Abdominal sacral colpopexy using autologous fascia lata

PURPOSE: Numerous techniques and materials have traditionally been used to correct vaginal vault prolapse, including cadaveric fascia, synthetic materials and autologous rectus fascia. We report our experience with autologous fascia lata used for abdominal sacral colpopexy. MATERIALS AND METHODS: A retrospective review identified all women who underwent abdominal sacral colpopexy using autologous fascia lata for vaginal vault prolapse with at least 18 months of followup. Preoperative and postoperative pelvic organ prolapse quantification (POP-Q) scores, relevant clinical and operative parameters, treatment efficacy, harvest site morbidity and patient satisfaction were assessed. RESULTS: Ten women underwent this procedure between 1999 and 2001. Mean patient age was 68.3 years (range 55 to 82). Followup was 19 to 42 months (mean +/- SD 30.5 +/- 7.78). Preoperatively POP-Q stages were II to IV in 3, 5 and 2 cases, respectively. Postoperative POP-Q scores improved to and remained at stage II or lower in all 10 patients. Mean operative time was 182 +/- 40.94 minutes (range 136 to 265). Mean blood loss was 107.5 +/- 50.07 cc (range 50 to 200). There was no morbidity associated with fascia lata harvest. Eight of the 9 women alive at review completed and returned the survey. When asked if they could return to how they were before surgery, would they still have the same procedure done and would they recommend the procedure to a friend, all respondents answered yes to each question. CONCLUSIONS: Autologous fascia lata compares favorably in efficacy to that reported for other materials in the contemporary literature and it is not associated with any significant morbidity.     

Changes in tensile strength of cadaveric human fascia lata after implantation in a rabbit vagina model

PURPOSE: We determined changes in tensile properties after vaginal implantation of human cadaveric fascia lata. MATERIALS AND METHODS: Baseline tensile properties were determined for freeze-dried, gamma irradiated human cadaveric fascia lata from 3 separate lots. Fascial strips (2 x 0.5 cm.) from 2 lots were implanted between the rectovaginal membrane and vaginal mucosa in New Zealand white rabbits. The strips were excised en bloc 12 weeks after implantation. Tensile property measurements were repeated and compared with pre-implantation values. RESULTS: Pre-implantation interlot and intralot variability in baseline tensile properties was significant. After implantation there was an approximate 90% decrease in tensile strength from baseline values. There was no gross evidence of graft autolysis. CONCLUSIONS: The decrease in tensile strength of cadaveric fascial graft was significant after implantation in this model.     

Intermediate term failure of pubovaginal slings using cadaveric fascia lata: a case series

PURPOSE: The pubovaginal sling procedure using autologous fascia has become the gold standard for treating intrinsic sphincter deficiency and stress urinary incontinence in women. A recent modification has been the use of cadaveric fascia as the sling material. We recently reported similar results for cadaveric fascia lata in 121 women and autologous fascia lata in 46 at a mean followup of 12 months. We have now identified 8 patients who experienced intermediate term failure at 4 to 13 months using cadaveric fascia lata. MATERIALS AND METHODS: We retrospectively reviewed the records of 8 of 121 patients who received a pubovaginal sling using cadaveric fascia lata between February 1997 and June 1999 and had recurrent stress incontinence after 4 to 13 months. We reviewed the type of fascia, surgical technique, preoperative and postoperative urodynamics, surgical history and medical co-morbidities. RESULTS: We identified 8 patients who underwent a pubovaginal sling using cadaveric fascia lata and had recurrent stress urinary incontinence at a mean of 6.5 months (range 4 to 13) after the procedure. Fresh frozen fascia from a local tissue bank was used and the surgical technique was identical in all cases. Postoperatively urodynamics confirmed recurrent intrinsic sphincter deficiency. Previous incontinence surgery had been done in 7 of the 8 patients. Patient co-morbidities included neurological disease, diabetes mellitus, previous pelvic irradiation and previous pelvic surgery. CONCLUSIONS: We identified a higher than expected intermediate term failure rate using fresh frozen cadaveric fascia lata. This risk must be weighed against the advantages of decreased operative time and patient morbidity. Longer followup and larger numbers are necessary to determine how much of a problem exists and what patient characteristics are relevant when selecting cadaveric grafts.     

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.     

Total abdominal wall reconstruction with two tensor fascia lata myocutaneous flaps

Summary A case of total abdominal wall reconstruction in a 22-year-old man is presented. He had an omphalocele which was covered initially with skin grafts, thus creating a huge abdominal hernia. Two tensor fascia lata flaps, each measuring 14 × 36 cm, were used to reconstruct the abdominal wall following delay. This method, whenever available, is in our opinion the best and most reliable way to reconstruct the abdominal wall. Myocutaneous flaps now have extended use in plastic and reconstructive surgery [1, 3, 5, 6, 8, 10]. The tensor fascia lata (TFL) myocutaneous flap is unique in its fascial extension and large overlying skin territory which makes it ideal for abdominal wall repairs.     

