2. • Anti-incontinence surgery- address the failure of normal anatomic
support of the bladder neck and proximal urethra, and intrinsic
sphincter deficiency.
• Anti-incontinence surgery does not necessarily work by restoring
the same mechanism of continence that was present before the
onset of incontinence.
• Rather, it works by a compensatory approach, creating a new
mechanism of continence.
3.
4. Choice of surgical technique.
• If hypermobility of urethra is cause –retropubic procedures is
preferred.
• If ISD- SUI might persist after retropubic procedure, hence sling or
artificial sphincter is preferred.
5. Specific Indication for open retropubic approach.
• (1) Patient undergoing a laparotomy for concomitant abdominal
surgery that cannot be performed vaginally.
• (2) Where there is limited vaginal access.
6. Potential Contraindications
1. H/O prior failed incontinence procedures- PVS to be considered.
2. SUI solely because of ISD.
3. Inadequate vaginal length or mobility of the vaginal tissues,
example-prior vaginal surgery, radiotherapy, prior vaginal
incontinence procedure.
7. Variables affecting outcome of therapy:
Age- Not a C/I to colpo-suspension: Success rate same in elderly and young.
Obesity- no data to suggest superiority of one surgical technique over another in the
obese population.
Surgery for recurrent stress incontinence has a lower success rate.
• Burch colpo-suspension - 81% success rate after 1 failed surgery .
• 25% after 2 previous repairs.
• 0% after 3 previous operations.
Duration of symptoms - predictor of outcome, better response in those with a shorter
history.
23% women undergoing UDS have mixed urodynamic stress incontinence and DO. Cure
rate in this population is 75%,and 95% in sui. Surgery not C/I ,but pts should have realistic
expectations of outcome.
8. Surgical procedures
• Open retropubic colpo-suspension- surgical approach of lifting the tissues near
the bladder neck and proximal urethra into the area of the pelvis behind the
anterior pubic bones.
• Incision- lower abdomen.
4 variations of open retropubic colpo-suspension:
• 1.Marshall-marchetti-krantz (MMK).
• 2.Burch colpo-suspension.
• 3.Vagino-obturator shelf (VOS).
• 4.Paravaginal procedures.
9. 1.The Burch colpo-suspension.
• Elevation of the ant. vaginal wall and para-vesical tissues
toward the iliopectineal line with use of 2 to 4 sutures on
either side.(2 cm lat to bladder neck).
• Sutures tied loosely so that 2 fingers can be placed between
the symphysis and urethra.
• This achieves broad support for the urethra and bladder neck
and minimizes the risk of postop voiding dysfunction.
• Medio-lateral direction of sutures.
10.
11. Re-operative Surgery
• Poorer results.
• Scarring and fibrosis from previous surgery can prevent adequate
suspension in some cases, and suture cut-through is more likely.
12. 2.The VOS repair(Turner-Warwick).
• Anchor the vagina to the internal obturator fascia.
• Here placement of the sutures is laterally.
• Tanagho’s modification-(Hybrid) insert stitches into the internal
obturator fascia and iliopectineal line.
15. 3.The paravaginal defect repair.
• Aims to close a presumed fascial weakness laterally at the site of
attachment of the pelvic fascia to the internal obturator fascia.
• ICS Recommendation- Paravaginal defect repair is not recommended
for the treatment of SUI alone (grade A recommendation).
16.
17. 4.The MMK procedure
• Suspension of the bladder neck toward the periosteum of the
symphysis pubis.
• Was thought to buttress the paraurethral area and bringing the
vesicourethral junction into a more elevated “intra-abdominal”
position.
18.
19. Complications specific to MMK repair.
• Rate-21% of cases.
• Placement of sutures through the pubic symphysis- risk of osteitis
pubis, reported in 0.9% to 3.2%.
• Risk of tethering the urethra influencing the function of the urethral
sphincter mechanism.
• Risk of urethral obstruction with the paraurethral sutures.
• ICS does not recommend MMK procedure for treatment of
SUI.(Grade A recommendation).
20.
21. General considerations.
• Retropubic Dissection- modified dorsal lithotomy position, allowing
access to the vagina during the procedure and a perineal-abdominal
progression.
• Foley catheter is inserted.
• Incision- Pfannenstiel or lower midline abdominal.
• Dissection over the bladder neck and urethra in the midline to be
avoided so as not to damage the intrinsic musculature.
• Suture used- surgeon choice , aim is to achieve adequate fibrosis ,
non absorbable-risk of erosion into bladder.
22. General considerations.
• Voiding trial on pod 5.
• Efficient voiding- PVR volume either <100 mL or less than 30% of the
functional bladder volume.
• Drain- kept in retropubic space, i/v/o bleeding from peri-vaginal
veins- removed from 1st to 3rd day when minimal output is noted.
24. Recommendation from the international consultation
on incontinence committee.
• Open retropubic CPS - effective treatment modality for SUI, especially
in the long term. (primary or secondary surgery)
• Within the 1ST year of surgery, overall continence rate is 85% to 90%.
• After 5 years approx. 70% of patients can expect to be dry.
• Lap colpo-suspension - allows speedier recovery, but its relative safety
and long-term efficacy remain to be established (lapitan et al., 2017).
