Cadaveric versus autologous fascia lata for the pubovaginal sling: surgical outcome and patient satisfaction

PURPOSE: We report our initial experience with cadaveric fascia lata in pubovaginal sling procedures. MATERIALS AND METHODS: We compared 121 consecutive women who underwent a sling procedure using cadaveric fascia lata from February 1997 through June 1999 (group 1) with 46 consecutive women who underwent a sling procedure using autologous fascia lata from May 1994 through July 1997 (group 2). RESULTS: Mean followup was longer in group 2 (44 versus 12 months). A total of 104 of the 121 group 1 patients (86%) responded to the questionnaire, of whom 85% were cured of stress incontinence, 83% reported overall improvement in urinary control and 74% had no or minimal leakage not requiring pads. Median catheterization time was 9 days (range 4 to 120). Overall 89% of the women were satisfied with the results and 83% would recommend this surgery. A total of 30 of the 46 group 2 patients (65%) responded to the questionnaire, of whom 90% were cured of stress incontinence, 90% reported overall improvement in urinary control and 73% had no or minimal leakage not requiring pads. Median catheterization time was 14 days (range 6 to 180). Overall 90% of the women were satisfied with the results and 83% would recommend this surgery. CONCLUSIONS: Cadaveric fascia lata pubovaginal slings appear to be safe. Early experience suggests that cadaveric fascia lata may be considered an alternative to autologous fascia. Cadaveric and autologous fascia lata appear to have a high success rate.     

Pubovaginal sling using cadaveric fascia and bone anchors: disappointing early results

PURPOSE: Pubovaginal sling procedures offer highly effective treatment for patients with female stress urinary incontinence. A recent modification of this technique is the use of cadaveric fascia lata as a sling material supported with titanium anchors placed bilaterally in the pubic bone. We reviewed our experience with this procedure and assessed our outcome. MATERIALS AND METHODS: A total of 154 consecutive patients underwent a bone anchored, cadaveric fascia pubovaginal sling procedure by a single surgeon from July 1998 to June 1999. All patients were evaluated preoperatively with a detailed history, pelvic examination and radiographic or multichannel video urodynamic studies to diagnose stress urinary incontinence. Our technique begins with the nonincision placement of titanium bone anchors transvaginally into the pubic bone bilaterally. A 2 cm. wide tunnel is created bluntly beneath the vaginal epithelium between the 2 puncture sites with a right angle clamp. A 2 x 7 cm. strip of cadaveric fascia is then passed through the tunnel, into the retropubic space and secured to 2-0 polypropylene sutures attached to the anchors. After securing the sling, the transvaginal puncture sites are closed with 2-0 polyglactin sutures. Patients were seen postoperatively at 6 weeks, and 3 and 6-month followup. Patient age averaged 60 years (range 38 to 85), with an overall average length of followup from surgery of 10.6 months (range 6 to 16). All patients were mailed a self-administered questionnaire and participated in a telephone interview with an office nurse to retrospectively assess outcome and evaluate for recurrent stress urinary incontinence. Recurrent stress urinary incontinence was graded as 0-none, 1-rare, 2-moderate and 3-severe. Repeat pubovaginal sling procedure that was performed in patients with grades 2 to 3 stress urinary incontinence was considered a failure for the purpose of our study. RESULTS: Of all 154 patients 58 (37.6%) had recurrent moderate to severe (grades 2 to 3) stress urinary incontinence at followup. A total of 26 patients underwent a second pubovaginal sling procedure for a reoperation rate of 16.9%. Intraoperative findings at reoperation revealed the titanium anchors to be in position, the polypropylene sutures to be intact, and retropubic fibrosis and scarring of the urethropelvic ligament suggesting appropriate retropubic placement of the sling in all cases. Uniformly all allogenic cadaveric fascia used for sling material appeared to be fragmented, attenuated or simply absent. Average time to reoperation was 9 months (range 3 to 15). CONCLUSIONS: Early results using a bone anchored cadaveric fascia pubovaginal sling procedure were discouraging. Based on findings at reoperation, we attribute this result to the failure of our sling material and have abandoned the use of cadaveric fascia allografts in all pubovaginal slings at our institution.     

