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Pubovaginal Sling Chapter 67. Scott Wilkinson, DO, MS. Brief Historical Note. Autologous material use for urethral suspension – old technique Muscle and fascia – Goebel 1910 Rectus fascia – Price 1933 Use for recurrent SUI – Millen 1947. Specific Indications for Fascial Slings.

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Pubovaginal sling chapter 67

Pubovaginal SlingChapter 67

Scott Wilkinson, DO, MS


Brief historical note
Brief Historical Note

  • Autologous material use for urethral suspension – old technique

  • Muscle and fascia – Goebel 1910

  • Rectus fascia – Price 1933

  • Use for recurrent SUI – Millen 1947


Specific indications for fascial slings
Specific Indications for Fascial Slings

  • Loss of Proximal Urethral Closure

    • Urethral failure and nonfunction

    • Neuropathic conditions

    • Acquired severe urethral dysfunction


Urethral failure and nonfunction
Urethral Failure and Nonfunction

  • Partial or total urethral sphincter failure

    • Congenital

    • Acquired

  • Severe, Complicated by abnormal bladder function and other conditions

  • SCI or disease, pelvic radiation, multiple prior surgeries

  • Autologous fascia – strong nonreative material for urethral closure (for lifelong CIC)


Neuropathic conditions
Neuropathic Conditions

  • Prototypical – myelodysplasia

    • Bladder decentralized , proximal urethra nonfunctional

  • Cystography – open bladder outlet

  • Stress testing – confirms low pressure leak

  • T12-L1 – intermediolateral cell columns, preganglionic

  • APR & TAH = loss of proximal urethral fxn, SUI, decent bladder – low compliance bladder

    • Must tx bladder storage prob before U resistance


Acquired severe urethral dysfunction
Acquired Severe Urethral Dysfunction

  • Ie. Repair of urethral diverticulum

    • Can result in loss of prox closure, pseudo-urethral closure, urethral-vag fistula

  • If periurethral fascia absent and/or fistula – fascia excellent to reinforce repair and tx SUI

  • Erosion of synthetic (after total removal)

    • May get fistula and loss of closure with scarring

    • Compression is now absolute

  • Pelvic fracture – standard sling to endopelvic fascia or rectus not always possible = wrap

  • Chronic cath of NGB – loss U fxn and SUI

    • Leads to vag or bladder flap, reconstruction of urethra and fascia sling


Relative indications
Relative Indications

  • Weakness of Proximal Urethral Closure

    • Less than absolute loss assoc with SUI

  • Three age groups:

    • Childbearing years – assoc with L&D

    • After L&D

    • Perimenopausal (45-65) – gradual, increased mobility

    • Later years – less mobility issues with inc ISD

  • Patients with one or more operations for SUI

    • Hypermobile, high LPP

    • Severe low LPP with ISD


  • Vaginal prolapse, esp cystocele, complicates PE

  • Grading in pelvic exam position = underestimation

  • VUDS – helps to dx when symptoms of SUI absent or minor

  • SUI alone = not indication for sling

  • Therefore , compression indicated with A fascia

    • Indefinite IC, erosion, failed

  • Slings not affected by growth (children)


Sling materials
Sling Materials

  • Autologous Tissue

  • All0grafts

  • Xenografts


Autologous tissue
Autologous Tissue

  • Rectus Fascia – SP incision

    • Adv – biocompatiblity

    • Erosion rare

    • Dis – inc op time, post op pain, SP tissue seromas

  • Fascia Lata – iliotibial tract (> trochanter to lateral femoral condyle

    • Adv – biocompatiblity

    • Dis – op time, pt reposition, post op pain

    • 67% pain 1 wk after, 7% after 1 week


Allografts
Allografts

  • Cadaveric

    • Shorter op time, less morbidity

    • Fascia lata and acellular dermis

    • Processing – solvent dehydration or lyophilization (freeze drying), gamma irradiation