• Burch CPS should be regarded as the standard open retropubic CPS
procedure.
25. Prophylactic Colpo-suspension.
• Colpopexy and Urinary Reduction Efforts (CARE) trial (2006) –
• The postop risk of stress incontinence in stress continent women
undergoing open abdominal sacro-colpopexy could be substantially
reduced by the addition of a Burch colpo-suspension.
• Initial results at 3 months- reduction of stress incontinence from 44%
in the untreated group to 24% in the Burch group, without increased
rates of voiding dysfunction or urgency symptoms.
• Subsequent 1- and 2-year outcomes from the trial showed continued
benefit in pts who received the concomitant Burch procedure.
26. Laparoscopic retropubic suspension.
• Lap colpo-suspension- short-term benefits over open surgery.
• Longer operative time.
• Medium-term results from a large, multicenter trial show the
effectiveness of lap colpo-suspension and are encouraging.
• If lap surgery is performed- the use of 2 paravaginal sutures appears
to be the most effective method.
• No long-term data available.
27. Laparoscopic retropubic suspension
• Only recommended for the surgical treatment of SUI in women by
surgeons with appropriate training and expertise (grade C
recommendation).
• Pt should be advised about the limited evidence available about the
long-term durability of lap colpo-suspension (grade C
recommendation).
28. Complications of retropubic repairs.
• 1.Postoperative voiding difficulty-
• Due to overcorrection of the urethro-vesical angle.
• Temporary urinary retention lasting more than 4 weeks postop-- 5%.
• Permanent retention- less than 5%.
• No significant difference from those of PVS.
• All patients to be counseled about need of CIC.
29. Complications of retropubic repairs.
• 2.Bladder Overactivity-
• Accompanies anatomic SUI,preop incidence is as high as 30% in pts
undergoing either first correction or repeated operations.
• Provided it is considered as a diagnosis, UDS has shown DO, an
attempt at treatment of the OAB symptoms has been made (with or
without success), and patient has been advised that the presence of
DO will increase the risk of continuing storage symptoms post-op,
then pre-operative bladder overactivity does not contraindicate a
retropubic suspension procedure, provided that anatomic SUI has
also been demonstrated.
30. Complications of retropubic repairs.
• 3.Vaginal Prolapse-
• Retropubic CPS alter vaginal and bladder Base anatomy, thus postop
vaginal prolapse is a potential complication.
• Genitourinary prolapse post Burch CPS reported in 22.1%.
• The Burch procedure, because of lateral vaginal elevation, may
aggravate posterior vaginal wall weakness, predisposing to
enterocele(Incidence - 3% to 17%).
• Prophylactic obliteration of pouch of douglas is sometimes
considered in performing retropubic suspensions to prevent
enterocele.
31. Comparisons of incontinence procedures.
• Retropubic Repair Versus Pubovaginal Sling-
• No significant difference in cure rates between retropubic Burch
procedure and PVS.
• Cochrane review by Lapitan et al. (2017)- autologous fascia PVS better
than CPS at mid-term to long-term follow-up, but with a higher rate
of early postop voiding dysfunction.
32. Tension-Free Vaginal Tape Procedure V/s Colpo-suspension
• 7-year objective and subjective success rate for TVT is 81%.
• At this time, TVT/TOT is equivalent to Open or lap Burch CPS, but have
largely supplanted CPS in practice.
• Open colpo-suspension- an option in pts undergoing open surgery and still
has a role when there is associated prolapse.
• Inform about the A/E of the 2 procedures-
1. Open CPS- associated with POP, particularly in the long term.
2. Sling surgery- higher risk for postop voiding dysfunction and late tape
erosion.
33. SLINGS- PUBOVAGINAL SLINGS.
• Procedure of choice for the surgical correction of female SUI.
• First use in 1907 by Von Giordano - Gracilis muscle graft.
• Blaivas and Olsson (1988)- completely detached the rectus fascial
strip at both ends and perforated the endopelvic fascia on either side
of the urethra to gain access to the space of Retzius.
• 1998- the U.S.FDA approved the first MUS for use in women with SUI.
34. Theories of UI causation.
• 1.Hypermobility theory- loss of structural urethral support resulting
in varying degrees of descent of the bladder neck and urethra causing
sui.
• 2.Hammock theory(DeLancey’s theory)- the pubo-cervical fascia
provides hammock like support for the vesical neck and thereby
creates a backboard for compression of the proximal urethra during
increased intra-abdominal pressure, loss of this support leads to UI.
35. Theories of UI causation.
• 3.Integral theory- (Petros and Ulmsten) (1990).
• Suggests that UI and SUI are caused by laxity in the vaginal wall
and/or surrounding structures (such as pubo-urethral ligaments).
• Means continence is maintained at mid-urethra with support from
vaginal wall and pubo-urethral ligaments.
• Stretch receptors in the bladder neck gets activated during increased
abdominal pressure with urine deposition in the proximal
urethra/bladder neck, contributing to urgency incontinence.
36. Theories of UI causation.
• 4.Intrinsic Sphincteric Deficiency- ISD implies the sphincter activity is
dysfunctional, whether because of a neural or a structural problem.
