pubovaginal sling chapter 67
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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