elsevier Vaginal Surgery for Stress Incontinence Initial surgical management of stress incontinence used a vaginal approach with plication of the periurethral tissue to narrow the urethral lumen and elevate the bladder neck ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300222"222] Kelly and Dumm, 1914). Retropubic suspensions ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300230"230] Marshall et al, 1949) or slings ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300206"206] Aldridge, 1942) followed in an attempt to improve efficacy and durability. [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300234"234] Pereyra (1959) introduced the vaginal needle suspension to achieve elevation as in the retropubic urethropexy with reduced morbidity. There have been many subsequent modifications with regard to the extent of dissection, location of sutures, method of fixation, and type of ligature carrier. The most widely adopted versions (modified [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300235"235] Pereyra [1967], [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300241"241] Stamey [1973], [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300236"236] Raz [1981], and [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300217"217] Gittes [1987]) are discussed later. Although early reports with short-term follow-up showed success rates comparable with those of retropubic suspensions, with less postoperative morbidity, longer-term follow-up has been disappointing ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300216"216] Elkabir and Mee, 1998; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300225"225] Kondo et al, 1998; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300231"231] Masson and Govier, 2000). A review of published studies by the American Urological Association Female Stress Urinary Incontinence Clinical Guidelines Panel showed a significantly lower cure (dry) rate beyond 4 years with transvaginal suspensions (67%) compared with retropubic suspensions (84%) or slings (83%) ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300229"229] Leach et al, 1997). The review panel still considered transvaginal suspensions to be a good option for the appropriate women with stress incontinence, those with smaller volume incontinence, with less intrinsic urethral sphincter deficiency, and who are willing to accept worse long-term benefit in favor of lower immediate morbidity. General Preoperative and Intraoperative Management Vaginal suspensions are routinely performed with the patient under general or alternatively regional anesthesia. Local anesthesia with sedation has been advocated for newer minimally invasive techniques ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300246"246] Ulmsten et al, 1998). Antibiotic prophylaxis is commonly employed, although there are no specific data supporting its use. Patients are positioned in dorsal lithotomy with Trendelenburg to optimize visibility and lower the chance of bowel injury with needle or suprapubic catheter passage. A weighted vaginal speculum, or Simms retractor, and pinning of the labia with sutures or a Scott retractor to spread the vaginal introitus, improve access. Placement of a Foley catheter allows identification of the bladder neck by palpation and decompresses the bladder to allow safe passage of the ligature carrier. With the vaginal incision, injection of sterile saline solution into the mucosa facilitates the development of the submucosal plane. Hematuria from the Foley catheter should alert one to suture penetration of the bladder (usually laterally, near the bladder neck). Cystoscopy during the procedure (first introduced by Stamey in 1973) allows for checking suture placement and elevation and ruling out bladder or urethral injury. Vaginal packing is optional, depending on bleeding encountered. Postoperative bladder drainage is with either a urethral Foley or a suprapubic catheter. A urethral catheter avoids potential complications of blind insertion of a suprapubic catheter. However, with prolonged postoperative retention, it requires the woman to master intermittent catheterization in the face of adjacent surgical swelling and pain. Care must be taken with percutaneous insertion of a suprapubic catheter of any type, especially when there is a history of previous lower abdominal surgery or radiation. The bladder must be very distended with the patient in exaggerated Trendelenburg to minimize the risk of bowel injury. Surgical Techniques Modified Pereyra The original description by [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300234"234] Pereyra (1959) involved a T-shaped vaginal incision with minimal periurethral dissection and no penetration into the retropubic space. A single-needle stylet and absorbable suture were used to fix the periurethral tissue over the rectus fascia. The needle stylet was delivered into the vagina through a single midline lower abdominal incision. Later, [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300235"235] Pereyra (1967) made his own modifications, incor HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/330.html?printing=true#top"1116 porating bladder neck plication but still using absorbable suture. Using this technique, he reported a 94% cure rate with 1-year follow-up in 210 patients ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300235"235] Pereyra and Lebherz, 1967). Stamey Needle Bladder Neck Suspension Stameys modifications to the transvaginal suspension ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300241"241] Stamey, 1973) incorporated three new aspects. Endoscopy was an adjunct to ensure sutures were placed precisely at the bladder neck. Nonabsorbable sutures were used with Dacron vaginal pledgets to buttress either side of the urethra and