• Pts have a “pipestem” urethra, meaning a fixed urethra with little
intrinsic closure function.
• Cause-
1. Previous surgery.
2. Secondary to ischemic injury (birth or other trauma).
3. Progressive pudendal nerve damage.
• Low VLPP (less than 60 cm H2O) has been associated with ISD.
37. PVS MOA
• Based on these theories, PVS are placed under mild tension at the
bladder neck to reestablish the sub-urethral hammock—Dynamic
urethral compression without obstruction.
• Goal - provide adequate urethral coaptation and increase urethral
responsiveness to abdominal pressure.
• MUS are placed loosely at the mid-urethra to prevent movement of
the posterior urethral wall.
38. Preoperative assessment (AUA guideline)-
• Components of an initial evaluation of a woman with SUI who is desiring
surgical intervention:
• Focused history-
• Including assessment of bother (e.g., Via validated questionnaire, e.g-Urinary
distress inventory(UDI)-6, Incontinence quality of life (IQoL) Questionnaire).
• Ask about onset, frequency, character, and severity of the incontinence, storage
and voiding symptoms.
• Factors that worsen incontinence, such as sexual intercourse or exercise.
• Assess degree of baseline urinary urgency, as it correlates with poorer outcomes
after sling surgery.
• H/O Neurologic diseases, medications, prior surgeries, and pelvic radiation, fecal
incontinence.
39. Preoperative assessment
• Focused physical examination (including pelvic examination)-
• Both at rest and with provocative maneuvers (i.e., Valsalva and
coughing):
• Assess vaginal anatomy, urethral meatus and vaginal support (i.e.,
POP); quality of vaginal tissues, the degree of urethro-vesical
hypermobility, fistulae, foreign materials, anatomic abnormalities.
40. Preoperative assessment
• Objective demonstration of SUI with full bladder (e.g., Cough or valsalva
stress test).
• If a supine stress test with a full bladder does not demonstrate urinary
incontinence, then a standing stress test should be performed.
• PVR (any method).
• Urinalysis.
• Based on the AUA SUI guideline, a urinalysis and measurement of PVR
volume should be performed in all women, but more extensive imaging is
not a part of the initial evaluation of a woman with a complaint of SUI.
41. AUA Indications for Additional testing-
• Inability to make a definitive diagnosis based on symptoms and initial evaluation.
• Inability to objectively demonstrate SUI.
• Known or suspected neurogenic lower urinary tract dysfunction (e.g., Multiple
sclerosis).
• Abnormal urinalysis (e.g. Unexplained hematuria or pyuria).
• Urgency predominant mixed urinary incontinence (MUI).
• Elevated PVR.
• High-grade POP (POP-Q stage ≥3) if SUI is not demonstrated by POP reduction.
• Concomitant overactive bladder (OAB) symptoms.
• Failure of previous anti-incontinence surgery.
• Previous surgery for POP.
42. Additional testing include Imaging, Cystoscopy, and
UDS.
• Imaging of the upper urinary tract- if concomitant hematuria or
suspected neurogenic dysfunction.
• MRI of the head, spine, and pelvis may be useful to detect spinal cord
or brain lesions.
• Cystoscopy should not be performed in the evaluation of SUI unless
there is a concern for urinary tract abnormalities, such as neoplasia or
foreign body.
43. UDS
• May be omitted when SUI is clearly demonstrated.
• ValUE trial (Value of Urodynamic Evaluation)-
• Randomized SUI pts into 2 arms-
• 1st arm- UDS before surgery.
• 2nd arm- Only clinical evaluation before anti-incontinence surgery.
• Outcome- preoperative office evaluation alone was not inferior to
evaluation with UDS for 1-year outcomes after SUI surgery in women with
uncomplicated, demonstrable SUI.
• UDS Costly.
• To be done in the above indications of additional testing.
44. PVS indications- highly versatile.
1. For both uncomplicated and complicated SUI(of all causes).
2. Neurogenic sui, eg- myelodysplasia, PVS is effective for the SUI
that occurs between CIC once a thorough UDS has confirmed
sufficient bladder capacity and compliance.
3. Reconstruction of the urethra after damage secondary to trauma,
synthetic mesh (or graft) perforation, and iatrogenic hypospadias.
4. Interposition during urethral repairs of urethrovaginal fistulae or
urethral diverticula.
5. Treating recurrent SUI after failed retropubic suspensions or MUS
placement.
• PVS using autologous fascia remains the gold standard for
management of ALL forms of SUI.
45. PVS types -Autologous, Allograft, Xenograft,
and synthetic materials.
• Adv of biologic grafts and synthetic prosthetics- decreased operative
time, morbidity, pain, and length of hospital stay.
1.Autologous -Gold std.
• Adv- bio-compatible, no urethral perforation.
• Disadv- increase in operative time, hospital stay, postoperative pain,
and harvest site complications.
• Mc used- Rectus abdominis fascia>fascia lata >>vaginal epithelium.
46. Fascia lata graft.
• Used when h/o prior ventral hernia repair.
• Harvested from lateral thigh, has similar properties to rectus fascia.
• Adv- recovery time is less, no abdominal harvest site complications.
• Disadv- additional operative time, area unfamiliar to most pelvic
surgeons.