Efficacy and morbidity of autologous fascia lata sling cystourethropexy

PURPOSE: Sling cystourethropexy for intrinsic sphincter deficiency has more recently been accepted as effective surgical treatment for all types of stress urinary incontinence. We report our experience using autologous fascia lata for sling cystourethropexy, regarding treatment efficacy, harvest site morbidity and patient satisfaction. MATERIALS AND METHODS: A retrospective data base review identified all women who underwent sling cystourethropexy using autologous fascia lata for stress urinary incontinence. A followup survey study using questionnaires (Black and Urogenic Distress Inventory-6) combined with questions regarding pad use, satisfaction and leg morbidity was done. RESULTS: A total of 100 women who could be contacted and who had undergone autologous fascia lata sling cystourethropexy performed by a single surgeon between 1993 and 2002 were surveyed. Mean patient followup was 4.4 years (range 0.8 to 9.3). Of the women 85% stated that they were dry or improved and 93% were pain-free at the harvest site by 7 days. There was no harvest site infection and no lower extremity thrombotic complication. Of the patients 83% indicated that the procedure had a positive effect on their life with only 4% stating that it had a negative effect, while 77% were satisfied with the procedure, 82% would recommend the procedure to a friend with incontinence and 83% would undergo the procedure if making the decision again. CONCLUSIONS: Autologous fascia lata sling cystourethropexy is associated with high patient satisfaction and treatment efficacy comparable to that of other sling cystourethropexy materials, as determined by questionnaire. Harvest site morbidity is low. Sling cystourethropexy using autologous fascia lata should be considered as a primary surgical approach in women with stress urinary incontinence.     

Poor Surgical Outcomes after Fascia Lata Allograft Slings

The objective of this retrospective case control study was to determine whether our poor surgical outcomes were associated with the material used to construct our pubovaginal slings. Autologous rectus fascia was used in 33 patients and cadaveric fascia lata was used in 12 patients who underwent pubovaginal sling placement for intrinsic urethral sphincter deficiency (ISD). Treatment was successful in 78.8% and 33.3% of patients who underwent rectus fascia and fascia lata allograft slings, respectively (P=0.006). Based on regression analysis, the sling material was found to be strongly associated with surgical outcome after controlling for all confounding variables (β coefficient = 1204.6, P<0.00005). We conclude that fascia lata allografts are a poor choice for pubovaginal slings.     

Comparison of video urodynamic results after the pubovaginal sling procedure using rectus fascia and polypropylene mesh for stress urinary incontinence

PURPOSE: Video urodynamic changes were compared after the pubovaginal sling procedure using rectus fascia or polypropylene mesh in women with stress urinary incontinence. MATERIALS AND METHODS: A total of 50 women with various types of stress urinary incontinence were treated with the pubovaginal sling procedure using randomly abdominal rectus fascia in 24 or polypropylene mesh in 26. The sling was placed at the level of the bladder neck and tied with sufficient tension to prevent urinary leakage without obstructing the bladder outlet. Video urodynamics were performed preoperatively, and 7 to 14 days and 3 to 6 months postoperatively in all cases. Surgical results and urodynamic changes after the pubovaginal sling procedure were compared in the 2 groups. Long-term results were evaluated at a mean followup of 2 years. RESULTS: Complete continence was achieved in 23 patients (95.8%) in the rectus fascia group and 26 (100%) in the polypropylene mesh group, including 1 initial failure with reoperation, at a median followup of 24 and 23 months, respectively. The subjective success rate was 91.6% for rectus fascia and 92.3% for polypropylene mesh. The main cause of dissatisfaction was persistent urge incontinence and dysuria in 2 cases each. In each group video urodynamics revealed a mild but nonsignificant decrease in maximum urinary flow and a significant increase in bladder neck opening time at 7 to 14 days versus baseline. However, these parameters returned to baseline within 3 to 6 months postoperatively. Voiding pressure, cystometric capacity and post-void residual urine also showed no significant change in either group after the pubovaginal sling procedure. Patients treated with a polypropylene mesh sling had a shorter operative time and hospital stay, a higher spontaneous voiding rate after catheter removal and a lower incidence of wound pain after surgery. One patient treated with polypropylene mesh had sling margin extrusion. The incidence of new onset detrusor instability and persistent dysuria was similar in the 2 groups. Transrectal sonography of the sling showed that it was located beneath the bladder neck and proximal urethra in all patients in each group. CONCLUSIONS: The results of this study show that the pubovaginal sling procedure using rectus fascia or polypropylene mesh as the sling material had similar effectiveness for treating female stress incontinence but the polypropylene group had more rapid recovery. Postoperatively video urodynamics demonstrated that the pubovaginal sling using either sling material did not cause bladder outlet obstruction with proper surgical technique.     

