Year : 2003 | Volume
: 20 | Issue : 1 | Page : 37--39
Midurethral bulbocavernous muscle sling for genuine stress incontinence - an alternative to synthetic slings?
N Rajamaheswari, Karthik Gunasekaran
Department of Urology/Urogynaecology, Govt. Kasturba Gandhi Hospital, Madras Medical College, Chennai, India
Urogynaecology Research Centre No. 18/86. C.P. Ramaswamy Road, Abiramapuram, Chennai - 600 018
Objectives: To assess the efficacy of midurethral bulbocavernous muscle sling (BCMS) in the treatment of genuine stress incontinence in women.
Methods: A prospective study comprising 25 women was carried out at the Govt. Kasturba Gandhi Hospital, Chennai. The women whose age was in the range of 30-65 years had GSI as proved by urodynamic evaluation. The bulbocavernous muscle sling implies the approximation of both the bulbocavernous muscles around the midurethra with prolene sutures. The procedure is done under regional anaesthesia.
Results: These patients were followed up for 2 years. Eighteen (72%) women reported complete cure, 4 (16%) were significantly improved and in 3 the surgery failed.
Conclusions: The bulbocavernous muscle sling is a promising new procedure for genuine stress incontinence. There is no need for intraoperative cystoscopy and the chances of bladder injury are nonexistent. Larger sample with long term follow up and randomized controlled trials comparing it with the other surgical techniques may prove its true efficacy.
|How to cite this article:|
Rajamaheswari N, Gunasekaran K. Midurethral bulbocavernous muscle sling for genuine stress incontinence - an alternative to synthetic slings?.Indian J Urol 2003;20:37-39
|How to cite this URL:|
Rajamaheswari N, Gunasekaran K. Midurethral bulbocavernous muscle sling for genuine stress incontinence - an alternative to synthetic slings?. Indian J Urol [serial online] 2003 [cited 2021 Jun 16 ];20:37-39
Available from: https://www.indianjurol.com/text.asp?2003/20/1/37/37122
Sling procedures with many different modifications have been used for more than 100 years in the treatment of female incontinence. Slings have been autogenous as well as man made. Goebell  and Stockell  utilized the pyramidalis muscle. Frangheim added strips of rectus fascia attached to pyramidalis. Giordano described the transposition of the gracilis wrapped around the urethra. Martius developed the use of the bulbocavernous fat pad to provide bulk around the urethra. The synthetic materials that have been used for suburethral slings include Nylon, Perlon, PTFE, Mersilene, Silastic and Polyglactin. In tension-free vaginal tape  (TVT) knitted prolene is used and it differs from conventional sling procedures in that, the sling is kept at the midurethral level. Similarly the bulbocavernous muscle sling is also placed at the level of the midurethra.
Patients and Methods
This prospective study was conducted at Govt. Kasturba Gandhi Hospital, Chennai from January 2000 to June 2000. Twenty-five multiparous women in the age range of 3065 years with GSI were selected and thorough clinical evaluation including gynaecological, urological and neurological assessment were performed. All women were subjected to urodynamic evaluation comprising of cystometrogram and pressure flow studies. Voiding disorder and detrusor overactivity in these women were ruled out. None of these women had prior surgery for GSI. For patient details and overview of the operative procedure refer to [Table 1]. Under regional anaesthesia the patient was placed in a lithotomy position and a vertical 1 cm sagittal vaginal incision was proximally made, 1 cm from the external urethral meatus. Minimal paraurethral dissection was done. A labial incision was made and the bulbocavernous muscle was dissected out on both sides.
Bulbocavernous muscle is represented as fibrofatty tissue in women. It covers the superficial parts of the vestibular bulbs and greater vestibular glands and passes forwards on each side of the vagina to attach to the corpora cavernosa clitoridis. It is attached posterioly to the perineal body, where its fibres decussate with those of sphincter ani externus and the contralateral transverse perineii. Blood supply (from the perineal branch of internal pudendal artery) was preserved by retaining its proximal attachment. The distal attachment of the muscle was freed. The bulbocavernous muscles were brought into the midurethral region through a subvaginal tunnel. Both the muscles were approximated in the midline using 1 `0' prolene sutures. The bladder was filled with 250 ml of saline. The patient was then asked to cough or if unable to do so, suprapubic pressure was applied. Tension was then adjusted. The vaginal and labial wounds were then closed with catgut. The urethral Foley catheter was retained for 6 hours. All patients went home on the 2nd or 3rd postoperative day. They were reviewed thereafter at monthly intervals for 3 months and then once in every 4 months for 2 years.
These patients were followed up for 2 years. All patients were evaluated with history, clinical examination and urodynamic studies. Eighteen (72%) women reported complete cure. Four (16%) patients were significantly improved which meant that there was an occasional leakage with a very strong cough with full bladder. In 3 patients the surgery failed. Two patients had granulation tissue at the midline which was treated by fulgration. Two patients had vaginal sloughing which healed in a month. The need for postoperative analgesia was minimal.
The bulbocavernous muscle sling is a minimally invasive simple and short procedure. It is an absolute vaginal procedure negating all the perils of an abdominal surgery. The bulbocavernous muscle sling differs from the traditional sling operation in that it is placed at the level of the midurethra. The bulbocavernous muscle sling offers aback board against which the midurethra (zone of maximum pressure transmission) gets compressed during exertion. As dissection around the bladder neck and proximal urethra are minimal, chances of denervation are reduced. Please refer to [Table 2] for the advantages of this procedure.
The bulbocavernous muscle sling is a simple vaginal procedure that has all the advantages of a minimally invasive synthetic sling like the TVT. However, bulbocavernous muscle sling lacks the complications and expenses of TVT. The success of any incontinence surgery in only established over time. The bulbocavernous muscle sling is still in its infancy. The long term results in a larger group will tell us whether it can replace the synthetic slings.
|1||Goebell RG. Zur operativen behandlung der incontinent der mannlichen harnrohre. Gynakol Urol 1910; 2: 187.|
|2||Stockel W. Uber di verwendung der muscli pyramidales bei der operativen behandlug der incotinentia urinae. Gynakol Urol 1917; 41: 11.|
|3||Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia in the treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunction 1996; 7:81-5.|