• Thigh pain- short-term sequela- 67% of women had pain on walking
for 1 week after fascia lata harvest.
• Only 7% of women complained of pain at the incision site 1 week
after harvest using a crawford fascial stripper.
• Thigh muscle herniation- when large strips of fascia are removed.
• The rate of thigh herniation was 51% with a 10- to 20-cm fascial graft
and 0% with a 1.5-cm by 12- to 15-cm fascial graft.
47. Vaginal epithelium- not used much.
• Disadvantage-
1. Lack sufficient tensile strength.
2. Risk for epithelial inclusion cyst formation.
3. Vaginal shortening.
48. PVS Allograft Materials.
1. Cadaveric fascia lata (CFL).
2. Acellular human dermis.
• After harvest- processed by 2 methods.
A. Solvent dehydration.
B. Lyophilization (freeze-drying).
• Remove genetic material and to prevent the transmission of infectious agents(risk
CJD-1 in 3.5 mill,hiv-1 in 1,667,600,risk of hepatitis transmission unknown).
• Secondary sterilization can be done by gamma radiation.
• Macrophages phagocytose the graft gradually-degrades-failure-reoperation.
• Solvent dehydrated materials have higher maximal load bearing capacity.
49. PVS Xenograft Materials
1. Porcine (dermis, small intestinal submucosa (SIS), or bladder
acellular matrix graft).
2. Bovine (dermis or pericardium).
• Intense inflammatory reaction in 30 to 90 days after implantation.
• Porcine SIS has less tensile strength than cadaveric fascia lata.
• Highest propensity to encapsulate, isolating the graft from the
periurethral tissue. Appeared similar to their original appearance at
time of implantation.
50. PVS Synthetic Prosthetic Materials.
• Suboptimal for placement at the bladder neck- perforation.
• Historical value as PVS.
• Mainly used as MUS.
• Mc used mesh- Type 1 (Amid classification)-
• Macro-porous, pores > 75 µm.
• Adv- macrophages, fibroblasts, blood vessels, and collagen fibers
ingrowth.
• Eg- Polypropylene.
51. Operative procedure PVS.
• Type- Clean contaminated case.
• Position- dorsal lithotomy
• Weighted speculum placed in vagina,18-Fr Foley(14 fr) in urethra.
• A vaginal ring retractor- improves visualization and ease of dissection.
52. Graft Harvest from rectus abdominis fascia.
• A 6- to 7-cm pfannenstiel incision, approx 2 cm above the pubic
symphysis-ensures tension free fascial closure.
• A 2-cm × 8-cm graft is marked on the rectus fascia in a transverse or
longitudinal direction and harvested using scalpel.
• Fascia closed with a running no. 1 polydioxanone suture (PDS).
• Graft is placed in 0.9% normal saline solution.
• A separate no. 1 PDS suture is secured to each end of the graft.
• Each suture should be placed perpendicular to the sling fibers and
tied. Sutures are left long.
53. Graft harvest-Fascia lata.
• Greater trochanter and lateral femoral condyle of the femur are
marked.
• These landmarks denote the proximal and distal attachments of the
fascia lata.
• 3-cm longitudinal incision is marked just above the patella over the
iliotibial band.
• Dissection is carried down to the fascia lata, and 2 parallel,
longitudinal, incisions are made 2 cm apart.
54. Graft harvest-fascia lata.
• Graft is lifted off the underlying muscle and clamped as far distally as
possible with a right-angle clamp (3 cm to 4 cm) and transected,
allowing one free end.
• The free end is secured with a No. 1 PDS, and the proximal fascia lata
is lifted off the muscle belly.
• With the free distal end under tension, a Crawford fascial stripper is
used to extend the fascial incision proximally and divide it before
removal.
• Shorter lengths (8 cm X 2 cm) are now commonly used to prevent
thigh muscle herniation.
55. Graft harvest-fascia lata.
• A second no. 1 PDS is secured to the other free end of the graft.
• Immediate compression is applied to the thigh
• The wound is closed in three layers without closing the fascia lata-to
prevent compartment syndrome.
• Compressive bandage to remain in place for 8 hours postoperatively
and early ambulation should be encouraged.
56.
57. Operative procedure PVS.
• Hydrodissection- inject 0.9% sterile normal saline/lignocaine and
adrenaline into the vaginal epithelium corresponding to the mid-
urethra and bladder neck- aid in tissue dissection.
• Incision- inverted U- provides excellent exposure of the urethra to the
level of the bladder neck and direct access to the endopelvic fascia &
retropubic space.
• Alternatively, a midline vaginal incision can be used.(our practice).
• The top of the incision is made approx 2 cm below the urethral
meatus and the arms of the inverted U-incision should extend to the
level of the bladder neck (determined by palpation of the Foley
balloon).
58.
59. Operative procedure PVS.
• Thick vaginal epithelial flaps are created with scissors.
• Angle scissor toward the ipsilateral shoulder and the tips pointed upward, the
endopelvic fascia is perforated by remaining directly medial and immediately
under the ischiopubic ramus at the superior margin of dissection.
• Empty bladder before this maneuver and again before the passage of stamey
needles or larger clamps.(Kelly clamp).
• Perforation occurs in a superolateral direction.