Suprapubic sling adjustment: minimally invasive method of curing recurrent stress incontinence after sling surgery

PURPOSE: Recurrent stress urinary incontinence after sling surgery is a complex problem. A minimally invasive method of correcting recurrent stress urinary incontinence after pubovaginal sling surgery is described. MATERIALS AND METHODS: We performed suprapubic sling adjustment in 10 women with recurrent stress urinary incontinence after sling surgery. Of these 10 women 4 had received antibacterial polytetrafluoroethylene patch sling, 3 an autologous dermis patch sling and 3 an autologous rectus fascia patch sling but stress incontinence recurred. To correct recurrent incontinence, a pubovaginal sling was revised by adjusting the sling tension suprapubically with the aid of a cotton swab test and bladder leak test. RESULTS: Mean followup was 13 months (range 8 to 28). Of the 10 women 9 became completely dry and 1 was greatly improved. One patient who had persistent stress incontinence generated an abdominal leak point pressure of 189 cm. H(2)O compared to a preoperative pressure of 120 cm. H(2)O. The incidence of de novo urge incontinence was 2% (2 of 10 cases). Mean resting cotton swab angle was (+) 20 and (+) 5 degrees, and mean Valsalva cotton swab angle was (+) 40 and (+) 5 preoperatively and postoperatively. Mean pad use decreased from 3 pads to less than 1 pad a day. Mean self-reported satisfaction score was 9 (range 8 to 10) on a visual analog scale. CONCLUSIONS: Pubovaginal slings may be revised safely with excellent results. Adjusting the sling tension suprapubically is a minimally invasive technique. Suprapubic sling adjustment may be performed as an intermediary step before resorting to a complete sling takedown/revision.     

High failure rate using allograft fascia lata in pubovaginal sling surgery for female stress urinary incontinence

Objectives. To present our unfavorable experiences using allograft fascia lata. Allograft fascia lata is an attractive sling material providing less pain, a shorter operation time, and a reported effectiveness equal to autologous fascia.Methods. A total of 18 women (mean age 51.7 years, range 37 to 76) underwent pubovaginal sling surgery for stress urinary incontinence between March 1999 and July 1999 and were enrolled in this study. Solvent dehydrated gamma-irradiated human fascia lata with a size of 7 × 2 cm was used as the sling. The results were collected with a questionnaire survey.Results. All patients were followed up for a mean of 9.2 months (range 6.9 to 11.6). Thirteen patients considered the surgery successful or to have provided improvement, with a mean of 82.5% (range 50% to 100%) subjective improvement. Five patients (27.8%) had significant failure with full recurrence of incontinence within 3 to 6 months.Conclusions. Solvent dehydrated gamma-irradiated allograft fascia is not reliable in pubovaginal sling surgery. The high failure rates within a short period prohibit its use in the operative management of stress urinary incontinence.     

