stress urinary incontinence ( sui ) is defined as the complaint of involuntary leakage on effort or exertion or on sneezing or coughing . although sui is not a life - threatening condition
surgical therapy is employed in patients who have severe degrees of sui or those patients in whom conservative or pharmacological treatments have failed .
sling procedures for genuine sui are today the mainstay of treatment and have been used for over a century with first procedure reported by schultze in 1888 .
the integral theory of female urinary continence described by petros and ulmsten redefined the modern approach to anti - incontinence surgery and ushered the era of the midurethral sling .
the concept was applied clinically by placing the sling to a more distal location beneath the urethra then as compared to the previous techniques .
subsequently excellent results were presented using suprapubic arc system ( sparc , american medical systems inc .
some authors have even termed midurethral sling surgery as the new gold - standard for sui . with the available midurethral slings , the trocar has to be passed blindly either from above ( suprapubically ) or below ( transvaginally ) , which increases the chances of injury to the pelvic organs and blood vessels .
shlomo raz modified the technique of sling placement with opening the endopelvic fascia and passing the needle under controlled digital palpation , thereby decreasing the chances of injury to surrounding pelvic organs as well as significantly decreasing cost using tailor - made mesh .
their finger - guided passing of needle was similar to the raz procedure of bladder neck suspension .
we present our experience with the use of large pore polypropylene mesh / polypropylene - polyglactin mesh as a pubovaginal sling ( midurethral ) in the treatment of sui with the modified raz technique .
a retrospective analysis was performed of consecutive 53 patients of pure sui who underwent midurethral slings procedure with the modified technique from june 2003 to december 2008 at our institute .
preoperative evaluation included a history , physical examination , urine microscopic examination , and culture .
severity of sui was defined by the number of pads used by the patients per day as mild ( < 2 ) , moderate ( 24 ) , and severe ( > 4 ) .
patients were examined in lithotomy and standing positions to demonstrate sui on cough test and valsalva maneuver .
four patients of our series underwent multichannel urodynamic examination for history suggestive of mixed incontinence in accordance with nice guidelines .
all patients were counseled regarding the need of postoperative clean intermittent catheterization ( cic ) and transient voiding dysfunction .
vaginal tissue was atrophic in four patients and they were preoperatively treated with local estrogen cream .
twenty patients gave previous history of hysterectomy ; others had history of undergoing gynecological procedures , details of which were not available .
none of the patients had previous history of surgery for incontinence or pelvic organ prolapsed .
eight patients had grade 1 cystocele and two patients had grade 1 rectocele , which did not require treatment .
five patients underwent simultaneous vaginal hysterectomy for gynecological indications . a polypropylene mesh ( prolene )
/polypropylene - polyglactin mesh ( vipro ) measuring 1  10 cm ( ethicon , johnson and johnson , usa ) was fashioned from commercially available 15  7.5 cm mesh .
this strip was soaked in antibiotic saline and stitched at all four corners to 1 - 0 polyglactin suture .
16 fr foley catheter was placed in urinary bladder and balloon was palpated at bladder neck to estimate urethral length .
two percent of xylocaine with adrenaline was infiltrated in the vaginal mucosa overlying the urethra .
a 1.52 cm mid - line incision was made over the midurethra ( 1.5 cm proximal to external urethral meatus ) .
vaginal mucosal flaps were dissected on either side extending into avascular plane , until endopelvic fascia was reached .
blunt dissection was carried out in retropubic space by inserting a finger and the bladder was swept medially .
two small punctures were made suprapubically and a double - pronged needle ( cook urological inc . ,
indiana , usa ) is passed under finger control through the fascia and retropubic space .
a marking catgut suture is placed in the center of the mesh along its length to ensure that mesh placement is equidistant .
the polyglactin suture was pulled and tension adjusted by placing the tip of an artery forceps while positioning sling against midurethra .
vaginal pack was removed after 24 hours of surgery and providine - iodine vaginal pressary was advised for 5 days .