  • One material not better than others

  • Fascia lata and acellular dermis – higher maximal load failure

  • Risk of dz transmission

    • HIV 1/8mill

    • Creutzfeldt-Jakob prion – 1/3.5 mill


Xenografts
Xenografts

  • Adv – off the shelf = immediate use

  • No intense immune response – processing

  • Porcine and bovine – diisocyanate

    • Loss of tensile strength (12 week – rabbit)

  • Porcine small intestine

    • Submucosa – growth factors = less host-graft immune rxn and less scarring


Evaluation of patients for slings
Evaluation of Patients for Slings

  • Physical examination

  • Tests for Bladder Function

    • The overactive bladder and overactive detrusor

    • The low-compliance bladder

  • Assessment of urethral continence function

  • Measurement of the Valsalva LPP


Physical examination
Physical Examination

  • Eval both urethra and bladder fxn

  • Find associated conditions (prolapse, diverticulum)

  • Eval for loss of urine – sitting or standing with cough or strain

  • May be difficult to discern stress from urge UI with large cystocele or urethral hypermobility

  • No absolute relationship exists btw the degree of urethral motion (Q-tip test) and the severity of SUI symptoms


Tests for bladder function
Tests for Bladder Function

The Overactive Bladder and Overactive Detrusor

  • Old detection –

    • No UDC = genuine stress incontinence

    • UDC = mixed

  • ICS now uses – overactive bladder (urgency, UUI, freq) for defining symptoms

    • CMG grossly inaccurate

    • Low % of symptoms with UDS evident UDC

  • Detrusor Instability – freq, urgency, UUI = dx by UDS (Bulmer and Abrams 2004)


  • Effect of OAB vs OAD dx may be moot when tx SUI

  • B/c tx of SUI often alleviates both UI and OAB symptoms

  • On the basis of the literature, neither overactive bladder symptoms nor objectively determined OAD dysfunction can be regarded as a risk factor for failure of operative therapy with any variety of sling procedures in patients with clearly defined SUI

    • Fascia, TOT, TVT, Burch

    • Gyn = UDS unnecessary


Low-Compliance Bladder

  • Gradually gains pressure with volume

  • Therefore D pressure approaches and equals U resistance

    • Tx only U resistance = worsens situation

    • Ie – irradiation, NGB, chronic foley, bladder decentralization syndromes (rad pelvic extirpative surgery)

  • CMG can identify its presence

  • If + then must be tx before treating urethral dysfunction


Assessment of urethral continence function
Assessment of Urethral Continence Function

  • How best to determine SUI and ISD = ?

    • Gyn – urethral pressure profilometry (MUCP) - ISD

    • Uro – LPP (VLPP)

  • To date – no established standard method

  • VLPP does correlate with VUDS findings

  • Patients with a low-pressure urethra did not have a higher failure rate than did those without the problem (Maher et al, 1999; Sand et al, 2000)


Measurements of the valsalva leak point pressure
Measurements of the Valsalva Leak Point Pressure

  • Measurement of the abdominal pressure required to produce leakage from an incompetent urethra has been used to characterize the degree of urethral dysfunction leading to SUI

    • <60, 60 – 100, > 100 (traditionally)

  • However, Vaginal prolapse can also make LPP inaccurate, either b/c the prolapse supports the urethra during stress or dissipates the pressure protecting the urethra

    • Thus need other information to characterize dysfunction

  • LPP vary with subject position, catheter size, bladder volume, and subjective effort


  • Additional Help:

  • Total vesical pressure identifies abnormal compliance

  • Ghoniem and coworkers, 1994 – reduce cystocele prior to testing for LPP

    • Useful when urethral failure is not so obvious and a compressive operative procedure is more beneficial


Operative procedure
Operative Procedure

Preliminary steps

  • General or regional anesthesia

  • Abx

  • Modified dorsal lithotomy with stirrups

  • 18 fr foley – Kelley clamp – slight fill for hematuria check after passage of sling sutures


Abdominal Approach and Sling Harvest

  • Rectus fascia

  • 6-8cm transverse incision 3-4cm sup to pubis

  • Leaves of fascia lifted and mobilized

  • Usually lower fascia leaf

  • Scarred and thickened fascia can be used

  • Fascia width – 1-1.5 cm with tapered ends (0.5-1cm)