Total abdominal wall reconstruction with two tensor fascia lata myocutaneous flaps

A case of total abdominal wall reconstruction in a 22-year-old man is presented. He had an omphalocele which was covered initially with skin grafts, thus creating a huge abdominal hernia. Two tensor fascia lata flaps, each measuring 14×36 cm, were used to reconstruct the abdominal wall following delay. This method, when-ever available, is in our opinion the best and most reliable way to reconstruct the abdominal wall. Myocutaneous flaps now have extended use in plastic and reconstructive surgery [1, 3, 5, 6, 8, 10]. The tensor fascia lata (TFL) myocutaneous flap is unique in its fascial extension and large overlying skin territory which makes it ideal for abdominal wall repairs.     

Three-layer reconstruction with fascia lata and vascularized pericranium for anterior skull base defects

Summary Background. We report an assessment of the efficiacy of a triple layer graft composed of fascia lata and vascularized pericranium for anterior skull base reconstruction. This technique is based on the concept that vascularized tissue over a free flap may promote vascularization and rapid wound healing. Method. A large fascial graft is prepared from the fascia lata and divided in two pieces and trimmed to a size larger than the bone and dural defect. Vascularized pericranium is harvested after bicoronal incision and elevating the bifrontal scalp flap down to the supraorbital rims. First is dural repair, which is performed with fascia lata placed between the brain and remaining dura. Second, fascia lata is placed over the skull base defect and secured with mini titanium screws over the cranial surface of the orbital ridges. Third, vascularized pericranium is laid between the two layers of fascia lata. Findings. We studied 17 patients of whom 2 had malignancy, 6 had olfactory groove meningioma, 6 had skull base fracture and rhinorrhea, 1 case had orbital meningioma, 1 had invasive pituitary adenoma and 1 had basal encephalocele. The transbasal approach was used as a single procedure in 13 cases. The extended transbasal approach combined with a transfacial approach was used in 3 cases and with a pterional approach in 1 case. In each patient, reconstruction of the cranial base was performed with triple layer graft of fascia lata and vascularized pericranium. The patients were followed-up 2 months to 5 years. None of the patients experienced postoperative cerebrospinal fluid leakage, meningitis, abscess, brain herniation and tension pneumocephalus. Interpretation. Fascia lata with vascularized pericranium is highly reliable, tensile and well suited for reconstruction of the anterior skull base.     

Porcine dermis interposition graft for repair of high grade anterior compartment defects with or without concomitant pelvic organ prolapse procedures

PURPOSE: Recent literature suggests that graft interposition may decrease the incidence of cystocele recurrence. We describe our experience with porcine dermis interposition grafts for the repair of high grade cystoceles. MATERIALS AND METHODS: We retrospectively reviewed the charts of all women who underwent surgical repair of high grade cystocele. Prolapse was graded with the Baden-Walker and Pelvic Organ Prolapse Quantitation systems, and all patients were evaluated with multichannel videourodynamics. Concomitant stress urinary incontinence was corrected with a pubovaginal sling and vault prolapse was corrected with iliococcygeus vault suspension. Postoperatively patients were evaluated at 2 weeks, 2 months, 6 months and annually thereafter. RESULTS: A total of 70 patients underwent cystocele repair with a porcine dermis interposition graft. Concomitant procedures included a pubovaginal sling in 65 patients and vaginal vault suspension in 50. Mean followup was 24 months. There were no intraoperative complications. Of the patient 59 (91%) are currently dry. One patient had recurrent vault prolapse without cystocele (C -2), which was successfully repaired with abdominal sacral colpopexy. Six patients (8.6%) experienced recurrent grade II (Ba 0) cystocele but continued to be asymptomatic. Three others (4.3%) had recurrence of grade III (Ba +2) cystocele and elected not to undergo reoperation. Two of 6 de novo rectoceles (grade II, Ap and -1 and Bp 0) were repaired with site specific repairs. Superficial vaginal wound separation in 1 case was successfully treated conservatively. CONCLUSIONS: In cases of high grade cystocele interposition of porcine dermis represents a successful and safe treatment option. Cystocele recurrence is typically low grade and it frequently may not require additional surgery.     