minimize suspensory suture pull-through on the vaginal side. Stamey also designed a single-pronged blunt-tipped needle (Stamey needle) that continues to be commonly used in many versions of transvaginal suspensions. The procedure involved two lateral suprapubic incisions and a suprapubic catheter. Many large outcome series have documented success in 72% to 91% ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300242"242] Stamey, 1980; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300249"249] Walker and Texter, 1992; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300225"225] Kondo et al, 1998). Success tends to be less with longer follow-up ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300225"225] Kondo et al, 1998) and in younger patients ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300220"220] Hilton and Mayne, 1991). Erosion of the Dacron pledgets has been reported at up to 3 years after surgery ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300209"209] Bihrle and Tarantino, 1990). Gittes Bladder Neck Suspension [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300217"217] Gittes and Loughlin (1987) described a no-incision pubovaginal suspension. Two lateral suprapubic stab incisions are made and the Stamey needle is passed twice on each side from over the rectus fascia through the vaginal wall at the bladder neck (guided by the Foley balloon) to retrieve the ends of a No. 2 polypropylene stitch. A Mayo needle is used to take helical bites of vaginal tissue before delivering the second end of the stitch to the abdominal wall. The sutures are tied over the rectus fascia without tension, as in all suspensions. Gittes postulated that the vaginal suspension sutures under slight traction cut through the vaginal wall and become buried in scar, creating an autologous pledget. A suprapubic catheter was also used. Good short-term results have been published ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300217"217] Gittes and Loughlin, 1987; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300223"223] Kil et al, 1991; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300212"212] Conquy et al, 1993). However, the no-incision technique has the poorest reported long-term outcome of needle suspensions. [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300225"225] Kondo and coworkers (1998) compared their experience with 382 patients undergoing a Stamey or Gittes suspension with a mean follow-up of more than 5 years in both groups. The Kaplan-Meier cumulative continence rates were 71.5% for the Stamey at 14 years and 37.0% for the Gittes at 6 years postoperatively (P<.0001). Elkabir and Mee (1998) found a similarly low cure rate of 38.5% at 2 years with the Gittes technique. Raz Procedures for Stress Incontinence In 1981, Raz described a modification of the Pereyra procedure (HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/330.html?printing=true#F030022" Fig. 3022 ). The technique employed an inverted-U vaginal incision to improve access. It also was the first to open the retropubic space sharply by detaching the periurethral connective tissue from the arcus tendineus. Opening the retropubic space facilitates blind passage of the ligature carrier from the abdomen to the vaginal incision by allowing finger guidance, permitting urethrolysis if required, and allowing placement of helical sutures into the abdominal and vaginal sides of the periurethral connective tissue, which results in a more secure purchase of tissue. A double-pronged ligature carrier is passed twice through a midline suprapubic incision to retrieve the No. 1 nonabsorbable suture. A suprapubic catheter was used. Figure 30-22 Raz bladder neck suspension. A, Inverted U-shaped incision is made in the anterior vaginal wall with the base of the U at a point midway between the bladder neck and the urethral meatus. The vaginal wall is dissected off the surface of the periurethral fascia. The retropubic space is entered by detaching the endopelvic fascia from the arcus tendineus. B, A No. 1 polypropylene suture is placed to include the endopelvic fascia and pubocervical fascia that underlies the vaginal wall. A similar suture is placed on the opposite side. C, A midline transverse incision is made just above the pubis and carried down to the rectus fascia. The double-prong suture carrier is placed through the rectus fascia and muscle, and the tips are palpated with the index finger in the retropubic space. The suture carrier is guided down and out through the vaginal incision. The sutures are placed into the needle holes and guided back up through the vaginal incision. The sutures are placed into the needle holes and guided back up through the rectus fascia. Cystoscopy is carried out. The vaginal incision is closed, and the sutures are tied suprapubically. The vagina is packed, and the suprapubic incision is closed. (AC, From Raz S: Female Genitourinary Dysfunction and Reconstruction. Philadelphia, WB Saunders, 1996.) Early results with 15-month follow-up reported by [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300175"175] Raz and colleagues (1992) showed a 92% success rate. Severity of incontinence was found to be a negative predictor for outcome. Other groups have confirmed good early results and low morbidity with Razs modified Pereyra procedure ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300218"218] Golomb et al, 1994). However, there is increasing evidence of poor long-term results from this version of the Raz procedure ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300226"226] Korman et al, 1994; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300245"245] Trockman et al, 1995; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300214"214] Das, 1998; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300231"231] Masson