1. Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology
Weil-Cornell Medical Center
Adjunct Professor of Urology
SUNY Downstate Medical Center

2. Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity
De-novo
Persistent
Erosion
Wrong indication

3. Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI

4. Urethral Obstruction Clinical: Urodynamics: De-novo symptoms
Weak stream
OAB
negative Q-tip angle
Urodynamics:
High detrusor pressure / low flow: pdetmax > 20 cm H20 Qmax < 12 ml/S
Blaivas Groutz nomogram

5. - 45O

6. High pressure (pdetmax = 75)
Low flow (0)
High pressure (pdetmax = 75)
MSCO

7. Blaivas - Groutz Nomogram
Figure 1.Blaivas-Groutz Nomogram divides woman into 4 groups.
Blaivas & Groutz, Neurourol & Urodynam 19: , 2000

8. Rx of Post op Urinary Retention
Depends on type of sling
Initial Rx intermittent catheterization
Synthetic sling
early intervention days – weeks
Autologous slings
Delayed intervention – months

9. Rx of Post op Urinary Retention
? Need for further workup
Q-tip
cystoscopy
urodynamics

10. Surgical Rx of Sling Obstruction
Sling incision
midline
lateral
Urethrolysis
antero-lateral
circumferential
+/- Martius flap interposition
Technique determined intraop

11. Transvaginal Incision of Sling
Slightly curved/horizontal incision over sling
Dissect superficial to sling
Identify normal urethra
Mobilize small vaginal wall flap & identify sling

13. Transvaginal Incision of Sling
Grasp sling with Allis clamps & pull outward
Dissect between sling & urethra
Incise sling in midline
Sling should spring apart

16. Sling Incision Results
Type
Success %
SUI %
Nitti, et al 19
Midline Incision
84%
17%
Amundsen, et al 32
Various
94% 9%
Goldman,
et al 14
93%
21%
Nitti et al. Early results of pubovaginal sling lysis by midline sling incision. Urology 2002.
Amundsen et al. Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure. J Urol
Goldman et al. Simple sling incision for the treatment of iatrogenic urethral obstruction. Urology 2003

17. Urethrolysis
Vaginal
Supra-meatal
Retropubic

18. Urethrolysis
Vaginal
Supra-meatal
Retropubic

19. Transvaginal Urethrolysis
Inverted “U” incision over point of obstruction
Dissect superficial to obstructing tissue
Incise sling laterally on either side

20. Transvaginal Urethrolysis
Perforate endopelvic fascia at lateral margin of dissection
Mobilize vesical neck & urethra
+/- Circumferential mobilization of urethra
+/- Omental or Martius interposition

26. Circumferential Urethrolysis

27. Urethrolysis
Vaginal
Supra-meatal
Retropubic

28. Supra-meatal Urethrolysis
Transverse incision just above urethral meatus
Dissect in midline above urethra
Press down on urethra with index finger

30. Supra-meatal Urethrolysis
Incise sling/sutures under direct vision
+/- circumferential urethral mobilization
+/- Martius or omental interposition

35. Urethrolysis
Vaginal
Supra-meatal
Retropubic

36. Retropubic Urethrolysis
Transverse incision just above the pubis
Enter retropubic space
Downward pressure on bladder neck & urethra

37. Retropubic Urethrolysis
Incise sling/sutures under direct vision
Open bladder if necessary
+/- circumferential urethral mobilization
+/- Martius or omental interposition

38. Urethrolysis Results N Type Success % SUI (%) Foster & McGuire 48
Transvaginal
65% 0%
Nitti & Raz 42
71%
Cross, et al 39
72% 3%
Goldman, et al 32
84%
19%
Petrou, et al
Suprameatal
67%
Petrou & Young 12
Retropubic
83%
18%
Carr & Webster 54
Mixed
78%
14%

39. Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI

40. Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI

41. Bladder neck
Bladder neck
Eroded mesh

42. VLPP Barbara Jankowski UDS December 2005
Barbara Jankowski is a 65-year-old married woman who underwent urethral diverticulectomy in 10/04 by Judy Siegel. The diverticulum was very large and extended from the meatus to bladder neck. “The repair was buttressed with a Pelivichol patch.” .12/5/05 – incision of urethral stricture; 8/05 “stricture lasered.” on 11/10 she underwent collagen injection at the bladder neck and, at that time, a “distal urethovaginal fistula was diagnosed. She was referred to Basil Kocur and was diagnosed with multiple vesicovaginal fistulas and needed abdominal surgery. Her chief complaint is daily incontinence, but she doesn’t know for sure exactly when it happens other that to say, its worst when she is physically active and does not occur at night when she is in bed. She denies classic stress or urge incontinence. She ordinarily feels the urge to void about once an hour, but does not actually void each time. On average, the longest time she goes without urinating during the day is about three hours. The main reason she urinates as often as she does is because of normal feelings to urinate. She ordinarily initiates micturition without difficulty. The force of her stream is usually strong. She feels that she has not emptied her bladder after urinating rarely. She wears absorbent pads daily, and she changes them 6 times per day. The pads are usually clearly wet. Her AUA symptom score is 9.
CYSTOMETROGRAM: The Cystometrogram was performed using radiographic contrast and a #7 double lumen catheter via constant infusion at a 'medium' filling rate with rectal pressure monitoring and the patient sitting. Residual bladder volume was 0ml, 0 hours after voiding. Empty bladder pressure was 0cm H20. First filling sensation occurred at 240.6ml, with a detrusor pressure of 0.5cm H20. The first urge occurred at 399.7ml with a detrusor pressure of 1cm H20 and a severe urge occurred at 1,006ml, with a detrusor pressure of 2cm H20. During bladder filling there were no spontaneous involuntary detrusor contractions. Bladder capacity was 1,006 ml. Maximum filling pressure was 3cm H20. Bladder compliance was high.

44. Treatment of Erosions. remove as much of sling as possible
closure of the urethra
+/ - urethral reconstruction
+/ - biologic sling
+/ - Martius flap

45. Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI

46. Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity
De-novo
Persistent
Erosion
Wrong indication

47. Too Loose Urethral hypermobility Intrinsic sphincter deficiency
Recurrent sphincteric incontinence

48. VLPP VLLP = 92 cm H20 Qtip = 0 > 60O AG AG AG
Figure 9. Stress incontinence with urethral hypermobility and type 1 OAB. This corresponds to Type 2 SUI according to the Blaivas/Green/McGuire classification. AG is a 51 year old white woman with a chief complaint of gradually worsening stress incontinence of 10 years duration. About once or twice a month she soaks her clothes when she has been walking or does high impact aerobics. She wears one mini-pad all day which, at the end of the day is damp; "sometimes they're wetter than others”. She also gets urgency & urge incontinence when she puts the key in her door lock, but has learned to control this by voiding beforehand.
A.Urodynamic tracing. FSF = 10 ml; First urge = 251 ml; Severe urge = 492 ml. VLLP = 85 cm H2O. Bladder capacity = 585 cm H20. When asked to void, she strained a bit, but could not generate a detrusor contraction and was unable to void (light blue oval). VLPP = 50 cm H20 AG AG AG

49. Figure 9 B. X-ray exposed at VLPP shows rotational descent of the urethra and incontinence. Q-tip angle was 65O.
Comment: AG has classic type 2 stress incontinence and would likely do well after anti-incontinence surgery, but when advised of the remote possibility of urinary retention, elected behavioral therapy. AG

50. JK
VLPP = 42 cm H20
Q tip = 0

52. Treatment of Recurrent SUI
no compelling data
for hypermobility, surgeon choice
for poorly mobile or pipe - stem urethra, biologic bladder neck sling

53. Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity
De-novo
Persistent
Erosion
Wrong indication

54. Wrong Position Too far proximal Too far distal
persistent sphincteric incontinence
urethral obstruction
ureteral injury
Too far distal
urethral hypermobility

55. Sling proximal to BN
VLPP = 35 cm H20 MS

56. sling

57. No flow
High pdet
Figure . Urethral obstruction due to autologous fascial pubovaginal sling.
A. Urodyanmic tracing. There is a sustained detrusor contraction to over 75 cm H20 and no flow.This corresponds to a grade 2 urethral obstruction on the Blaivas Groutz nomogram.
MSCO

58. Fig B.X-ray exposed at pdetmax shows complete obstruction of the urethra at the bladder neck (black arrow), presumably from a prior sling operation. Note the left vesicoureteral reflux (white arrows)
MSCO

59. MSCO
C. The vesicoureteral reflux extends into the kidney and distends the collecting system.(grade 3).

60. Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity
De-novo
Persistent
Erosion
Wrong indication

61. Wrong Indication Urinary fistula mistaken for sphincteric incontinence
Overactive bladder mistaken for sphincteric incontinence
Sine-qua-non - Never operate on stress incontinence without actually diagnosing sphincteric incontinence with your own eyes

62. Conclusion
Complications & failures after incontinence surgery are not uncommon
Early evaluation to rule out remediable causes should be undertaken
UTI
Urethral obstruction
sling erosion
foreign body
A successful outcome is likely in the majority of patients