Diaphragm reconstruction with autologous fascia lata: Report of a case

When the diaphragm is excised so wiely that the defect cannot be closed directly during an operation on either thoracic or epigastric tumors, a reconstruction of the defect is necessary. We used harvested autologous fascia lata to reconstruct the diaphragm in a patient undergoing a pleuropneumonectomy with a partial diaphragmatic resection for malignant mesothelioma.     

Anterior vaginal wall length and degree of anterior compartment prolapse seen on dynamic MRI

The objective of the study was to determine the relationship between midsagittal vaginal wall geometric parameters and the degree of anterior vaginal prolapse. We have previously presented data indicating that about half of anterior wall descent can be explained by the degree of apical descent present (Summers et al., Am J Obstet Gynecol, 194:1438–1443, 2006). This led us to examine whether other midsagittal vaginal geometric parameters are associated with anterior wall descent. Magnetic resonance (MR) scans of 145 women from the prior study were suitable for analysis after eight were excluded because of inadequate visibility of the anterior vaginal wall. Subjects had been selected from a study of pelvic organ prolapse that included women with and without prolapse. All patients underwent supine dynamic MR scans in the midsagittal plane. Anterior vaginal wall length, location of distal vaginal wall point, and the area under the midsagittal profile of the anterior vaginal wall were measured during maximal Valsalva. A linear regression model was used to examine how much of the variance in cystocele size could be explained by these vaginal parameters. When both apical descent and vaginal length were considered in the linear regression model, 77% (R ² = 0.77, p < 0.001) of the variation in anterior wall descent was explained. Distal vaginal point and a measure anterior wall shape, the area under the profile of the anterior vaginal wall, added little to the model. Increasing vaginal length was positively correlated with greater degrees of anterior vaginal prolapse during maximal Valsalva (R ² = 0.30, p < 0.01) determining 30% of the variation in anterior wall decent. Greater degrees of anterior vaginal prolapse are associated with a longer vaginal wall. Linear regression modeling suggests that 77% of anterior wall descent can be explained by apical descent and midsagittal anterior vaginal wall length.     

The use of tensor fascia lata interposition grafts for the treatment of posttraumatic radioulnar synostosis

PURPOSE: There is no agreement on the ideal treatment of traumatic radioulnar synostosis, especially the type of interposition material to be used. The purpose of this study is to report our experience with synostosis resection and interposition of tensor fascia lata grafts. METHODS: A chart review was conducted for all patients treated for posttraumatic radioulnar synostosis between 2000 and 2004. Demographic data, mechanism of injury, length of time to synostosis resection, range-of-motion, patient satisfaction, and postoperative complications were analyzed. RESULTS: Thirteen patients were identified for this study. The mean preoperative pronation was 14 degrees and the mean postoperative pronation was 62 degrees. The mean preoperative supination was 4 degrees and the mean postoperative supination was 62 degrees. The mean follow-up time was 30 months. CONCLUSIONS: These results indicate that synostosis resection with tensor fascia lata graft interposition is an effective technique for the treatment of posttraumatic radioulnar synostosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Anatomic analysis of the vascular network and vascular pedicle of the tensor fascia lata flap (angiographic and cadaver study)

Knowing the vascular network and properties of the vascular pedicle is of crucial importance for elevation of the tensor fascia lata (TFL) transpositional or free flap; therefore, the origin of the lateral circumflex femoral artery (LCFA), its diameter at the site of origin, the length of the vascular pedicle, the number of lateral branches, the number of terminal branches and the anastomosis of the LCFA ascending branch are of utmost importance for successful elevation and clinical application of this flap. The study was conducted on clinical (100 angiographic images of the femoral artery) and autopsy (48 preparations) material. The first part of the study comprised analysis of the angiographic images that were used to obtain the information on LCFA. The diameter of LCFA at its origin was measured to be 0.44 cm, while it was 0.33 cm at the origin of ascending branch. The mean value of the diameter at the bifurcation of the terminal branches of ascending branch (inside tensor fascia lata muscle) was 0.24 cm. It has been established that the vascular pedicle of the tensor fascia lata flap (ascending branch of LCFA) is anastomosed with the superior gluteal artery in all cases. Measurement of the tensor fascia lata muscle revealed an average length of 15.91 cm, width of 3.55 cm and thickness of 1.98 cm. Injection of colour-ink into the ascending branch LCFA that enters directly into the TFL muscle was used to measure the extent of the TFL flap vascularization and on the average, the TFL flap was 20.32 cm long and 16.57 cm wide while the surface was 17.52 cm³.     

