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Midurethral slings for female stress urinary incontinence
1. for female stress urinary incontinence
AMIR Saad aljboory
3rd grade urological resident
2. The Evolution of Slings
von Giordano, 1907”gracilis muscle
•Goebell 1910”pyramidalis muscle
•Frangenheim 1914”abdominal wall fascia with pyramidalis
•Stoeckel 1917”same as Frangenheim
•Price 1933”fascia lata
•Aldridge 1942”rectus fascia
•Ridley 1974 description of sling in textbook
•Zoedler 1961”gauze hammock synthetic sling
Needle suspension 1980
Periurethral bulking
McGuire 1994”Contigen® injection
3. Tension-free Vaginal tape
The surgical management of female SUI has been deeply changed when Ulmsten described a new
concept in 1995:
the mid-uretheral support without tension (TVT). FDA APPROVED in 1998
In 2001, Delorme described a new approach(TOT) eliminating the complications related to the
penetration of the retro-pubic space
single-incision sling (SIMS) operation was introduced in 2006
4. Pathophysiology of stress incontinence
Sphincteric Dysfunction Theory
Agency for Health Care Policy and Research, 1992
SUI: the condition of ISD “intrinsic sphincteric deficiencyʼʼ
In this condition, the urethral sphincter is unable to generate enough resistance to
retain urine in the bladder especially during stress maneuver
5. Hammock hypothesis
In 1996, De Lancey proposed a consolidated theory
He hypothesized that the pubo-cervical fascia provides a hammock like support for
the vesical neck and there by creates a backboard for the compression of proximal urethra during
increased intra abdominal pressure.
Loss of this support would compromise equal transmission of intra abdominal pressure
6. Integral theory (1990)
The continence of female depend on adequate functions of three factors
1. Pubourethral ligaments
2. Suburethral vaginal hammock
3. Pubococcegus muscles
7. Based on these theories
Pubovaginal slings are placed under mild tension at the bladder neck
To re establish the suburethral hammock
Mid urethral slings are placed loosly at the mid urethra to prevent movement of post.
Urethral wall.
8. Pre operative assessment ( AUA guidline)
Initial evaluation (Basic evaluation)
1. Focused history
2. Focused physical examination
3. Objective demonstration of SUI
4. Assessment of urinalysis
5. Assessment PVR
10. 1. uncertain diagnosis
2. Inability to demonstrate SUI objectively
3. Known or Suspected neurological cause
4. Abnormal urinalysis
5. Urgency predominant mixed UI
6. High PVR
7. HIGH grade POP if SUI NOT demonstrated by POP reduction
8. Previous anti incontinence surgery or previous sx for POP
11. PVS is placed at the bladder neck
Its effective for both uncomplicated and
complicated SUI :
1. deficiency of mid urethral complex
2. MUI
3. Concomitant cystocele or urethral diverticulum
4. ISD
5. Neurological conditions
12. PVS is effective for Failed previous retropubic suspensions or MUS
PVS Materials :
Autologus : most commonly used rectus abdominis fascia & fascia lata
The PVS using autolougus fascia remains for management all forms of SUI
Allograft : cadaveric facia lata(CFL) OR acellular human dermis
Xenograft
Prosthetic materials : polypropylene mesh
13. Anaesthesia : general or spinal
Hydrodistention of vagina
Empty bladder (foley cath inserted )
Incision either inveted U shape 2 cm below the urethral meatus or mid line vaginal incision.
2 suprapubic incisions
Cystoscopy should be done postoperative.
14.
15.
16. 90% Success rates ( 24% _ 97% )
PVS is an effective treatment for recurrent SUI.
UUI developed in 2 % to 22%
Persistent urinary retension is less than or equal 5%
Preoperative DO may be associated with decrease the success rate of surgery
Complication depend on sling materials , more with synthetic
17. In recent years, midurethral synthetic slings have replaced pubovaginal slings as the
gold standard for surgical correction of stress urinary incontinence
MUS impending the movement of the posterior urethral wall above the sling directing its
movement anterio- inferior or ant.
MUS narrowing of urethral lumen ( compression)
Retro-pubic trans-obturator
19. Sling material
Synthetic mesh :
macroporous, monofilament (Prolene)
Relative resistant to infection & inflammation
Early and sustained filling with fibrous connective tissue & capillaries
Promote tissue host in-growth with integration lead to anchoring mesh
within tissue
Inflammation reduce with time
20. The sling is anchored to the endopelvic fascia(paravaginal connective tissue
or pubocervical fascia) for retropubic directed sling &
to obturator internus and externus m and fascia for transobturator directed slings.
MUS are placed typically at least 2cm from mid line , ?
Incisions 1.5cm from the meatus will provide access to the midurethra
The surgery begins with dissection in the vesicovaginal space
22. Transobturator:
Delorme 2001: thru the obturator foramen
Avoid passage thru retropubic space : decrease bladder,bowel, vessel injury
Decrease in voiding dysfunction
Less OT time
Trocar passage btw vaginal incision -- obturator membrane
--- obturator internus muscle ---- groin incision below adductor muscle insertion
“outside-in”: Transobturator tape (TOT)
“inside-Out”: TVT-O
23. TVT
Dorsal lithotomy position, Foley cath.
Mark abdominal percutaneous puncture and mid-urethral vaginal wall incision
Midline ant vaginal wall incision at level of mid urethra
Dissect vaginal wall off laterally to develop space btw vaginal wall & urethral & paraurethral
tissue until the junction of pubic ramus & urethropelvic complex is reach
2x 5mm stab incision over top of pubic symphysis 2.5cm from midline on either side
24.
25. CONTRAINDICATIONS
•Pregnancy
•Women with plan for future pregnancy
significant detrusor instability
• Urethrovaginal fistula
• Urethral diverticulum
• Intra-operative urethral injury
• Untreated urinary malignancy
27. TOT
The transobturator sling (tot sling) is subfascial, ie the needle or the sling
NEVER enters the retropubic space
28. WHO are the suitable for TOT ?
Where suprapubic route is not preferred
Transplant
Neobladder
Obese patients
Multiple prior retropubic surgery
Patient’s choice
29.
30. Obturator approach (TOT) shows identical urinary results to the retropubic
approach.
Major hemorrhage and bowel perforation are excluded in the TOT
procedure.
Thus simplicity, safety and continence result mean that the obturator
approach is the best method of suburethral tape insertion for the
treatment of USI
31. PROCEDURE
Dorsolithotomy position
Thigh at right angle to pelvis for better access to obturator foramen
1cm incision ant vaginal wall at mid-urethra
A point in the groin fold level with the clitoris is selected and a 5 mm
incision is made on each side
Safer approach with less bowel and bladder injury
34. no difference btw the two TOT.
Thigh/groin pain 16%
De novo urgency 4%
Urinary retention 2%
Vaginal erosion 2%
Urethral perforation 1%
Vaginal perforation 1%
Bladder perforation 0.5%
35.
36. Suburethral sling made of polypropylene
surgical mesh and a surgical placement instrument, placed beneath the
urethra via a transobturator approach through a single
vaginal incision.
37. The slings and their delivery systems are intended for single use only.
They have self-fixating tips that allow fixation into the obturator internus muscle,
which is located partially within the lesser pelvis and the back of the hip joint.
Fixation can also occur in the levator fascia
38.
39. AUA SUI guidelines :
immaturity of evidence regarding SIMS efficacy and safety .