and Govier, 2000). [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300231"231] Masson and Govier (2000) showed of 135 patients with a mean follow-up of more than 4 years that only 14% were dry and 53% continued to wear pads. Raz Vaginal Wall Sling In 1989, Raz and coworkers reported a new vaginal technique to treat stress incontinence caused by intrinsic sphincter dysfunction. A rectangular flap of vagina was buried at the bladder neck and suspended by nonabsorbable sutures at each corner by passage of a ligature carrier. In 1992, they reported on 54 patients who had this sling performed, showing a success rate of 94% with a mean follow-up of 24 months ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300221"221] Juma et al, 1992). Others confirmed similar short-term success and low morbidity ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300213"213] Couillard et al, 1994). Subsequently, Raz and coworkers modified the procedure in that the vaginal flap is no longer buried. The current technique is based on the importance of the midurethral mechanism to prevent incontinence. The surgical goals of the anterior vaginal wall sling were (1) to provide elastic support to the midurethra and bladder neck and (2) to create a strong hammock of vaginal wall and underlying tissues, which provides a backboard against which the urethra can be compressed with increases in intra-abdominal pressure ( [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300176"176] Raz et al, 1996). It is applicable to patients with any type of stress incontinence. A similar technique of six-corner suspension is described and illustrated in HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/331.html#F030025" Figure 3025. Two oblique incisions are made in the anterior vaginal wall extending from the level of the midurethra to 3 cm beyond the level of the bladder neck. The incisions are 1 cm medial to the folded lateral margin of the anterior vaginal wall. The same dissection to enter the retropubic space is then carried out as just described. The proximal (bladder neck) sutures are placed in the same fashion as the modified Pereyra stitches, using No. 1 nonabsorbable suture with the addition of several helical passes under the vaginal epithelium, capturing further periurethral and perivesical tissue. The distal (midurethral) sutures are then placed again using No. 1 nonabsorbable suture. To facilitate multiple helical passes with a good purchase of periurethral tissue in this location, Russian forceps are opened widely in the retropubic space, with gentle downward trac HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/330.html?printing=true#top"1117 HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/330.html?printing=true#top"1118 tion maintaining the forceps parallel to the ground. After this deep tissue is taken, several helical bites of anterior periurethral fascia underlying the vaginal epithelium are taken at the midurethra level. Care must be taken to avoid urethral perforation by maintaining the needle parallel to the vagina. The identical sutures are then placed on the contralateral side. These four sutures suspend a rectangle of support (sling) for the bladder neck and midurethra. The double-pronged ligature carrier is then passed in the same fashion as in the Raz procedure through a midline suprapubic incision. It must be passed four times to transfer the sutures, which are then tied over the immobile portion of the rectus fascia. The vaginal incisions are closed using running, locking 2-0 delayed absorbable suture. Cystoscopy is used to rule out bladder or urethral penetration. Early results in 160 women with incontinence from either sphincteric deficiency or hypermobility who underwent the Raz vaginal wall sling with a median follow-up of 17 months showed 152 to be cured of stress incontinence ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300176"176] Raz et al, 1996). Longer-term results and comparative trials are awaited. Tension-Free Vaginal Tape Procedure Another technique focusing on the midurethral continence mechanism is the tension-free vaginal tape (TVT) procedure. Early attempts to place a fine mesh sling around the urethra showed 90% success at a mean follow-up of 16 months. However, a rejection rate approaching 10% was found using Gore-Tex and Mersilene tapes ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300248"248] Ulmsten and Petros, 1995). Revisions in this early methodology, including the use of loose-weave polypropylene mesh, have led to the current technique (HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/330.html?printing=true#F030023" Fig. 3023 ). The TVT does not seem to abolish urethral hypermobility as assessed by preoperative and postoperative Q-tip tests ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300224"224] Klutke et al, 2000). Figure 30-23 Tension-free vaginal tape placement. Passage of the curved trocar through the endopelvic fascia, retropubic space, and abdominal wall. (Reprinted from Urology, Volume 56, Carlin BI, Klutke JJ, Klutke CG, The tension-free vaginal tape procedure for the treatment of stress incontinence in the female patient, 2831, 2000, with permission from Elsevier Science.) A neuroleptic anesthetic with preprocedure antibiotic coverage is recommended. The patient is placed in a dorsal lithotomy position and a urethral Foley catheter (No. 18 Fr) is inserted to drain the bladder. Sixty to 80 ml of dilute local anesthetic is injected into the abdominal skin above the pubis and downward along the back of the pubic bone to the space of Retzius. Two abdominal skin incisions of 1 cm are made, one on each side of the midline, just above the symphysis, approximately 5 cm apart. Further local anesthetic is then injected transvaginally into the