A long term follow up of resection interposition arthroplasty of the knee using chromicised fascia lata

Summary We have reviewed the results of 25 patients who had a resection interposition arthroplasty of the knee using chromicized fascia lata, with a mean follow-up of 22 years. No patient had severe pain although 10 had occasional pain after heavy labour. Thirteen knees had 60° of movement or more but 12 had 45° or less. The radiographs all showed adaptive remodelling of the resected bone ends. This procedure successfully restored function in the majority of cases with absence of pain over a long period.Read at the SICOT 84 Congress, London, England October 5, 1984     

The versatility of tensor fascia lata allografts for soft tissue reconstruction

The purpose of this retrospective study was to introduce our successful use of tensor fascia lata allograft to reconstruct various soft tissue defects. Since May 2021, we have applied tensor fascia lata allografts in eight cases. A frozen type of fascia of 0.6 mm thickness was used in all cases, and allografts were covered by vascularized soft tissue. We used tensor fascia lata allograft in eight cases to cover the infected wounds, donor site closure, and pedicle protections. These were abdominal wall and back reconstructions following rectus muscle and latissimus dorsi muscle harvest, coverage of infected spine wound after posterior fusion, pressure ulcer reconstruction, and pedicle protection of free and pedicle flaps. The follow-up periods were from one to 14 months. None of the cases showed wound problems after initial reconstruction using tensor fascia lata allografts. Tensor fascia lata allograft could be an excellent cost-effective surgical option comparable to autologous tissue grafts. Level of evidence: IV.     

The tensile properties of tension-free vaginal tape and cadaveric fascia lata in an in vivo rat model

OBJECTIVE: To examine the tensile properties (break load and maximum average load), after in vivo implantation in a rat animal model, of tension-free vaginal tape (TVT) and cadaveric fascia lata (CFL), as pubovaginal slings of these materials have become popular for treating stress urinary incontinence. MATERIALS AND METHODS: Twenty Sprague-Dawley rats (300-400 g) had 1 x 2 cm strips of commercially available TVT and CFL implanted on the right and left anterior abdominal wall, respectively. Half of the animals were then killed at 6 weeks and the remainder at 12 weeks, after which the strips of TVT and CFL were removed and their tensile properties measured using a tensiometer. The tensile strength of TVT and CFL strips maintained only in normal saline served as controls. RESULTS: The TVT strips had a mean break load of 0.740 kg in the control and only 0.390 kg for CFL (P < 0.05). At 6 weeks the TVT material had a mean (sd) maximum average load of 0.634 (0.096) kg and a mean break load of 0.589 (0.249) kg, whereas the respective values for the CFL were 0.323 (0.198) and 0.167 (0.063) kg (P < 0.05). Similarly at 12 weeks, TVT had a greater mean maximum average and break load than CFL, at 0.742 (0.052) and 0.274 (0.126), and 0.737 (0.056) and 0.185 (0.128) kg, respectively. CONCLUSION: This is the first study to assess the tensile properties of the currently used sling materials, TVT and CFL, in an in vivo model. TVT has a greater break load and maximum average load than CFL; the tensile strength of these materials does not decrease with time.     

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.     

In situ anterior vaginal wall sling formation with preservation of the endopelvic fascia for treatment of stress urinary incontinence

The indications for sling procedures have evolved and encompass patients with either intrinsic sphincteric deficiency (ISD), anatomic incontinence or both. We have refined a technique that can be performed in a minimally invasive fashion with low attendant morbidity to provide a reproducible method of sling formation. Twenty patients with stress urinary incontinence underwent the in situ sling (ISS) with bone fixation. Subsequent evaluation at 24–29 months (mean =26.2 months) revealed that 95% of patients were cured. No recurrent cystoceles, paravaginal defects or significant detrusor instability have been noted. Urinary retention appeared transiently in only 3 patients and resolved in under 3 weeks. We feel the in situ sling with bone fixation provides a safe and effective means of management for stress urinary incontinence. Furthermore, the reduced surgical dissection may minimize the incidence of postoperative ISD and recurrent paravaginal defects that may accompany more traditional needle suspension procedures.Editorial Comment: The authors present an interesting approach to the performance of a suburethral sling procedure which utilizes the anterior vaginal mucosa beneath the urethra as the supportive section of the sling, similar to the Raz vaginal wall sling technique. The patch is secured with sutures which are transported to the suprapubic site and attached to the symphysis pubis with bone anchors. Whether this procedure will provide longterm support to the urethrovesical junction will only be judged with time, and with prospective studies with pre-and postoperative objective urodynamic evaluation. The present study is truly an initial report of the technique, performed on a small group of patients with genuine stress incontinence or intrinsic sphincter deficiency with or without urethrovesical junction hypermobility. One major concern with any technique utilizing bone anchors attached to sutures coming from the perivaginal tissue following dissection of the anterior vaginal compartment is the potential risk of introducing pathogens to the bone, with resultant osteitis pubis or osteomyelitis.