• Using blunt finger dissection,retropubic space is dissected on either side of the
urethra.
60. Operative procedure PVS.
• Stamey needles/kelly clamp are passed from above, through the abdominal incision by
careful guidance behind the pubis-for suture advancement.
• The needles are in contact with the pubis until they are brought out lateral to the
bladder into the vaginal incision.
• Bladder must be completely drained.
• Cystoscopy should be performed with a 70-degree lens after passage of needles to
confirm integrity of the bladder by following the course of needles while an assistant
moves the needles downward and medially toward the bladder.
• In case of a small bladder injury, the needles are removed and passed again and the
procedure is completed.
• After extravesical passage is confirmed, the ureteral orifices are monitored for brisk
efflux on each side confirming ureteral patency.
• Foley catheter is replaced for completion of the case.
61. Operative procedure PVS.
• Graft suture is passed through the stamey needle eyelets.
• Ends of the suture are brought out through the abdominal incision.
• The distal aspect of the graft is sutured to the periurethral tissue with two simple
4-0 vicryl sutures.
• Vaginal incision closed with watertight, running 2-0 vicryl suture.(Our center-
chromic catgut 3-0,or monocryl 3-0).
• Before final tensioning, remove weighted speculum.
• Additional procedures, such as transvaginal pop repair, should be completed
before sling tensioning.
• Sutures are tied above the rectus fascia leaving a 2-fingerbreadth distance
between the rectus fascia and the PDS knot.
• The abdominal incision is closed.
• Foley catheter is left in situ.
• Vaginal packing to be done.
62.
63.
64. PVS Postop Care.
• Vaginal packing and urethral catheter are removed on POD-1.
• If voids adequately with low PVR volumes--discharged home.
• If unable to void or has elevated PVR, pt is discharged home with
foleys and asked to return within 5 days for a repeat trial of voiding.
• Avoid lifting in excess of 10 pounds and sexual intercourse for at least
6 weeks after surgery.
• Sexual intercourse to be resumed only after examination and
confirmation of vaginal healing by the surgeon.
65. Outcomes of PVS for predominantly SUI.
• Autologous pvs outcome- Success rate-high-range-24% to 97%.
• Mc reason for failure- urinary storage symptoms/UUI.
• Postoperative urgency incontinence rates range from 2% to 22%.
• Outcome of Allograft PVS- data limited.
• Failure rates for freeze-dried grafts range from 6% to 38%, often in the
short-term.
• Average time to re-operation was 9 months, and intraop findings at
reoperation revealed the entire allograft to be fragmented, attenuated, or
simply absent.
• Not to be used for uro-gynecologic procedures because of the high
material failure rate.
• Solvent dried is better-however rarely used.
66. Outcomes Of Autologous PVS For Mixed UI.
• The treatment of MUI is complicated and involves a combination of
anticholinergic therapy and surgery.
• Medical therapy for MUI -resolution of the urgency in only 2/3rd of pts.
• Postop urgency symptoms were not significantly associated with any preop
clinical or urodynamic variables.
• The presence of preop DO on UDS may relate to decreased Quality of life and
decreased urgency resolution after a PVS.
• Overall, the PVS remains an effective treatment option for women with MUI, with
cure rates similar to those of women with SUI only.
• Anti-incontinence surgery may cure, improve, or aggravate storage symptoms.
This aspect of anti-incontinence surgery is unpredictable and a major cause of
patient dissatisfaction.
67. Voiding dysfunction secondary to BOO after PVS.
• Incidence- 2.5% to 35%.
• Temporal relationship-improves with time.
• Obstruction, DO, and impaired detrusor contractility are manifestations of
voiding dysfunction from iatrogenic outlet obstruction after a PVS.
• Incidence of urinary retention >4 weeks after PVS placement was 8%, and
the risk for permanent retention “generally does not exceed 5%”
• The PVS is known to be associated with higher rates of voiding dysfunction
than the burch CPS, and this finding was again confirmed in the
randomized sister trial.
• The PVR volume is important in the evaluation of voiding dysfunction,
although no clear cutoff values for obstruction exist
68. Voiding dysfunction secondary to BOO after PVS
• Cystoscopy is useful to rule out bladder pathology, sling perforation,
and a hyper-suspended urethra.
• Video-urodynamics may be useful in selected cases; however, a
classic high-pressure, low-flow pattern that is pathognomonic for
obstruction is frequently absent.
• In the SISTEr trial, urodynamic findings did not predict voiding
dysfunction after surgery.
• A key factor in assessing voiding dysfunction is the presence of POP
that was either uncorrected at time of surgery or that occurred
postoperatively.
69. Surgical Management of Voiding Dysfunction After PVS.
• Transient urinary retention is common, most pts return to
spontaneous and efficient voiding within the first 10 days.
• Obstruction usually improves with time, therefore wait for up to 3
months before considering surgical intervention.
• Persistent postop voiding dysfunction should be treated
conservatively initially. This includes temporary indwelling catheter
drainage, CIC, timed voiding, double voiding, biofeedback, PFMT, and
anticholinergic therapy.
70. Surgical Management of Voiding Dysfunction After PVS.
• If pt is in complete retention, sling revision to be undertaken sooner.
