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.

The surgical technique performed  withh the patient in the lithotomy position. Under tension, two parallel incisions are made in each sulcus, from bladder neck to pubic bone. The incisions are opened out laterally with forceps or dissecting scissors to reveal the two branches of PUL. A No.5 polyester suture, penetrates the PUL, fascial tissues behind the pubic bone and the proximal part of the PCM.

How the sutures are tied is important, so as not to distort the longitudinal direction of the urethra. The sutures are inserted, one at a time, but tied at the same time after the insertion is complete, but not tied tightly. In the normal position of the structures at REST, indicates the suture should be tension‐free, just sufficient to bind the structures together, so as to prevent the extension of the PUL which causes SUI. The vaginal skin incisions are approximated with 00 Vicryl.

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.

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.

Petros P. The integral system. Cent European J Urol. 2011;64(3):110-9. doi: 10.5173/ceju.2011.03.art1. Epub 2011 Sep 6. PMID: 24578877; PMCID: PMC3921723.
Petros P, Palma P. Conceptualizing stress urinary incontinence surgery beyond midurethral slings: Very early results from simplified ligament repair without tapes. Neurourol Urodyn. 2023 Feb;42(2):383-388. doi: 10.1002/nau.25049. Epub 2022 Oct 19. PMID: 36259766; PMCID: PMC10092634.