if residual urine was more than 50 ml , patient was advised cic . in sexually active patients ,
the patients were followed up with history and clinical examination by the operating surgeon in the opd .
social dryness was defined as patient requiring 1 pad per day and acceptable leak while carrying out routine tasks .
five of the patients also underwent simultaneous vaginal hysterectomy for gynecological indications with no increase in morbidity .
mean duration of follow - up was 46.1 months ( 1278 months ) [ table 1 ] .
forty - five ( 85% ) patients were completely dry and eight ( 15% ) were socially dry at the end of the follow - up .
four patients failed voiding trial and were advised cic , which was later discontinued after 38 weeks , when their pvr fell to < 50 ml .
two patients complained of dull aching lower abdominal pain , which was relieved by administration of oral analgesic agents .
five of our patients complained of mild dyspareunia , which was transient and did not require treatment [ table 2 ] .
none of the patients reported significant voiding dysfunction , infection , nonhealing , or erosion of the sling till their last follow - up [ table 2 ] .
over last few years , many procedures using autologous material ( rectus sheath , fascia lata ) or synthetic material ( polypropylene , mersilene ) have been reported in literature
. continued refinements in materials were sought to identify an ideal compound for use in transvaginal slings that would be inert , sterile , noncarcinogenic , and mechanically durable .
synthetic materials have the advantage of being readily available and do not require harvesting from another site .
this decreases the operative time , discomfort , and potential donor site complications after the surgery .
histological and clinical studies have shown that polypropylene is a synthetic material that is well - tolerated by the body , with little exposure of the patient to infection and vaginal or urethral erosion .
cure rates using synthetic slings have been shown to be around 7395% . in a review of contemporary literature ,
daneshgari et al . have found complication rates ranging from 4.3% to 75.1% for retropubic midurethral slings .
they have quoted postoperative obstruction ranging from 1.9% to 19.7% from various series . in these patients ,
resolution is commonly spontaneous ; the intervening period can be managed with cic or indwelling catheter .
a recent meta - analysis showed that tvt outperformed burch colposuspension both in terms of postoperative continence rates , whereas success rate efficacies were similar after tvt and pubovaginal slings . comparing tvt to the other retropubic tension - free midurethral vaginal slings , tvt was more efficacious than both intravaginal slingplasty ( ivs ) and sparc .
some authors have even described midurethral slings as the new gold - standard for the treatment of female sui .
the reasons for popularity of these procedures are effectiveness , ease , and low rate of serious complications .
a recent meta - analysis of complications of these procedures have highlighted significantly high rates of bladder perforation after tvt .
have questioned the authenticity of reported complication rates and have described major complications and even 10 deaths as retrieved after systemic search of food and drug administration ( fda ) manufacturer and user facility device experience ( maude ) database .
rodriguez and raz have described a mid - distal urethral sling procedure in which distal urethra is defined as anything distal to the pubourethral ligament .
they have explained the mechanism of action of tvt procedure by providing support as well as contributing to normal function of distal urethral complex ( composed of the pubourethral ligaments , intrinsic sphincteric mechanism , extrinsic sphincter , and levator muscles located immediately distal to the pubourethral ligaments ) .
furthermore , they have enumerated the drawbacks of current midurethral sling systems as being blind procedures with consequently higher incidences of major complications . in their modification
, a sling is refashioned from commercially available mesh , which is cheap , does not require any special instrumentation , and is placed only within the retropubic space .
the optimal surgical approach should minimize the risk of damage to the bladder neck , vagina , and urethra .
this is achieved by developing retropubic space with blunt dissection and passing double - pronged needle under finger guidance .
the procedure should augment the urethral resistance during sudden increase in the intra - abdominal pressure without preventing normal decreases in urethral pressure during voiding . placing a sling beneath
the urethra increases the urethral compression and provides a plate for receiving the transmitted intra - abdominal pressure to the bladder neck and proximal urethra .