• In the first 6 weeks, there may be success with loosening the sling
under anaesthesia. Done by inserting a cystoscope into the bladder
and then gently applying inferior pressure to the urethra,(not advised
with synthetic slings).
• After 6 weeks, or when conservative measures fail, sling incision or a
formal urethrolysis is indicated.
• Success rates ranging from 65% to 93%.
71. Surgical Management of Voiding Dysfunction After PVS.
• The supra-meatal approach is superior to the transvaginal approach
because it allows access and division of the lateral wings of the sling.
• Recurrent SUI after formal urethrolysis ranges from 0% to 19%.
• Sling incision has comparable success rates (84% to 100%), shorter
operative time, and less morbidity than formal urethrolysis.
72. Complications of PVS.
• PVS perforation and exposure- Synthetic slings perforate 15 times
more often into the urethra and are exposed 14 times more often in
the vagina than autologous, allograft, and xenograft slings.
• Synthetic slings- urethral perforation rate - 0.02%, and vaginal
exposure rate- 0.007. Therefore no longer used for bladder neck
slings.
• Autologous sling procedures- 0.003% urethral perforation and
0.0001% vaginal exposure.(Rare).
• Diagnosed 1 to 18 months after surgery, mean presentation time of
approx. 9 months.
73. Complications of PVS.
• Etiology- tissue quality(postsurgical scarring, urethral atrophy,
estrogen deficiency, and radiation-induced ischemia), surgical
technique(excessive sling tension, dissection too close to the urethra,
or perforation of the urethra or bladder), or the sling material.
• Management of urethral perforation- incision or excision of the
intraluminal sling portion and simple closure of the urethra. Rarely,
additional coverage with Martius flap.
75. MID-URETHRAL SLINGS(MUS).
• MOA- based on integral theory-
1. Dynamic urethral kinking during stress events.
2. Reinforce functional pubo-urethral ligaments, thereby securing
proper fixation of the mid urethra to the pubic bone.
3. Reinforce the sub-urethral vaginal hammock.
4. Prevent hypermobility of bn from opening the mid urethra.
• MUS works by impeding the movement of the posterior urethral wall
above the sling, directing its motion in an antero-inferior or anterior
direction. In addition, MUS results in narrowing of the urethral lumen
(compression).
76. Mid-Urethral Sling Materials
• UraTape (Mentor-Porgés)-1st TOT MUS, Delorme(2003).
• It was microporous sling with a central silicone core, and was
replaced by ObTape (Mentor-Porgés) because of a high rate of vaginal
exposure likely related to the silicone core.
• Obtape also removed from market because of vaginal exposure due
to its semi-microporous (<50 µm) size.
• 2nd gen- TOT MUS developed by Mentor-Porgés (Aris TOT) has a
larger, 200-µm pore size.
77.
78. Mid-Urethral Sling Materials
• Bioarc- New, has a biologic (porcine dermis, intexen) graft material
that is sutured on either end to the polypropylene mesh. The biologic
material occupies a sub-urethral position.
• Many have been removed from the market.
• Cost in India- Approx 32 thousand.
79. 2 types-TOT and TVT.
• MUS is placed loosely at the mid-urethra, and its function does not
require the sling to be tight.
• The sling is anchored to the endopelvic fascia for retropubic-directed
(TVT) slings and to the obturator internus and externus muscle and
fascia for trans-obturator directed(TOT) slings.
• Over time, the mesh sling becomes fixed and provides support along
its entire course. This broad support may be the reason why, women,
remained continent after MUS incision for obstruction.
80. Retropubic.
1. Bottom to top- route- trocar from mid urethral incision- endopelvic
fascia-retropubic space-suprapubic exit point. Eg-TVT.
2. Top to bottom-eg -SPARC(2001).
81. Trans-obturator.
• Delorme 2001- through the obturator foramen.
• Avoid passage through retropubic space→ decreases bladder, bowel,
blood vessel injury.
• Decrease in voiding dysfunction.
• Less ot time, no cystoscopy requirement.
• Route- trocar passage b/w vaginal incision- obturator membrane-
obturator internus muscle- groin incision below adductor muscle
insertion.
• Outside in TOT --> AMS,BARD TOT.
• Inside out → TVT-O
82. Applied Anatomy of the Retropubic MUS.
• Obese women have more adipose tissue in the pre-vesical space--lower
rate of trocar-related bladder injuries seen.
• The left and right dorsal nerves of the clitoris (DNC)(Terminal br of
pudendal nerve) run along the inferior surface of the ischiopubic rami and
cross under the pubic bone approximately 1.4 cm from the midline.
• Study on cadavers found Sling 1.1 cm from the DNC at its closest point.
• Superior incisions for a retropubic MUS are made at least 2 cm from the
midline this ensures that the DNC are not injured by a trocar or sling.
• Obturator vessels are the closest major vascular structures to a retropubic
MUS at a distance of 3.2 cm (laterally).
• Female urethra is 4 cm in length, therefore, an incision 1.5 cm from the
meatus will provide access to the mid-urethra.
83. Applied Anatomy of the Trans-obturator MUS.
• Trocar must pass the obturator internus muscle, obturator membrane, and
obturator externus muscle as it goes through the obturator foramen.