periurethral area extending up to the retropubic space. A midline incision is made about 1.5 cm long, starting approximately 1 cm from the external urethral meatus. Two small periurethral spaces are created, not entering the retropubic space. The TVT rigid catheter guide is inserted into the channel of the Foley catheter. The purpose of the guide is to move the bladder and urethra away from where the tip of the needle passes into the retropubic space. By using the handle with the prethreaded needles loaded, the surgeon places the tape around the urethra as follows: The tip of the needle is inserted into the prepared paraurethral incision on the right side of the urethra (catheter guide pushed to the right to displace the bladder to the left). The endopelvic fascia is perforated, and the tip of the needle is brought up to the abdominal incision by hugging the back of the pubic bone. Cystoscopy is performed to rule out bladder perforation. The procedure is then repeated on the left side. When the sling is placed in a U shape around the midurethra, the patient is asked to cough with a full bladder, and the tension of the tape is adjusted just to the point of abolishing leakage. Excess tension on the tape is avoided. The plastic sheath is then removed. The abdominal ends are cut flush with the skin and are not sutured in place. Friction from the coarse weave of the mesh holds the tape in place. The skin and vaginal incisions are then closed over the tape. The bladder is drained, and postoperative catheterization may not be required. To date, most published series of TVT have been for primary repairs. A multicenter trial ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300246"246] Ulmsten et al, 1998) showed a 91% cure rate in 131 patients with a minimum 1-year follow-up. Mean operative time was 28 minutes, and all procedures were performed under local anesthetic with 90% as day-care patients. Three-year follow-up with 50 consecutive women showed an 86% cure rate with no mesh rejection or permanent retention ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300247"247] Ulmsten et al, 1999). [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300250"250] Wang and Lo (1998) found a subjective cure rate of 87% in 70 women using the same technique. Epidural anesthesia was used, and mean hospital stay was 3 days. Three bladder perforations occurred but healed with conservative management. [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300219"219] Haab and coworkers (2001) described 16 patients with previous retropubic or vaginal suspension undergoing successful TVT. In their series of 62 HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/330.html?printing=true#top"1119 women followed over a median of 16.2 months, 87% were cured and 9.6% improved. No erosion or infection occurred ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300219"219] Haab et al, 2001). Bladder perforation is treated by repositioning the needle and catheter drainage. Potential severe complications include bowel perforation ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300210"210] Brink, 2000) and pelvic bleeding. Bone Anchoring Techniques Most transvaginal suspensions for stress incontinence fix the suspensory sutures over the anterior rectus fascia. Some have postulated that the rectus fascia is mobile and that this motion leads to shearing forces that may lead to pull-through of the suspensory suture at the vaginal end. Others believe that stitches placed laterally in this region lead to nerve entrapment and prolonged postoperative pain. In an effort to combat these theoretical problems, various bone anchoring systems have been developed and marketed, including the In-Tac and Vesica systems. The In-Tac bone anchor system was described by Nativ and coworkers in 1997. Nickel/titanium alloy bone anchors threaded with No. 1 nonabsorbable sutures are inserted transvaginally through a spring-loader multiuse inserter. Initial experience with 50 women with type or II stress incontinence found a 1-year cure rate of 82%. Transient dyspareunia occurred in 6% ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300232"232] Nativ et al, 1997). [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300215"215] El-Toukhy and associates (1999) used a similar surgical technique in 30 women reporting a 1-year subjective cure rate of 80%. Dyspareunia resulting from the vaginal polypropylene stitches occurred in 23%, requiring successful revision in all. Braided nonabsorbable suture is now used to avoid this complication. There are no reports of anchor infection after transvaginal insertion. The Vesica system uses a drill to place screws into the pubic symphysis through a suprapubic incision ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300227"227] Leach, 1988; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300228"228] Leach and Appell, 1996). Nonabsorbable No. 1 polybutester suture is preloaded into the screws and may then be passed with a suture passer into the vagina to suspend the bladder neck. Percutaneous bladder neck stabilization using the Vesica system has shown a 94% cure rate at 1 year in 71 women ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300207"207] Appell et al, 1996). The results of [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300240"240] Schultheiss and coworkers (1998) were less promising. Of 37 patients with maximum follow-up of 18 months, 43% were dry and 24% were significantly improved. Furthermore, 25% of patients reported prolonged pelvic pain. Surgical removal of the anchors was necessary in two patients for bacterial infection and painful granuloma ( [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300240"240] Schultheiss et al, 1998). [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300244"244] Tebyani