Clinical and urodynamic outcomes of pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence

AIM: We report the clinical and urodynamic outcomes of the pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence (SUI) and determined the urodynamic parameters that could predict the occurrence of postoperative voiding difficulty. METHODS: Between 1998 and 2005, a total of 29 consecutive women with SUI underwent pubovaginal sling surgery with autologous rectus fascia. Patients were preoperatively and postoperatively evaluated with regard to symptoms and urodynamic findings including uroflowmetry (UFM), postvoid residual urine volume (PVR), filling cystometry (CMG) and pressure flow study (PFS). RESULTS: Overall SUI was cured in 23 patients (80%) and improved in 3 patients (10%). Three patients (10%) who developed persistent urinary retention or severe voiding difficulty after surgery underwent urethrolysis. Of 17 patients who had urgency before the pubovaginal sling, urgency was cured postoperatively in seven, while de novo urgency appeared in one patient. Maximum flow rate (Qmax) in UFM was significantly decreased (P < 0.05) and PVR was increased (P = 0.08) after surgery. PFS showed a significant increase in detrusor opening pressure and detrusor pressure at Qmax (P < 0.01) after surgery. Eight patients (28%) needed prolonged intermittent self-catheterization. Patients who had PVR >100 mL (P < 0.05) or Qmax < or = 20 mL/s (P = 0.09) in preoperative UFM were more likely to require prolonged intermittent catheterization after surgery. CONCLUSIONS: The pubovaginal sling procedure with autologous rectus fascia is an effective treatment for SUI. A comparison of preoperative and postoperative urodynamic parameters indicates an increase in urethral resistance after pubovaginal sling surgery. PVR >100 mL and Qmax < or = 20 mL/s before surgery are risk factors for postoperative voiding difficulty.     

Bovine dermis: a novel biologic substitute for autologous tissue in sling surgery

Women at high risk for sling failure (advanced age, previous surgical failure, and intrinsic sphincter deficiency) underwent either bovine dermis (BOV) or autologous rectus fascia (ARF) pubovaginal sling at two hospitals. "Global cure" encompassed stress, emptying, anatomic, protection, and instability (SEAPI) composite = 0 and subjective satisfaction. Cure of stress urinary incontinence (SUI cure) equaled SEAPI (S) = 0 and negative cough-stress test. Eighty-five women (48 ARF, 37 BOV) completed a 12-month evaluation. Preoperative SEAPI and quality of life indices (QOL) were not statistically different (NS). "Global cure" for ARF and BOV was 60.4% and 54.1%, respectively (NS). "SUI cure" for ARF and BOV was 81.3% and 83.8%, respectively (NS). Postoperative SEAPI and QOL indices were significantly improved for each material; improvement was similar between ARF and BOV groups (NS). BOV is a promising substitute for ARF in women at high risk for surgical failure. Longer follow-up is needed before indications for this material are expanded.     

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.     

Pubovaginal or Vicryl Mesh Rectus Fascia Sling in Intrinsic Sphincter Deficiency

The aim of this study was to compare the pubovaginal sling with a new Vicryl mesh rectus fascia (VMRF) sling in the surgical treatment of low urethral pressure genuine stress incontinence. Fifty-one consecutive women who had a VMRF (n= 27) or a pubovaginal sling (n= 24) procedure between March 1995 and December 1997 were evaluated. The patient-determined subjective success rate of the VMRF sling (85%) was significantly higher than that of the pubovaginal sling (58%) in women with low urethral pressure stress incontinence (P=0.03). The objective success rates following the VMRF and the pubovaginal sling were 52% and 50%, respectively. The prevalence of postoperative symptomatic voiding dysfunction and de novo detrusor instability was 7% after the VMRF sling and 25% following the pubovaginal sling (P=0.08). The VMRF sling had a higher patient-determined success rate and a lower complication rate than the pubovaginal sling, and should be considered in the surgical management of women with low urethral pressure stress incontinence.     

Bone-anchored suburethral sling: Surgical technique and outcomes

The gold standard treatment for stress urinary incontinence (SUI) is the autologous rectus fascia pubovaginal sling. Although successful, it is associated with increased morbidity related to the graft harvest. Because of this, less invasive techniques were developed, including the retropubic and transobturator midurethral sling and the bone-anchored sling (BAS). Early reported outcome failures and concern for bone-anchored-related complications caused BAS to fall out of favor. However, technique modifications and use of a more durable graft or mesh have proven that the transvaginal placement of BAS is actually safe and effective in treating patients with SUI. Further, recent evidence suggests that the bone-anchored sling may be a reasonable option for treatment of patients with moderate to severe and/or recurrent SUI.     