Comparison of solvent-dehydrated allograft dermis and autograft rectus fascia for pubovaginal sling: questionnaire-based analysis

Objectives To evaluate the efficacy of pubovaginal sling using human cadaveric dermis processed by solvent dehydration and compare results to those of another group in which autograft rectus fascia was used. Material and methods The efficacy of autologous rectus fascia (group 1, n = 25) or solvent-dehydrated cadaveric dermis (group 2, n = 24) for pubovaginal sling were compared in women with stress urinary incontinence (SUI). Surgical outcome, patient satisfaction and quality of life was assessed by the urogenital distress inventory (UDI-6) and the incontinence impact questionnaire (IIQ-7). Results Mean follow-up for patients in group 1 and group 2 were 18 and 13 months, respectively. Our questionnaire-based assessment revealed that SUI was either cured or improved in a total of 21 (84%) patients in group 1 and 19 (79%) patients in group 2. No statistically significant difference was found for the overall success (P < 0.05) and no major complications were encountered in both groups. Conclusions Use of allograft dermis as an alternative to autologous rectus fascia for pubovaginal sling had comparable improvement in patient satisfaction and quality of life at intermediate term.     

A Minimally Invasive Technique for Harvesting Autologous Fascia Lata for Pubo-Vaginal Sling Suspension

Objective: To access donor site morbidity associated with harvesting of autologous fascia lata for pubovaginal sling suspension in treating stress urinary incontinence. Methods: A retrospective study was performed of 25 female patients who underwent pubovaginal sling suspension for stress urinary incontinence. Autologous fascia lata strip was harvested in all patients with a minimally invasive approach using a fascial stripper. Demographic, intraoperative, and immediate postoperative data were recorded to determine the incidence of complications. Follow-up data was reviewed for documentation of long-term complications. Results: Adequate length of fascia lata was harvested in all of our patients. Ten patients required a single 2 cm incision just above lateral femoral epicondyle to harvest fascia lata. Twelve patients needed two incisions and remaining three required three incisions. There were no intraoperative complications. There was no incidence of wound related infection or hematoma in the immediate post-operative period. On follow-up no patient had bothersome problems pertaining to the site of graft harvesting. Conclusions: Harvesting fascia lata with fascial stripper is a minimally invasive which is easy to learn and provides an excellent fascial strip with minimal morbidity.     

Comparative Cost Analysis of Collagen Injection and Fascia Lata Sling Cystourethropexy for the Treatment of Type III Incontinence in Women

Purpose

We examined the cost of 2 common forms of surgical treatment of genuine stress urinary incontinence due to intrinsic sphincter deficiency, that is sling cystourethropexy and periurethral collagen injection.

Materials and Methods

Between May 1994 and July 1995, 14 women with intrinsic sphincter deficiency underwent sling cystourethropexies. A total of 14 matched patients with intrinsic sphincter deficiency underwent endoscopic collagen injection during the same period.

Results

The total cost per treatment of fascia lata sling cystourethropexy ($10,382) was 2.1 times greater than that for collagen injection ($4,996, p < 0.001). At an average followup of 14.9 months for fascia lata cystourethropexy and 21.3 months for collagen injection, 71.4% of patients in the former and 26.7% in the latter groups were completely continent (p = 0.05). One or no pads were used daily by 85 and 40% of the patients, respectively.

Conclusions

Fascia lata sling cystourethropexy may be a more cost-effective surgical treatment than periurethral endoscopic collagen injection for treating genuine stress urinary incontinence in women with intrinsic sphincter deficiency when the greater success rate of the former procedure is considered.     

