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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
slide8

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)
slide16

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
slide17

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
slide20

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
slide22

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)
slide23

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
slide24

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
slide25

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
slide26

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
slide27

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
slide29

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
  • 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

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
slide32

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
slide33

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
slide34

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
outcome studies
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)
outcomes literature review
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
slide37

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
slide38

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
slings combined with reconstructive procedures
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
slide40

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
slide41

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)
slide42

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.