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.     

The long-term results of pubovaginal sling surgery using acellular cross-linked porcine dermis in the treatment of urodynamic stress incontinence

PURPOSE: Acellular cross-linked porcine dermis is a potential substitute for rectus fascia as a sling material with the advantage of decreased morbidity. However, the long-term efficacy is unknown. We compared the 3-year efficacy of PD vs autologous rectus fascia as a sling material for pubovaginal sling surgery in the treatment of urodynamic stress incontinence. MATERIALS AND METHODS: Between July 2000 and December 2001 a total of 101 consecutive, nonrandomized patients with USI underwent a PD (51) or RF (50) sling procedure. Patients were assessed at 6 weeks, and at 3, 6 and 12 months postoperatively. Urodynamic study was repeated in cases of treatment failure. A detailed survey questionnaire was mailed to all patients at least 36 months after surgery and all responders were then retested by telephone interview by a blinded assessor. The primary outcome measure was patient perceived success rate (cured or improved) at least 36 months after PVS. Secondary outcome measures were patient satisfaction 36 months after surgery, durability of success with time and reoperation rate. RESULTS: Complete data were available on 94 patients (48 treated with PD and 46 treated with RF sling). The groups were well matched for age, leak point pressure, prior incontinence surgery and urge symptoms. Pubovaginal sling was successful (cured or improved) in 37 (80.4%) patients treated with RF but in only 26 (54%) patients treated with PD 36 months after surgery (Fisher's exact test p = 0.009; 95% CI 8.03, 44.4). Treatment failure occurred by 9 months after RF and by 24 months after PD sling procedure. Repeat urodynamic study showed USI to be the cause of treatment failure in 18 (37.5%) of 20 patients treated with PD but in only 3 (6.5%) of 8 patients treated with RF. CONCLUSIONS: We have shown that use of the PD sling, although reducing early morbidity, results in a significantly inferior long-term cure rate in comparison to the RF sling. Therefore, acellular cross-linked porcine dermis should not be used as a substitute for rectus fascia.     

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.     

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.     

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.     

Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome

PURPOSE: We present a series of urethral erosion following a pubovaginal sling procedure due to synthetic and nonsynthetic materials and discuss their management and continence outcome. MATERIALS AND METHODS: During a 3-year period 57 patients underwent urethrolysis for urethral obstruction after receiving a pubovaginal sling. Urethral erosion, defined as sling material entering the urethral lumen, was present in 9 patients and this cohort comprises the focus of our review. In 3 patients the eroded material was synthetic, that is ProteGen (Boston Scientific, Natick, Massachusetts) in 2 and polypropylene in 1. This condition was treated with removal of the whole sling, multilayer closure of the erosion and selective use of a Martius flap. In 6 patients the eroded material was nonsynthetic, that is allograft fascia in 5 and autograft fascia in 1. This condition was treated with sling incision and multilayer closure of the urethra. Preoperative assessment included a urogynecologic questionnaire, measurement of pad use, a voiding diary, cystourethroscopy and videourodynamics. Postoperatively similar parameters were used to assess continence outcomes and the need for subsequent procedures. RESULTS: Nine patients were followed 30 months after urethrolysis. All 9 women had some manifestation of voiding dysfunction following the pubovaginal sling procedure, including urinary retention in 4, urge incontinence in 3 and mixed incontinence in 2. Urinary retention resolved in 3 patients and urge incontinence resolved in 4. Stress urinary incontinence (SUI) persisted in 2 of the 3 patients in the synthetic group, while no patient in the nonsynthetic group had recurrent SUI. There were no recurrent urethral erosions or fistulas in either group. CONCLUSIONS: Urethral erosion after a pubovaginal sling procedure can occur irrespective of the sling material. However, recurrent SUI is not an invariable outcome of the management of urethral erosion following the pubovaginal sling procedure.     

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.     