• Obturator nerve and vessels are located in the obturator canal at the
superior aspect of the obturator foramen.
• A properly placed sling remains outside the pelvic space and does not
penetrate the levator ani muscular group.
• In cadaver dissections after an inside-out TOT MUS-
Mean distance from vaginal incision to the obturator memb. was 4.0 cm and
from the vaginal incision to the obturator neurovascular bundle 6.75 cm.
84.
85. Mid-urethral sling operative procedure
• Pt counselling.
• Study-Local vs spinal anesthesia- no difference in success rate after
MUS or in the incidence of complications between the groups.
• Additional thigh flexion (≥70 degrees) -beneficial during this
procedure.
86. Surgical Approach for Retropubic MUS (TVT).
• The standard MUS- 2 specially curved 5-mm diameter insertion
trocars and a 40-cm long and 1.1 cm wide segment of polypropylene
mesh.
• Sling covered with clear plastic sheath, protects the mesh from
contamination and allows easy passage through host tissues.
88. Bottom-up technique.
• Dorsal lithotomy position.
• A rigid catheter guide(figure) is placed in the urethra with an 18-fr
foley catheter to help deflect the bladder away from the path of
trocar insertion.
• 2 small suprapubic stab incisions are created just above the symphysis
pubis, approx 2 cm lateral to the midline.
• Vaginal incision- midline approximately 1.5 cm long and 1.5 cm
proximal to the external urethral meatus---vaginal flaps raised on
either side to the level of the pubo-cervical (endopelvic) fascia, which
is not perforated.
89. Bottom-up technique.
• Trocar is placed in the dissection tunnel immediately beneath the
vaginal epithelium on one side of the urethra with the trocar tip in
close proximity to the lower rim of the pubic ramus.
• Tactile contact with the bone and slow graded pressure during trocar
advancement ensures direct apposition of metal to bone and
avoidance of bladder injuries.
• The trocar is elevated through the endopelvic fascia, into the space of
retzius, through the rectus muscles, and through the previously
created suprapubic skin incision.
• The same is repeated on other side.
90. Top-down technique.
• The technique for top-down trocar passage is similar.
• A catheter guide with foley in the urethra is typically not used.
• The tip of the trocar is guided onto the index finger of the opposite hand
and out of the vaginal incision lateral to the urethra.
• Cystoscopy is performed to exclude any injury.
• If perforation noted- the trocar is withdrawn and passed once more.
• If no injury, the bladder is drained and the mesh is brought through the
incisions and the sling is tensioned.
• Sling tension adjustment is done by inserting a clamp between the sling
and urethra while the protective plastic sheath is removed from the field.
• Redundant mesh is excised at the level of the suprapubic skin incisions, and
the vaginal incision is closed.
91. Contraindications(same for TOT sling also)
1. Pregnancy.
2. Women with plan of future pregnancy (Prolene mesh will not
stretch significantly),incontinence may recur.
3. Motor urge incontinence and significant detrusor instability.
4. Urethrovaginal fistula.
5. Urethral diverticulum.
6. Intra-operative urethral injury.
7. Untreated urinary malignancy.
94. Surgical Approach for TOT placement.
• Suitable candidates for TOT.
Where suprapubic route is not preferred-
1. Transplant.
2. Neobladder.
3. Obese pts.
4. Multiple prior retropubic surgery.
5. Patients choice.
95. Outside-in Slings:- surgical approach.
• Tape is completely perineal and transverse.
• Needle never enters the retropubic space- Less bowel and bladder injury.
• Placed under the mid urethra b/w the 2 obturator foramen.
• Position- dorsal lithotomy position with legs in hyperflexion (120 degrees).
• Vaginal incision-same as TVT.
• Dissection is carried out laterally to the ischiopubic ramus.(develop a periurethral
pocket to level of the internal obturator membrane).
• A puncture incision(5 mm) is made in the crease b/w labia majora and the
thigh, at the notch along the internal edge of the inferior pubic ramus and the
adductor longus tendon.(1 cm inferior to the adductor longus tendon insertion,
at the level of clitoris).
• The adductor longus tendon can be pinched with the thumb and index finger and
the skin incision typically corresponds to location of the thumb.
96. Outside-in Slings:-
• The obturator membrane is perforated, at which point resistance is
noted.
• Using the non-dominant index finger in the vagina and identifying the
landmarks of ramus and the obturator internus muscle, the trocar is
turned in a medial orientation and advanced on the tip of the index
finger and brought out through the vaginal incision.
• Cystoscopy.
• The synthetic material is then attached to the trocar and brought out
through the inner thigh stab wound.
• Tensioning done by passing a clamp between the sling and urethra.
• The procedure is then repeated on the contralateral side.
97.
98. Inside-Out Slings- surgical approach.
• The vaginal component is same as in the outside-in
technique.
• Stab incisions are created approx 2 cm superior to the
horizontal line at level with the urethra and 2 cm lateral to
the labial folds, which will be the exit point for the helical
passer.
• Once the upper part of the ischio-pubic ramus is reached,
the obturator memb is perforated sharply with scissors.
• The introducer is passed at a 45-degree angle relative to the
midline sagittal plane until it reaches and perforates the
obturator membrane.