  • 6-8 cm long

  • Sutures placed perpendicular to sling fibers

  • Suture ends tied and left long then placed in saline

  • Absorbable 0 vicryl (play no role after immediate postop period)


Development of Retropubic Tunnels

  • At rectus insertion to pubis, muscle swept medial

  • Triangular space identified

  • Transversalis fascia bluntly pierced = retropubic space (? Metz)

  • Finger passed and bladder swept medially until endopelvic fascia

  • Moist gauze pack


Vaginal Approach

  • Elevate legs

  • Weighted spec

  • Inverted U-shaped incision in ant vag wall

  • Vag mucosa dissected from periurethral fascia

  • Metz medial to ischiopubic ramus and pierce endopelvic fascia in superolateral direction

  • Careful – Any intervening tissue above the level of the EPF is often the bladder fixed to the pubis


Sling Placement and Fixation

  • McGuire suture guide (ligature carrier) placed from above

  • Sling sutures loaded and passed

  • Bladder drained, check for hematuria

  • If + then cystoscopy and keep passer in place

  • Injuries usually at dome or 11 / 1 o’clock positions

  • Small injuries, remove passer and place again; large injuries = repair before continue

  • Sling then passed

  • Sutured to periurethral fascia 3-0 vicryl

  • Sling located at level of bladder neck and prox urethra

  • Vag mucosa closed with running 3-0 chromic or similar


Determination of Sling Tension

  • Sling sutures passed through inferior leaf of rectus fascia, rectus then closed with running 0 vicryl

  • Sutures tied down with least amount of tension to prevent urethral motion

  • Weakness – degree of tension varies for continence

    • U hypermobile with VLPP>90 = need support = loose

    • HG prolapse with occult SUI = no tension

    • ISD with scarring = tension

    • Poor U fxn (VLPP<60) with mobility = compressive sling


Wound Closure

  • Post op analgesia – 0.25% bupivicaine

  • Scarpa – approximated

  • Skin – subcuticular

  • Urethral catheter and vag packing (betadine)


Modifications of the standard sling
Modifications of the Standard Sling

Crossover Variety

  • U fxn is poor (VLPP<60) and min mobility = need compressive

  • Myelodysplasia or failed prior procedures

  • Cross sutures in retropubic space before tied


Deliberate Closure of the Urethra in Combination with Other Reconstructive Procedures

  • Augmentation cystoplasty

  • Neourethra construction

  • Idea – continence and cath through accessible abd stoma

  • Tied with foley out


  • Post operative care
    Post-Operative Care Reconstructive Procedures

    • Vaginal packing and foley out POD 1

      • If cystotomy – 7 days with cystogram

    • DVT proph – off POD 1

    • Pulm toilet

    • Discharge POD1 or 2 with instructions of avoid strenuous activity 5-6 wks, sex in 3-4 wks

    • F/u in 3 wks

    • Narc’s & Toradol

    • All taught CIC and continued till PVR < 100ml

      • Mean 8 days, 2% beyond 3 months

      • If unfit – foley or SPT


    Complications and problems
    Complications and Problems Reconstructive Procedures

    Retention

    • Pts with UR, without UU, who have some urethral mobility – resume low-pressure voiding in 30-40 days

      • If urgency and UUI, no volitional voiding, reeval freq

    • If the urethra appears hypersuspended, or higher than it was placed, probably best to take sling down

    • Early identification and take down may prevent long term probs (UUI)

    • If retention 5-6 wks, any sling should be taken down


    Methods of Sling Release Reconstructive Procedures

    • Within 6 wks – cut sling under urethra

    • If the urethra is hypersuspended, complete removal of the sling under the urethra and take down of the lateral sling attachments at the EPF are usually required


    Erosion Reconstructive Procedures

    • Relative rare (autologous fascia)

    • Usually assoc with traumatic cath (coude)