Solvent-dehydrated cadaveric dermis: a new allograft for pubovaginal sling surgery

AIM: The aim of this study was to evaluate the efficacy of solvent-dehydrated cadaveric dermis in pubovaginal sling surgery for the first time in the literature. METHODS: Twenty-five women with stress urinary incontinence underwent pubovaginal sling surgery using 2 x 12 cm allograft dermis. Preoperatively, all patients were evaluated by a detailed urogynecologic evaluation, voiding diary, pelvic examination and urodynamic investigation. Outcome was assessed by the Urogenital Distress Inventory short form and standardized follow-up questionnaires. RESULTS: Twenty (80%) patients were cured of stress incontinence symptoms. Seventeen wore no pad and three reported occasional stress urinary incontinence and used no or one pad at a mean follow up of 12 months. Five (20%) patients in our series experienced the same amount of leakage as before the surgery. Seventy-six percent of the patients indicated that urinary incontinence was no longer negatively affecting their daily life and were satisfied with the procedure. CONCLUSIONS: Questionnaire-based assessment of outcome suggests that solvent-dehydrated cadaveric dermis is effective in the treatment of stress urinary incontinence. However, larger and comparative prospective studies with long-term results and randomized comparison of tissue preparation techniques are warranted.     

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.     

Long-term patient satisfaction following cadaveric pubovaginal sling incontinence surgery using the UDI and IIQ-7 questionnaires

AIMS: The goal of any incontinence surgery is overall long-term patient satisfaction. The purpose of our study was to assess long-term patient satisfaction following cadaveric fascia lata pubovaginal sling surgery using the urogenital distress inventory (UDI) and the short form of the incontinence impact questionnaire (IIQ-7). MATERIALS AND METHODS: A total of 47 patients who underwent pubovaginal sling incontinence surgery with a minimum follow-up of 2 years were sent by mail the UDI (total score = 300) and the IIQ-7 (total score = 100). Thirty-seven responses (78.7%) were obtained, with a mean follow-up of 3.8 years (range 2.0-6.2). RESULTS: Of the 37 patients who responded, the mean UDI score was 75.8 and the mean IIQ-7 score was 21.4. There was no difference in the mean IIQ-7 score for patients with more than 4 years follow-up as compared to the entire group (28.8, P = 0.22). In contrast, the mean UDI score for patients with more than 4 years follow-up was greater compared to the entire group (99.1, P = 0.04). UDI subscale analysis revealed that patients mainly complained of both irritative and stress symptoms as opposed to obstructive/discomfort symptoms (P < 0.01). Patients with pre-operative mixed incontinence had greater mean UDI and IIQ-7 scores compared to patients with pre-operative pure stress incontinence (96.7 vs. 58.0, P = 0.04; 32.5 vs. 11.9, P = 0.03). CONCLUSIONS: Overall long-term scores assessing quality of life (IIQ-7) were good and those assessing symptom distress (UDI) were satisfactory following pubovaginal sling surgery. Patients with pre-operative mixed incontinence are at greatest risk for post-operative dissatisfaction.     

Cadaveric fascia lata pubovaginal slings: early results on safety,efficacy and patient satisfaction

OBJECTIVE: To prospectively evaluate and quantify the efficacy of cadaveric fascia lata (CFL) as an allograft material in pubovaginal sling placement to treat stress urinary incontinence (SUI). PATIENTS AND METHODS: Thirty-one women with SUI (25 type II and six type III; mean age 63 years, range 40-75) had a CFL pubovaginal sling placed transvaginally. The operative time, blood loss, surgical complications and mean hospital stay were all documented. Before and at 4 months and 1 year after surgery each patient completed a 3-day voiding diary and validated voiding questionnaires (functional inquiry into voiding habits, Urogenital Distress Inventory and Incontinence Impact Questionnaire, including visual analogue scales). RESULTS: The mean (range) operative time was 71 (50-120) min, blood loss 78.7 (20-250) mL and hospital stay 1.2 (1-2) days; there were no surgical complications. Over the mean follow-up of 13.5 months, complete resolution of SUI was reported by 29 (93%) patients. Overactive bladder symptoms were present in 23 (74%) patients before surgery, 21 (68%) at 4 months and two (6%) at 1 year; 80% of patients with low (< 15 cmH2O) voiding pressures before surgery required self-catheterization afterward, as did 36% at 4 months, but only one (3%) at 1 year. Twenty-four (77%) patients needed to adopt specific postures to facilitate voiding. After surgery there was a significant reduction in daytime frequency, leakage episodes and pad use (P < 0.05). The severity of leak and storage symptoms was also significantly less (P < 0.002), whilst the severity of obstructive symptoms remained unchanged. Mean subjective levels of improvement were 69% at 4 months and 85% at 1 year, with corresponding objective satisfaction levels of 61% and 69%, respectively. At 1 year, approximately 80% of the patients said they would undergo the procedure again and/or recommend it to a friend. CONCLUSION: Placing a pubovaginal sling of CFL allograft is a highly effective, safe surgical approach for resolving SUI, with a short operative time and rapid recovery. Storage symptoms are significantly improved, and subjective improvement and satisfaction rates are high.     