Banked cadaveric fascia lata: 3-year follow-up

Autologous fascial and synthetic materials have been widely used to repair the stress form of urinary incontinence (SUI) as well as pelvic floor prolapse. The safety and long-term durability of cadaveric fascia lata in orthopedic and ophthalmologic surgery have encouraged urogynecologists to use this material for a sling material. The rationale of placement of a sling from cadaveric fascia lata is based upon decreasing the complication rates caused by autologous and synthetic materials. However, the high costs of the commercially available tissues in Brazil have limited its use in public health. In our institution we developed a cadaveric fascia lata bank, harvesting the material according to the Brazilian Transplantation Legislation and storing it at -70 degrees C. The safety of the tissue is achieved by 25-kGy irradiation. Since 1999, 30 patients have undergone surgery using material from five donors in repairs for stress urinary incontinence and pelvic floor prolapse at a mean of 34 months' follow-up (ranging from 30 to 40 months), there was no evidence of rejection. Therefore, we have shown the safety of cadaveric fascia lata harvested and treated as described above in our group of patients.     

Tissue strength analysis of autologous and cadaveric allografts for the pubovaginal sling.

The aim of this study was to compare the mechanical properties of autologous rectus fascia (ARF), two groups of commercially available cadaveric fascia lata commonly used in pubovaginal sling surgery [freeze-dried (FD) and solvent-dehydrated (SD)], and commercially available cadaveric dermal grafts (DG) evaluate differences in tissue strength and stiffness. We prospectively studied the maximum load to failure (MLF) and stiffness in 20 specimens of ARF, 20 specimens of FD, 20 specimens of SD, and 10 specimens of DG. Autologous fascia was obtained from patients undergoing pubovaginal sling operation utilizing rectus fascia. Cadaveric fascia was re-hydrated in saline. All specimens were then tailored into 1 x 1-cm samples and mounted onto the Instron tensiometer. Samples were loaded to failure at a 100% strain rate and force-elongation curves were generated. MLF was defined as the minimum force needed to tear the tissue. Stiffness was determined by the slope of the linear portion of the force/elongation curve between 5 and 15% strain. Statistical analysis was performed using Student's t-test. There is no statistical difference in both MLF and stiffness among ARF, SD, and DG. These data show that MLF and tissue stiffness of SD and DG are comparable to that of ARF. FD has a significantly lower MLF and is significantly less stiff than ARF, SD, and DG. The SD cadaveric fascia lata allograft and the cadaveric dermal allograft may be suitable alternatives to ARF for pubovaginal sling surgery. Neurourol. Urodynam. 18:497-503, 1999.     

Tensile strength of cadaveric fascia lata compared to small intestinal submucosa using suture pull through analysis

PURPOSE: The modified pubovaginal sling has become popular as first line treatment for stress urinary incontinence. With the increasing use of cadaveric fascia as a sling material, widespread shortages are prevalent, hence limiting its availability. The increased morbidity with the use of synthetic sling materials and autologous fascia has stimulated investigation of other sling materials. We evaluated the tensile strength of 4 suture types, and compared tensile strength of cadaveric fascia lata to porcine small intestinal submucosa using suture pull through analysis to assess their efficacy and durability for use in anti-incontinence procedures. MATERIALS AND METHODS: Suture breaking load was determined using 2 and 1-zero polypropylene suture, and 2 and 1-zero polyglactin suture. Freeze dried gamma irradiated human fascia lata and freeze-dried small intestinal submucosa were evaluated. Suture was fixed to sling material using the cross fold technique. Mean suture breakage and suture pull through were determined using a tensionometer by measuring the load applied to the sling/suture system. Statistical analysis was performed. RESULTS: Mean suture breakage load was greatest with 1-zero polyglactin (8.10 pounds) and least with 2-zero polypropylene (3.68 pounds). Mean suture breakage strength was similar for 1-zero polypropylene and 2-zero polyglactin at 5.26 and 5.40 pounds, respectively. Mean suture pull through load using 1-zero polypropylene suture and the cross fold technique was 5.64 pounds for cadaveric fascia and 2.74 pounds for small intestinal submucosa (p <0.0001). Maximum load was limited by the suture strength when using cadaveric fascia, whereas, maximum load was limited in small intestinal submucosa by its inherent tensile strength. However, using a new technique for suture fixation to the small intestinal submucosa, we were able to increase significantly mean suture pull through load to 3.36 pounds (p = 0.008). Additionally, with this new technique small intestinal submucosa allowed gross stretching before suture pull through that was not seen with cadaveric fascia. CONCLUSIONS: Despite the current standard use of 1-zero polypropylene suture for pubovaginal sling fixation, our data suggest that 1-zero polyglactin suture is the strongest, and its use with pubovaginal sling fixation warrants further investigation. Using the cross fold technique and 1-zero polypropylene suture, tensile strength was greatest with cadaveric fascia compared to small intestinal submucosa. Although small intestinal submucosa was not as strong as cadaveric fascia, our persuasive preliminary data suggest that further investigation is warranted in the use of small intestinal submucosa and other suture fixation techniques, and its observed stretch capacity. Hence, with further studies small intestinal submucosa may remain a viable option for pubovaginal sling material.     