the safety of the procedure has also been demonstrated in their series with no incidence of major complications .
conventional guidelines recommended multichannel urodynamic studies in sui patients planned for surgery . with the advent of midurethral slings , which have shown to be effective in all types of urinary incontinence , studies have questioned the routine use of urodynamic parameters like valsalva leak point pressure in predicting outcome of sling surgery .
have proposed that standard use of urodynamic investigation in the preoperative workup of midurethral slings needs to be revisited . in our series
we had cure rate in all the 53 patients till their last follow - up .
sling procedures that are successful at 6 months are likely to remain successful for many years . in our series , all the patients had a follow - up of more than 12 months and all these patients were doing well till their last follow - up . in a comprehensive meta - analysis of complications of midurethral slings , novara et al .
have found the incidences of various complications  bladder / vaginal perforation 2.919.31% ; hematoma 1.453.9% , uti 3.77.5% , and cic in 77.5% of cases in various rcts and non - randomized studies .
rodriguez et al . have described pelvic hematoma ( not requiring treatment ) in 0.33% and suprapubic pain in 0.66% of cases .
three of their patients required cic for maximum of 3 months after which they were all spontaneously voiding . in our series , four ( 7.5% )
patients required cic after failed voiding trial , which was discontinued after a period of 38 weeks .
we attribute this to be the procedure - related local tissue edema / pain , which gradually subsided .
other minor complications in our series were hematoma ( not requiring treatment ) in 1.8% , uti in 3.7% , low back pain in 3.7% , and dyspareunia in 9.4% of cases .
major concerns about the erosion of the sling into the urinary tract have been diminished as a result of meticulous detail in placing the mesh through a small incision and tying the mesh loosely so as to avoid excessive compression and ischemia .
we did not encounter any incidence of mesh erosion into the urethra in our series of patients .
we faced none of the major injuries like vascular injury , bowel injury , necrotizing fasciitis , sepsis , or death , a fact emphasized by the shlomo raz group .
one standard - sized polypropylene mesh costs around inr 1800 and polypropylene - polyglactin ( vipro ) mesh costs around inr 2300 .
this is economically friendlier as compared to custom - made mesh systems commercially available , ranging from inr 18,000 to 25,000 , especially in developing country like india . the limitations of this study are lack of objective analysis and quantification of sui .
outcomes were based on patients interview on opd basis by the operating surgeon and not by patient - driven questionnaires , possibly influencing the overall results . despite the limitations of the study
, we believe this procedure is a cost - effective alternative to other minimally invasive procedures using commercially available kits and with comparable outcomes .
polypropylene mesh as midurethral slings by modified raz technique is cost - effective , safe , and has acceptable complication rates .
although our series is a not big enough to draw any formal conclusions , but we can safely infer that the results of this procedure are comparable to other techniques used in patients with pure sui .
 objectives : we report our experience of pure stress urinary incontinence ( sui ) treated by midurethral synthetic sling placement by modified raz technique.materials and methods : fifty - three patients with pure sui operated at our institute between june 2003 and december 2008 were included in this study . 
 midurethral sling tape , fashioned from commercially available large pore synthetic mesh , was placed using the modified raz technique . 
 the technique consisted of placing the tape within retropubic space using double - pronged needle , which is passed under finger control through the fascia and retropubic space . 
 outcomes were assessed on the basis of patient 's interview in follow - up opd.results:mean age was 57.68 ( 2869 ) years . 
 forty - five ( 85% ) patients were totally dry and eight ( 15% ) socially dry at the end of the follow - up . 
 mean operative time was 46.5 + 11.3 minutes ( 3580 minutes ) . 
 none of the patients required blood transfusion or had bladder / bowel injury . 
 mean duration of hospital stay was 2.17 days ( 24 days ) . 
 mean duration of follow - up was 46.1 months ( 1278 months).conclusions : modified raz technique is safe and cost - effective for placing midurethral sling for genuine stress incontinence . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS