PRELIMINARY COMMUNICATION URINARY INCONTINENCE: A CHALLENGE AND A SOLUTICb’+; III. Plication of Muscles of Deep Pe:t--iI-lea1 Pouc.bh M. ISLAM, M.D. From The Medical and Surgical Clinic, Peoria, Illinois ABSTRACT - A new operation, very simple to perform under local anesthesia., is describedfor urinary incontinence caused by operations on the prostate gland or the bladder neck; satisfact-oq results have been obtained, with no complications to date. The surgical procedure ccnsists essentially of plication of the external urethral sphincter and other muscles in the deep perineal pouch thereby in- creasing their tone, which appears to assist the smooth muscle sphincter for urinary continence. ____-- Urinary incontinence which occasionally follows surgery of the prostate gland or bladder neck is a frustration to the patient and a challenge to his physician. Various procedures, including a new operative technique, vesiconeosphincteroplasty, have been described and successfully performed, but they are either too extensive or too com- plicated. l-4 The purpose of this article is to describe a simpler procedure of plication of muscles of the deep perineal pouch performed under local anes- thesia, with satisfactory results. Surgical Technique The patient is placed in the dorsal lithotomy position. His external genitalia and perineal region are prepared and draped in the customary manner. The bladder is filled with approximately 250 cc. of water via an inlying uretheral catheter which is then removed. If severely incontinent, the patient will dribble freely; otherwise only on stress (for example, coughing or sneezing). After incontinence is confirmed, local anesthesia is ad- ministered in the perineal region around the bulbous urethra and the largest acceptable Van Buren sound is inserted all the way to the bulbous urethra. Inlying sound would make the bulbous urethra easily palpable and visible as a bulge. The membranous urethra is just above the bulbous urethra around which the operation takes place. An assistant holds the sound in place. Turo 5mm. incisions are made, one on each side and slightly posterior to the bulbous urethra (Fig. 1A). Using 0 Mercelin on a large curved atraumatic: needle, a stitch is placed by entering from one skin in- cision deeply aiming to the external urethral sphincter and coming out from the opposite incision (Fig. 1). Continuing the same suture, it is reversed entering from the second incision and coming out the first. The sound is removed from the urethra, incontinence is observed, and the suture tightened just enough to control it. If necessary, one or two more such sutures are inserted to achieve full continence. As the sutures are tied they go beneath the skin; usually, there- fore, it is not necessary to close the skin incisions. This operation can be repeated with impunity if necessary. It has been performed in 3 cases which follow. Case 1 Case Reports This patient had a transurethral resection of the bladder neck and prostate on February 6, 1973, following which he became completely and un- explainably incontinent. On May 29, this opera- tion was performed, and he has been completely continent for more than fifteen months without any dysuria, frequency, or residual urine. This is considered a very satisfactory result. UROLOGY / FEBRUARY 1975 / VOLUME V, NUMBER 2 257