Pubovaginal Sling Chapter 67

1. Pubovaginal SlingChapter 67 Scott Wilkinson, DO, MS

2. 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

3. Specific Indications for Fascial Slings • Loss of Proximal Urethral Closure • Urethral failure and nonfunction • Neuropathic conditions • Acquired severe urethral dysfunction

4. 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)

5. 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

6. 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

7. 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

8. 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)

9. Sling Materials • Autologous Tissue • All0grafts • Xenografts

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. Wound Closure • Post op analgesia – 0.25% bupivicaine • Scarpa – approximated • Skin – subcuticular • Urethral catheter and vag packing (betadine)

28. 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

29. 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

30. Post-Operative Care • 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

31. Complications and Problems 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

32. Methods of Sling Release • 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

33. Erosion • 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

34. Pain Syndromes • 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

35. Outcome Studies • 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)

36. Outcomes – Literature Review • 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

37. Cadaveric Fascia Lata • 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

38. Cadaveric Dermis • 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

39. Slings Combined with 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

40. Slings and Reconstruction of the Eroded Urethra • 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

41. Slings and Urethral Diverticula • 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)

42. Slings Associated with Bladder Reconstruction • 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.

43. QUESTIONS