The Gold Standard: Autologous Fascial Pubo-Vaginal Sling

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Presentation transcript:

The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University Adjunct Professor of Urology SUNY Downstate Medical School

Cartoon of taking fascia

Surgical Technique Horizontal suprapubic incision (4 cm) Excise rectus fascial strip (6 – 8 cm) Temporarily leave fascia open Horizontal incision over vesical neck

Surgical Technique Mobilize vesical neck from below Perforate endopelvic fascia Create tunnel & pass sling around vesical neck Cystoscopy

Surgical Technique Close vaginal wound Bring sutures through fascia Close rectus fascia Suture ends of sling together in midline without tension Close abdominal wound

Cartoon of skin incision

Picture of Cartoon of skin incision

Balloon Incision

Allis clamps

Push up with index finger on vaginal wall Traction of clamp

Left index finger pushing up on vaginal wall Shiny white surface superficial to pubo-cervical fascia

Right wrist flexed downward

Incorrect (deep) plane Correct (superficial) plane

Correct plane Incorrect plane Vaginal wall Pubo-cervical fascia

Correct (superficial) plane Pubo-cervical fascia Incorrect (deep) plane

Index finger between clamp & urethra & bladder at all times

Separate Fascial incision Inferior edge of rectus Separate Fascial incision Separate stab wound for sling

Ends of sling thru fascia Sutures through separate stab wounds in rectus fascia Ends of sling thru fascia

How much tension? None (create a backboard) (Almost) can’t make it too loose Make sure Q-tip is not negative (elevation of vesical neck)

Take slack out of sling Push down on cystoscope parallel to the floor

Tie loosely with no tension

URINARY INCONTINENCE OUTCOME SCORE Groutz & Blaivas, Neurourol & Urodyn 19:127, 2000.

Urinary Incontinence Outcome Score

PVS for Simple & Complex SUI OUTCOME SCORE 93% 7%

PVS for Simple SUI OUTCOME SCORE 100% 0%

Mixed Incontinence Cure/Improved Rates (UIOS <= 4) : SUI: 97% (n= 44) MUI: 93% (n= 47) non-significant difference (p: 0.33), with study powered a priori to detect > 20% difference in outcome score Chou et al, J Urol, 2003

Autologous Sling Outcomes Cure/Improve rate - 82% at 4 years Urinary Retention requiring intervention - 8% De Novo OAB - 9% (Dmochowski, et al. AUA Guidelines on the Surgical Management of Female Stress Urinary Incontinence, 2010)

Conclusions Pubovaginal sling effective for: Urethral hypermobility Intrinsic sphincter deficiency Mixed incontinence Long lasting results Minimal morbidity

Conclusions Recurrent stress incontinence is rare Major risk factor for recurrent SUI is “pipe stem” urethra Urge incontinence is the most common cause of failure Major risk factor for UI is: increasing # of preop urge episodes increasing # of preop UI episodes

Conclusions Permanent urinary retention is rare Risk factors for permanent urinary retention are : preop areflexic neurogenic bladder grade 3 or 4 cytocele excessive sling tension > urethral obstruction