and coworkers (2000) also reported disappointing results with cure in 5% and improvement in 12% of 42 patients with mean follow-up of 29 months. Recurrent hypermobility, shown by urodynamics, was the most common cause for recurrent stress incontinence, with 2 women showing obvious bone anchor migration. Surgical dbridement of osteomyelitis was required in another woman ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300244"244] Tebyani et al, 2000). [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300208"208] Bernier and Zimmern (1998) reported difficulties in removing painful bone anchors that required wedge excision of the pubis. Although bone anchoring techniques offer an alternative for suture stabilization, there is insufficient evidence to suggest that they are superior to traditional needle suspensions in the short or long term. With their increased cost compared with traditional methods of rectus fascia anchoring, cost-effectiveness will also have to be examined. Complications of Vaginal Suspensions Intraoperative Complications The most commonly encountered intraoperative complications are bleeding, suture passage through the bladder, or laceration of the bladder or urethra during dissection. Bleeding from vaginal veins may be brisk but can generally be controlled with electrocautery or absorbable stitches. Bleeding from the retropubic dissection may be more problematic and is often a result of dissection too far laterally into the obturator fossa. Temporary vaginal packing can slow bleeding along with digital compression. Suture ligatures may be required to stop bleeding. Vaginal closure with packing may tamponade bleeding that is not too brisk or flowing freely into the retropubic space. Rarely, an abdominal approach may be required to control bleeding. Transfusion requirement for suspensions is estimated at 1% ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300229"229] Leach et al, 1997). When hematuria is identified after passage of a ligature carrier, puncture of the bladder is likely. Cystoscopy should be carried out and the offending suture removed. This is usually on the lateral side, near the bladder neck. Removal and replacement of the stitch along with catheter bladder decompression for 48 hours is generally sufficient. Finally, if dissection leads to urethral or bladder laceration, this should be repaired using absorbable suture with a multilayer closure and consideration given to longer catheter bladder decompression. Postoperative Complications Postoperative complications from stress incontinence surgery are not unique to transvaginal suspension techniques. Many result from an increased urethral resistance or relative obstruction and as such are believed to be more common after sling-type procedures ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300229"229] Leach et al, 1997). The most commonly encountered postoperative complication is urinary retention. This persists beyond 2 weeks in 5% to 8% ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300229"229] Leach et al, 1997; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300216"216] Elkabir and Mee, 1998; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300225"225] Kondo et al, 1998; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300243"243] Tamussino et al, 1999). Permanent retention is a rare complication and may not be predicted by preoperative urodynamics. De novo instability symptoms or worsening of preexisting instability symptoms such as frequency, urgency, and urge incontinence is estimated to occur in 4% to 16% ( [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300175"175] Raz et al, 1992; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300245"245] Trockman et al, 1995; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300229"229] Leach et al, 1997; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300225"225] Kondo et al, 1998). For some, this is quite problematic and does not respond to anticholinergics. Both retention and de novo instability symptoms, if from obstruction, may respond to urethrolysis ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300233"233] Nitti and Raz, 1994; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300211"211] Carr and Webster, 1997). Cutting the suspensory sutures beyond the initial postoperative period is not generally effective. Other complications that are less frequent but well recognized include persistent pelvic pain or dyspareunia in 5% ( [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300175"175] Raz et al, 1992; [HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300216"216] Elkabir and Mee, 1998); pelvic prolapse, including enterocele, rectocele, or cystocele in 6% ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300175"175] Raz et al, 1992); and death in 0.05% ([HYPERLINK "http://home.mdconsult.com/das/book/body/0/1049/332.html#R0300229"229] Leach et al, 1997). Conclusions In general, the long-term success of transvaginal needle suspensions is not as good as that of open retropubic repairs or sling procedures. Of the transvaginal suspensions, the Gittes no-incision procedure appears to be the least durable. The morbidity associated with transvaginal suspensions for stress incontinence is lower than that with open retropubic or sling surgery. There are many new, minimally invasive techniques for vaginal repair of stress incontinence that hold promise, but longer-term follow-up and comparative studies will confirm their merit. !"<('(),-._˼~o\oF\3\o%hhKhhKB*CJOJQJaJph+jhhKhhKCJOJQJUaJ%jhhKhhKCJOJQJUaJhhKhhKCJOJQJaJhhKhhK5CJ OJQJaJ hhKhhKCJOJQJaJhhKhhK5CJOJQJaJhhKhhKCJOJQJaJhhKhhKCJOJQJaJhhKhhK5CJOJQJaJhhKhhK5CJ"OJQJaJ"(hhKhhK5B* CJ"OJQJaJ"ph3f"<On'( yz   & 0` P@1$7$8$H$gdhK~_`a% & ' * + , y z { ! 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