Conceptualizing stress urinary incontinence surgery beyond midurethral slings: Very early results from simplified ligament repair without tapes

AIMS AND METHODS: To find a simpler cure for stress urinary incontinence (SUI) without tapes. Proposed is a paraurethral operation with incisions in both sulci to plicate pubourethral ligaments (PUL) with thick polyester sutures. RESULTS: VIDEO and ultrasound experiments showed the main cause of SUI was weak PULs extending on effort, allowing the posterior pelvic muscles to open out posterior urethral wall, so urine was lost on effort. Midurethral sling (MUS) tapes prevent PUL extension and SUI. The research question: “Would PUL plication by 0.5 or 0.25 mm polyester tapes create sufficient new collagen to cure SUI in the longer term?” Instron‐testing of collagen from a rejected polyester aortic graft indicated sufficient potential collagen strength. Five surgeons unrelated to the authors who tested the new operation, reported negative cough tests on 30/31 women before patient discharge; these data were encouraging, but not conclusive. CONCLUSIONS: PUL ligament repair by large polyester sutures, like the MUS, appears to prevent PUL elongation and cure SUI in the very short term, thereby validating the predictions of the Integral Theory as regards the role of ligaments in continence. If successful long term, this operation could avoid many problems associated with MUS operations. 1. Simplicity: less surgical skill is required; the local anesthetic methodology makes the operation widely scalable especially in poor countries with few health facilities. 2. Built‐in safety: there is no tape to compress urethra, no applicators to damage bladder, nerves, blood vessels, bowel. 3. Cost: a polyester suture.