    • If with autologous fascia – 10 day foley

    • Blaivas and Sandu, 2004 – synthetic (remove sling, multilayer closure, Martius flap), autograft or allograft (incised and closed)

      • Results better in non-synthetic group


    Pain Syndromes Reconstructive Procedures

    • Just above abd wound when upright

    • Resolves when suture dissolves

    • Relief – supine with knees bent upward

      Sling Failure

    • Within days is rare

    • Late is also rare

    • Often related to vag prolapse – breaks lat fixation points = recurrent SUI

      • If cystocele repair loosens sling = redo sling


    Outcome studies
    Outcome Studies Reconstructive Procedures

    • Difficult to compare because of vast variations in research criteria

    • Patient selection – hx, PE, pad use, UDS, QOL questionnaires, degree of symptoms, geographic and racial distributions, bias by excluding subsets (obese, prolapse, prev UI surgeries), incomplete f/u

    • Definition of study endpoints – “cure rate” (patient vs physician scoring)


    Outcomes literature review
    Outcomes – Literature Review Reconstructive Procedures

    • 1997 Female Stress Urinary Incontinence meta-analysis = PV slings had 83% cure rate at 48 months

    • Autologous Rectus Fascia

      • 67-97%

      • 88% indicated improved QOL, 82% would do again

    • Autologous Fascia Lata

      • 85% cured of symptoms, 83% would do again

      • 98% cured based on PE and UDS

      • 87% no pads


    Cadaveric Fascia Lata Reconstructive Procedures

    • Outcomes mixed

    • Cure ranged 33-93%

    • Although 80% of patients reported significant improvement of symptoms at 12 mo, only 33% had complete resolution of urine leakage

    • No clinical data to suggest that the method of tissue prep (freeze vs solvent dehydration) influences the cure rate


    Cadaveric Dermis Reconstructive Procedures

    • Little data

    • At mean follow up of 18 months, 57% and 55% of patients with type II and type III UI were completely dry

      Xenograft

    • Porcine subintestinal mucosa – median f/u of 2.3 yrs, 94% cured

    • Porcine dermal – 89% cured at 12 mo f/u


    Slings combined with reconstructive procedures
    Slings Combined with Reconstructive Procedures Reconstructive Procedures

    Slings and Pelvic Organ Prolapse

    • Bai and coworkers, 2002; inverse relationship btw degree of prolapse and risk of SUI

    • However, prolapse can mask = UDS (secondary signs – open bladder neck, filling of prox urethra on valsalva, severe U hypermobility)

      • 60% with cystocele but no symptoms of SUI and UDS evidence of leakage

    • Shah – pelvic reconstruct with mesh (66% SUI, 79% AP, 45% PP) 79% no pads and 7% recurrent prolapse

    • Kobashi – CFL with ant repair = recurrent 13%, de novo 10%, SUI 18%

    • No data to suggest sling type influenced outcome


    Slings and Reconstruction of the Eroded Urethra Reconstructive Procedures

    • Blaivas and Sandhu, 2004 – postop incont 44-83%, with anti-incont procedure at same time UI 13%

    • Autologous rectus with Martius flap – 42 of 49 successful


    Slings and Urethral Diverticula Reconstructive Procedures

    • Swierzewski and McGuire, 1993 – tic > 4 cm and horseshoe-shaped at greater risk of complication of SUI after repair

    • Studies report postop SUI as high as 25%

    • Using Autologous PV sling at time of urethral diverticulectomy – approach 90% cure rate (no SUI)


    Slings Associated with Bladder Reconstruction Reconstructive Procedures

    • Little info available

    • Quek and coworkers, 2004 – pts tx with orthotopic ileal neobladder 4% approx. needed tx of postop SUI

    • Watanabe and colleages, 1996 – 18 women with indwelling cath, tx with PV slings and ileovesicostomy or bladder aug – efficacy not quantified but established “perineal dryness” in 13 pts. Most had improvement in body image or sexual quality of life after indwelling cath removal.


    Questions

    QUESTIONS Reconstructive Procedures


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