Further developments of pubourethral ligament surgery for stress urinary incontinence.

Midurethral slings (MUS) have revolutionized the treatment of stress urinary incontinence (SUI). MUS operations work by creating a collagenous pubourethral ligament (PUL). Since 1996, more than 10 million operations have been performed worldwide. Early complications with the MUS included bowel perforations, massive retropubic hemorrhages, nerve injuries, even death. Though the invention of the transobturator tape (TOT) operation, and later, minislings, has eliminated many such complications, the most frequent complication, post-operative urinary retention, remains. MUS operations are unavailable in many countries because of expense. Low-cost surgical options discussed include the tension-free artisan minisling which uses a 10 cm × 1 cm tape inserted as a "U" below the urethra; 91% cure was achieved at 5.7 years in a study of 90 women, though it was accompanied by a 4.2% erosion rate. The more recent urethral ligament plication (ULP) is based on transperineal ultrasound studies which showed that the main cause of the SUI was elongation of weak PULs. This allowed the posterior pelvic muscles to open out the posterior urethral wall to cause SUI. Basic science collagen studies indicated that suturing PULs with No. 2 wide-bore polyester sutures would provide sufficient collagen to repair weakened PULs. Cure of SUI, when it occurred, was immediate. Reference to the original experimental animal studies indicated that collagen 1, the key structural support of PUL, had formed by 3 months. This is an optimistic sign for longer term cure, substantiated by very little deterioration after 3 months over a 12-month period in the first surgical trial (unpublished data). In conclusion, the ULP operation can be performed under local anesthesia/sedation. If it fulfils its promise for longer-term cure, SUI cure will be available for hundreds of millions of women in underdeveloped countries for a few dollars per case.