Long-term outcomes of autologous fascia lata sling for stress incontinence secondary to intrinsic sphincter deficiency in women

ObjectiveTo report our long-term pubovaginal sling (PVS) outcomes using fascia lata for stress urinary incontinence (SUI) secondary to intrinsic sphincteric deficiency (ISD).Methodology and methodsFollowing Institute Review Board approval, charts from women undergoing PVS with fascia lata, with at least 6 months of follow up, were reviewed. Preoperative and postoperative data collected included demographics, validated questionnaires, prior anti-incontinence procedures, associated repairs, urodynamic findings, and reoperation procedures for SUI. Success was defined as cure of SUI (no pad, UDI-6 Question 3 related to SUI at ≤ 1, and no SUI reoperation).ResultsBetween 1997 and 2013, 22 women met the inclusion criteria with mean age of 73 (52–88) years, mean BMI 29 (17–38) and mean parity 2.7 (1–4). Mean follow up was 96 months (8–190). Indication for fascia lata sling included obesity (13) and prior abdominal procedures (9), including abdominoplasty. Fifteen women had received one or more prior antiincontinence procedures and five a prior injectable agent. No perioperative complications were noted. Overall, 14 of 22 women met success criteria [UDI-6 Question 3 at 0 (10) and at 1 (4)]. Three women underwent a subsequent procedure for residual SUI with periurethral bulking agent and one is awaiting an artificial urinary sphincter.ConclusionAt long-term follow-up of over 8 years after fascia lata sling, women who underwent fascia lata sling had acceptable continence outcomes with minimal complications.     

PUBOVAGINAL FASCIAL SLING FOR ALL TYPES OF STRESS URINARY INCONTINENCE: LONG-TERM ANALYSIS

Purpose

There is a lack of consensus regarding indications and long-term efficacy of the many surgical techniques for treating stress incontinence. Historically pubovaginal sling has been reserved for cases of intrinsic sphincter deficiency or prior surgical failure. Transvaginal needle and retropubic suspensions have been used mainly for sphincteric incontinence unassociated with intrinsic sphincter deficiency. We report the long-term results of pubovaginal sling for all types of stress incontinence.

Materials and Methods

A total of 251 consecutive women with all types of stress incontinence who underwent pubovaginal fascial sling by a single surgeon were retrospectively and prospectively reviewed. Patients were evaluated preoperatively with history, physical examination, standardized symptom questionnaire, voiding diary, pad test, uroflow, post-void residual urine, video urodynamics and cystoscopy. Postoperatively women with at least 1-year followup were assessed by an independent third party (J. R.) who had no prior knowledge of them, and who recorded the parameters of the questionnaire, examination with a full bladder, voiding diary, pad test, uroflow and post-void residual urine.

Results

Overall stress incontinence was cured or improved in 92% of the patients with at least 1-year followup (median 3.1 years, range 1 to 15). The majority of patients with postoperative incontinence had de novo (3%) or persistent (23%) urge incontinence. Permanent urinary retention developed in 4 patients (2%).

Conclusions

Fascial pubovaginal sling is an effective treatment for all types of stress incontinence with acceptable long-term efficacy.     