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.     

Bladder outlet obstruction after pubovaginal fascial sling

The purpose of this cross-sectional study was to evaluate patients’ satisfaction and urodynamic findings in women undergoing pubovaginal fascial sling procedure. We have evaluated, clinically and urodynamically, 45 women who underwent the rectus fascia pubovaginal sling for urodynamically proven stress urinary incontinence with at least 12 months of postoperative follow-up. After a mean follow-up of 25 months, 93.3% of patients reported being stress continent and 73.3% were satisfied with the result of the surgery. Patients with longer follow-up had a significantly lower satisfaction score (6.4 vs. 9.3, p = 0.005). Using the Blaivas–Groutz nomogram, some degree of obstruction was observed in 51.1% of women. Storage symptoms were related to obstruction (p = 0.004), longer follow-up (p = 0.022), and negative impact on quality of life. Half of the patients had some degree of obstruction, which was directly related to urge syndrome and decrease in quality of life.     

Treating stress urinary incontinence in female patients with neuropathic bladder: the value of the autologous fascia rectus sling

Objective/background

The aim of this study was to evaluate the efficacy of the autologous fascia rectus sling in treating stress urinary incontinence in female patients with neuropathic bladder. Furthermore, correlations between preoperative parameters and outcome were evaluated.

Methods and design

We retrospectively reviewed operative logs from a single surgeon (EM) of 33 female patients with neuropathic bladder treated over a 3-year period for stress urinary incontinence by implantation of an autologous fascia rectus sling. Efficacy was evaluated objectively in terms of the number of pads used per day, while subjective patient satisfaction was also recorded using a global assessment question. Possible correlations between age, obesity, preoperative Valsalva leak point pressure and incontinence severity and outcome were investigated using univariate analysis.

Outcome measures and results

The mean follow-up time was 52?months, while the mean age of the patients was 37?years. Causes of neuropathic bladder were myelomeningocele in 21 (63.63?%) and spinal cord injury in 12 patients (36.36?%). A total of 30 patients were successfully treated and satisfied with the outcome of the operation (90.9?%). Twenty-five patients (75.75?%) were totally dry, while 5 patients (15.15?%) had markedly improved but still required one pad per day. The complication rate was 15.20?%. Univariate analysis failed to show any correlation between the final outcome and the checked parameters.

Conclusion

The free autologous rectus fascia sling is a highly effective technique for the treatment of female stress incontinence in patients with neuropathic bladder, while the morbidity is mild.     

Surgical management of lower urinary mesh perforation after mid-urethral polypropylene mesh sling: mesh excision, urinary tract reconstruction and concomitant pubovaginal sling with autologous rectus fascia

Introduction and hypothesis

We present our management of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling using a novel combination of surgical techniques including total or near total mesh excision, urinary tract reconstruction, and concomitant pubovaginal sling with autologous rectus fascia in a single operation.

Methods

We retrospectively reviewed the medical records of 189 patients undergoing transvaginal removal of polypropylene mesh from the lower urinary tract or vagina. The focus of this study is 21 patients with LUT mesh perforation after mid-urethral polypropylene mesh sling. We excluded patients with LUT mesh perforation from prolapse kits (n?=?4) or sutures (n?=?11), or mesh that was removed because of isolated vaginal wall exposure without concomitant LUT perforation (n?=?164).

Results

Twenty-one patients underwent surgical removal of mesh through a transvaginal approach or combined transvaginal/abdominal approaches. The location of the perforation was the urethra in 14 and the bladder in 7. The mean follow-up was 22 months. There were no major intraoperative complications. All patients had complete resolution of the mesh complication and the primary symptom. Of the patients with urethral perforation, continence was achieved in 10 out of 14 (71.5 %). Of the patients with bladder perforation, continence was achieved in all 7.

Conclusions

Total or near total removal of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling can completely resolve LUT mesh perforation in a single operation. A concomitant pubovaginal sling can be safely performed in efforts to treat existing SUI or avoid future surgery for SUI.