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

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Presentation on theme: "Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center."— Presentation transcript:

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 Clinical: –De-novo symptoms Weak stream OAB negative Q-tip angle Urodynamics: –High detrusor pressure / low flow: pdetmax > 20 cm H 2 0 Qmax < 12 ml/S –Blaivas Groutz nomogram Urethral Obstruction

5 - 45 O

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

7 Blaivas - Groutz Nomogram 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

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

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16 NTypeSuccess %SUI % Nitti, et al19Midline Incision84%17% Amundsen, et al 32Various94%9% Goldman, et al 14Midline Incision93%21% Sling Incision Results Nitti et al. Early results of pubovaginal sling lysis by midline sling incision. Urology 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

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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

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

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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 NTypeSuccess %SUI (%) Foster & McGuire 48Transvaginal65%0% Nitti & Raz 42Transvaginal71%0% Cross, et al 39Transvaginal72%3% Goldman, et al 32Transvaginal84%19% Petrou, et al 32Suprameatal67%3% Petrou & Young 12Retropubic83%18% Carr & Webster 54Mixed78%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 Eroded mesh

42 VLPP

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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 Intrinsic sphincter deficiency Urethral hypermobility Recurrent sphincteric incontinence

48 VLPP AG VLLP = 92 cm H 2 0 Qtip = 0 > 60 O

49 AG

50 JK VLPP = 42 cm H20 Q tip = 0

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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 –persistent sphincteric incontinence –urethral obstruction –ureteral injury Too far distal –persistent sphincteric incontinence –urethral obstruction –urethral hypermobility

55 MS VLPP = 35 cm H 2 0 Sling proximal to BN

56 sling

57 MSCO High pdet No flow

58 MSCO

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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


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