Broad based tension-free synthetic sling for stress urinary incontinence: 5-year outcome

PURPOSE: The use of nonabsorbable synthetic material has been questioned due to reports of erosion and infection. We present the 5-year followup outcome of stress urinary incontinence (SUI) treated using polypropylene mesh as a pubovaginal sling. MATERIALS AND METHODS: A retrospective analysis was performed of 58 consecutive patients who underwent pubovaginal sling procedures using polypropylene mesh since April 1996 for types II and III SUI at our institution. The technique included a single midline anterior vaginal wall incision with full-thickness flaps. Broad based polypropylene mesh was used to support the vesicourethral junction entering the retropubic space through the endopelvic fascia and bone anchors were used for fixation. Patient satisfaction was evaluated during followup office visits and/or telephone interview by an individual not involved in any surgeries. All procedure failures were evaluated by urodynamics. RESULTS: Of the 58 patients 49 were available for analysis. Average followup was 59.34 months (range 29 to 77). Of the 49 patients 40 (81.63%) were dry and 2 (4.08%) improved (1 pad daily). De novo urgency and urgency related incontinence was reported in 1 case each. Three patients (8.16%) had recurrent SUI, while prolonged retention developed with subsequent urethrolysis required in 2 (4.08%). None of the patients have experienced infection, nonhealing or erosion of the synthetic slings to date. CONCLUSIONS: In our experience polypropylene mesh used as a broad based tension-free sling was successful for treating all types of SUI. In our opinion technique and case selection have a bearing on outcomes.     

Failure of allograft suburethral slings.

OBJECTIVES: To report our experience of using freeze-dried irradiated fascia lata allografts for suburethral sling procedures. PATIENTS AND METHODS: Between December 1996 and September 1998, 35 patients (mean age 60.25 years, range 37-79) underwent suburethral sling placement with fascia allograft. These patients were reviewed, with the findings at the time of any surgical re-exploration. Eleven (31%) had undergone prior surgery for genuine stress incontinence and 32 (91%) had a preoperative diagnosis of intrinsic sphincter deficiency. RESULTS: On re-operation for persistent or recurrent stress incontinence, the allograft was present but grossly degenerated in two (6%) patients and completely absent in five (14%) patients. Histology of a retrieved graft fragment showed both fibroblast proliferation and degeneration within the graft. CONCLUSION: The use of freeze-dried, irradiated fascia lata for suburethral sling procedures was associated with a material failure rate of >/=20%. We caution against its use in this setting.     

Comparative analysis of urinary incontinence severity after autologous fascia pubovaginal sling, pubovaginal sling and tension-free vaginal tape

PURPOSE: Autologous fascia, Pelvicol implant and polypropylene are common materials used in suburethral anti-incontinence procedures. We explored the relative effectiveness of the autologous fascia pubovaginal sling, Pelvicol pubovaginal sling and Gynecare TVT on self-reported postoperative urinary incontinence. MATERIALS AND METHODS: The study was a mailed cross-sectional survey of health related quality of life 1 to 3 years after suburethral anti-incontinence surgery performed at our institution. The Incontinence Symptom Index was used to assess the presence and severity of urinary incontinence symptoms and the Incontinence Impact Questionnaire-7 was used to assess impairment. Regression models were developed to identify factors with an independent effect on the presence, severity and impairment of urinary incontinence symptoms. RESULTS: The questionnaire was returned by 69% of eligible respondents (173 of 250). Those with previous incontinence surgery (OR 11.0, 95% CI 2.3-51.4) and medical comorbidities (OR 1.6, 95% CI 1.1-2.2) were more likely to report urinary incontinence symptoms, ie incontinence symptom index greater than 0. Symptom severity, which was analyzed only in respondents with urinary incontinence symptoms, was greater in the Pelvicol than in the autologous fascia pubovaginal sling and TVT groups (each p <0.01). No significant difference was observed between the TVT and autologous fascia pubovaginal sling groups (p = 0.15). Also associated with higher urinary incontinence symptom severity scores were body mass index (p = 0.03), a history of incontinence surgery (p = 0.01) and lower education (p <0.01). Impairment from urinary incontinence, as assessed by the Incontinence Impact Questionnaire-7, was associated with body mass index, severe depression and current smoking (each p = 0.01) but not with surgical treatment group. CONCLUSIONS: Women who received an autologous fascia pubovaginal sling or TVT reported lower symptom severity scores than those who had a Pelvicol pubovaginal sling. Impairment was not associated with procedure type. These findings suggest better outcomes with autologous fascia pubovaginal sling and TVT. Randomized, controlled trials are needed to confirm these findings.     

