SCOTT WILKINSON, DO, MS

Pubovaginal SlingChapter 67

Brief Historical Note

Autologous material use for urethral suspension – old technique

Muscle and fascia – Goebel 1910Rectus fascia – Price 1933Use for recurrent SUI – Millen 1947

Specific Indications for Fascial Slings

Loss of Proximal Urethral Closure

Urethral failure and nonfunction

Neuropathic conditions

Acquired severe urethral dysfunction

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

Prototypical – myelodysplasia Bladder decentralized , proximal urethra

nonfunctionalCystography – open bladder outletStress testing – confirms low pressure leakT12-L1 – intermediolateral cell columns,

preganglionicAPR & TAH = loss of proximal urethral fxn,

SUI, decent bladder – low compliance bladder Must tx bladder storage prob before U resistance

Acquired Severe Urethral Dysfunction

Ie. Repair of urethral diverticulum Can result in loss of prox closure, pseudo-urethral closure,

urethral-vag fistulaIf periurethral fascia absent and/or fistula –

fascia excellent to reinforce repair and tx SUIErosion 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

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 PEGrading in pelvic exam position = underestimationVUDS – helps to dx when symptoms of SUI absent

or minor

SUI alone = not indication for slingTherefore , compression indicated with A fascia

Indefinite IC, erosion, failed Slings not affected by growth (children)

Sling Materials

Autologous Tissue

All0grafts

Xenografts

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

Cadaveric Shorter op time, less morbidity Fascia lata and acellular dermis Processing – solvent dehydration or lyophilization

(freeze drying), gamma irradiationOne material not better than othersFascia lata and acellular dermis – higher

maximal load failureRisk of dz transmission

HIV 1/8mill Creutzfeldt-Jakob prion – 1/3.5 mill

Xenografts

Adv – off the shelf = immediate useNo intense immune response – processingPorcine 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

Physical examinationTests for Bladder Function

The overactive bladder and overactive detrusor The low-compliance bladder

Assessment of urethral continence functionMeasurement of the Valsalva LPP

Physical Examination

Eval both urethra and bladder fxnFind associated conditions (prolapse,

diverticulum)Eval for loss of urine – sitting or standing with

cough or strainMay be difficult to discern stress from urge UI

with large cystocele or urethral hypermobilityNo absolute relationship exists btw the

degree of urethral motion (Q-tip test) and the severity of SUI symptoms

Tests for Bladder Function

The Overactive Bladder and Overactive DetrusorOld 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 SUIB/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 BladderGradually 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 presenceIf + then must be tx before treating urethral

dysfunction

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 methodVLPP 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

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

Preliminary stepsGeneral or regional anesthesiaAbxModified dorsal lithotomy with stirrups18 fr foley – Kelley clamp – slight fill for

hematuria check after passage of sling sutures

Abdominal Approach and Sling HarvestRectus fascia6-8cm transverse incision 3-4cm sup to pubisLeaves of fascia lifted and mobilizedUsually lower fascia leafScarred and thickened fascia can be usedFascia width – 1-1.5 cm with tapered ends (0.5-1cm)6-8 cm longSutures placed perpendicular to sling fibersSuture ends tied and left long then placed in salineAbsorbable 0 vicryl (play no role after immediate

postop period)

Development of Retropubic TunnelsAt rectus insertion to pubis, muscle swept

medialTriangular space identifiedTransversalis fascia bluntly pierced =

retropubic space (? Metz)Finger passed and bladder swept medially

until endopelvic fasciaMoist gauze pack

Vaginal ApproachElevate legsWeighted specInverted U-shaped incision in ant vag wallVag mucosa dissected from periurethral fasciaMetz medial to ischiopubic ramus and pierce

endopelvic fascia in superolateral directionCareful – Any intervening tissue above the level

of the EPF is often the bladder fixed to the pubis

Sling Placement and FixationMcGuire suture guide (ligature carrier) placed from

aboveSling sutures loaded and passedBladder drained, check for hematuriaIf + then cystoscopy and keep passer in placeInjuries usually at dome or 11 / 1 o’clock positionsSmall injuries, remove passer and place again; large

injuries = repair before continueSling then passedSutured to periurethral fascia 3-0 vicrylSling located at level of bladder neck and prox urethraVag mucosa closed with running 3-0 chromic or similar

Determination of Sling TensionSling sutures passed through inferior leaf of rectus

fascia, rectus then closed with running 0 vicrylSutures tied down with least amount of tension to

prevent urethral motionWeakness – 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 ClosurePost op analgesia – 0.25% bupivicaineScarpa – approximatedSkin – subcuticularUrethral catheter and vag packing (betadine)

Modifications of the Standard Sling

Crossover VarietyU fxn is poor (VLPP<60) and min mobility =

need compressiveMyelodysplasia or failed prior proceduresCross 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

Vaginal packing and foley out POD 1 If cystotomy – 7 days with cystogram

DVT proph – off POD 1Pulm toiletDischarge POD1 or 2 with instructions of avoid

strenuous activity 5-6 wks, sex in 3-4 wksF/u in 3 wksNarc’s & ToradolAll taught CIC and continued till PVR < 100ml

Mean 8 days, 2% beyond 3 months If unfit – foley or SPT

Complications and Problems

RetentionPts 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 ReleaseWithin 6 wks – cut sling under urethraIf 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

ErosionRelative rare (autologous fascia)Usually assoc with traumatic cath (coude)If with autologous fascia – 10 day foleyBlaivas and Sandu, 2004 – synthetic (remove

sling, multilayer closure, Martius flap), autograft or allograft (incised and closed) Results better in non-synthetic group

Pain SyndromesJust above abd wound when uprightResolves when suture dissolvesRelief – supine with knees bent upward

Sling FailureWithin days is rareLate is also rareOften related to vag prolapse – breaks lat fixation

points = recurrent SUI If cystocele repair loosens sling = redo sling

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

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 LataOutcomes mixedCure 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 DermisLittle dataAt mean follow up of 18 months, 57% and

55% of patients with type II and type III UI were completely dry

XenograftPorcine 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 and Pelvic Organ ProlapseBai and coworkers, 2002; inverse relationship btw

degree of prolapse and risk of SUIHowever, 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 leakageShah – pelvic reconstruct with mesh (66% SUI, 79%

AP, 45% PP) 79% no pads and 7% recurrent prolapseKobashi – 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

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 DiverticulaSwierzewski 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 ReconstructionLittle info availableQuek 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