Pubovaginal sling using Duraderm graft: intermediate follow-up and patient satisfaction

AIM: To assess outcome and patient satisfaction utilizing Duraderm allograft as sling material. METHODS: Twenty five patients undergoing the Duraderm sling procedure were evaluated by pelvic examination, post-void residual urine, and multi-channel urodynamics. Follow-up included repeat examination, stress test, and chart review. Patient satisfaction was assessed by phone interview with an independent examiner. Outcome was defined as dry (no leaking at all and patient perception of satisfaction), improved (minimal leak requiring < or =1 pad daily and patient perception of satisfaction), or failure. RESULTS: Average age was 62.0 years (30-83); average daily preoperative pad usage was 3.5 (2-8). Duraderm allograft measuring 2 x 12 cm was used. Mean postoperative catheter time was 7.7 days (3-37 days). At 6 months, 17/25 (68%) were dry, 6 (24%) improved, and 2 (8%) failed. Mean intermediate follow-up at 14.8 months (8-23 months) revealed 8/25 (32%) patients were dry, 9 (36%) were improved, and 8 (32%) failed Duraderm sling. Mean pad use after surgery was 1.4 (0-6). Of the 25, 19 (76%) were satisfied with the surgical outcome, 17 (68%) noted they would have surgery again, and 17 (68%) would recommend the procedure. CONCLUSIONS: Initial results of pubovaginal sling using Duraderm graft are satisfactory; however, longer term follow-up is disappointing. Graft degeneration previously described after utilization of cadaveric fascia lata may be possible following implantation of cadaveric dermis.     

Surgical treatment for stress urinary incontinence associated with valsalva induced detrusor instability

PURPOSE: Detrusor instability initiated by increased intra-abdominal pressure that results in incontinence has always been difficult to treat. This form of incontinence may be due to traction on the pelvic nerves when increased abdominal pressure is applied to already weakened pelvic supportive tissue. In most patients pharmacological attempts to correct this problem fail. We describe a pubovaginal sling designed to stabilize the urethrovesical junction during the Valsalva maneuver, which is our treatment of choice for such patients. MATERIALS AND METHODS: From 1994 to 1998 we treated 36 patients with a pubovaginal sling procedure for Valsalva induced detrusor instability diagnosed on preoperative urodynamics. The sling material was in situ vaginal wall in 20 cases, free swing vaginal wall in 6, rectus fascia in 4, cadaveric fascia in 3 and synthetic material in 3. Urodynamic evaluation was performed preoperatively in all patients. Followup of 6 months to 4 years involved subjective questions and objective examination. RESULTS: Cure was achieved in 33 of the 36 patients (92%), of whom leak point pressure was less than 50, 50 to 100 and greater than 100 cm. water in 9, 17 and 7, respectively. In the 3 failed cases leak point pressure was 50 to 100 cm water, including 2 in which cotton swab test results were less than 30 degrees. Urge incontinence resolved in 75% of the patients. CONCLUSIONS: The pubovaginal sling procedure may cure Valsalva induced detrusor instability. Leak point pressure does not determine which patients do well. Evaluation for hypermobility may help to predict the success or failure of a procedure by identifying those in whom Valsalva induced detrusor instability results from traction on the pelvic nerves.