• The open side of the introducer is passed facing the surgeon.
99. Inside-Out Slings- surgical approach.
• The more distal end of the tubing is then mounted on the spiral
segment of the helical passer and slipped along the open gutter of
the introducer.
• The passer is aligned parallel to the sagittal axis and rotated so that
the tip of the tubing exits the inter-thigh stab incision.
• The tubing is then removed from the passer until the first few
centimeters of the mesh become externalized, and the procedure is
repeated on the contralateral side.
• Cystoscopy.
• All plastic covering are removed from the sling while maintaining no
tension on the sling itself.
101. Single-Incision mid-urethral Slings(SIMS).
• Every design has a proprietary method of placement that
varies by manufacturer.
• In general, sling devices consist of a short segment of
loosely woven polypropylene mesh with two self fixating
tips.
• Stainless steel applicator device is used to push the ends of
the sling into a secure position.
• Sling is placed under the mid-urethra and fixed in the
hammock position into the obturator internus muscle or in
the U-shaped position into the connective tissue of the
urogenital diaphragm (endopelvic fascia) behind the pubic
bone.
109. Surgical Approach
• Dissection under the vaginal flaps on either side to elevate the vaginal epithelium
from the underlying periurethral tissue to the level of the pubo-cervical fascia,
which is not perforated.
• Trocar is placed in the right dissection tunnel immediately beneath the vaginal
epithelium and advanced up to the ischiopubic bone and into the obturator
internus muscle, where the trocar holder anchors the sling edges.
• The left side is introduced in the same way, creating a hammock-shaped sling.
• Definitive sling tension is achieved when the tip of a hemostat is easily passed
between the urethra and the sling.
• Cystoscopy before completion of the procedure.
• Tension of the SIMS should be tighter than the classic TVT or TOT MUS surgeries
to achieve the same result.
111. The Trial of Mid-Urethral Slings (TOMUS)
• Multi-center, randomized equivalence trial(2010).
• TVT vs TOT in women with SUI.
• 597 women.
• Result:- tvt vs tot.
1. Treatment success(objective) at 12 month-equivalent(80% vs 77.7%).
2. Treatment success(subjective) at 12 month-equivalent(62% vs 55%)
3. Tvt has higher voiding dysfunction, bladder perforation and UTI.
4. TOT has higher neurological symptoms (leg pain and groin numbness)(9.4
% vs 4%).
5. No difference in urge incontinence, satisfaction with result and QOL.
112. Outcomes of MUS for predominantly sui
• MUS currently surgical TOC for predominantly SUI.
• Efficacy and safety of MUS are not compromised in the elderly, the
obese, or those undergoing concomitant vaginal surgery.
113. Complications of retropubic, trans-obturator, and SIMS.
• Mid-Urethral Sling Mesh Exposure- 0.5% to 8.1%.
• 1st-conservative management- observation, conjugated oestrogen
and antibiotic creams.(approx. 3 month).
• 2nd-limited excision- of the exposed mesh, undermining of vaginal
mucosal flaps, thorough irrigation with antibiotic solution, and re-
approximation of vaginal edges with delayed absorbable sutures.
• 3rd – Excision of most of the mesh from a transvaginal approach.
• A trial of conservative management in selected patients (i.e.,
Exposure < 1cm) is reasonable, and, if no epithelialization occurs after
3 months of follow-up, the mesh should be surgically removed.
114. MUS trocar injury to the urinary tract.
• TVT- 2.7% to 23.8 %
• TOT- 0% to 1.3%
• Urethral perforation during MUS.
• Defined as presence of sling material within the urethral lumen.
• 0% to 0.6%
• Conservative treatment is not an option.
• Management- 1st- endoscopic excision(if small area)-endoscopic
scissors/holmium laser.
• 2nd- if fails-removal transvaginal or retropubic.
• A labial fat pad or autologous fascial sling may be used for reconstruction.
115. Infection and Pain After MUS.
• Managed with NSAIDS, rest, and physical therapy.
• Failure of nonoperative therapy, it may be necessary to attempt a
complete mesh excision from both sides of the bone.
116. Voiding Dysfunction After MUS Surgery
• Temporal relationship.
• TVT > TOT- 2.7% vs 0%.
• Sling revision or removal rate of 1.3%.
• Frequently transient and can be managed with short-term CIC, indwelling catheter, timed
voiding, PFMT, alpha blocker.
• Urethral dilation- detrimental to the urethra and should not be performed.
• Loosening the sling- done within 1st week, opening the vaginal incision and placing a
clamp between the urethra and sling. Downward traction on the sling for 1 to 2 cm may
lead to a significant improvement in greater than 95% of patients.
• In cases of significant obstruction or retention, the sling should be incised within 4
weeks of surgery.
• Cutting the MUS in the midline through a single vertical vaginal incision is the preferred
method to manage persistent voiding dysfunction that results from an obstructive sling
within the first 3 months after surgery.
• After 3 month- formal sling excision has to be done as MUS sling gets fixed.
117. Management of recurrent or persistent SUI after MUS.
• Persistent SUI (no dry period after MUS) - due to poor surgical technique, wrong
choice of procedure, or suboptimal patient selection.
• Recurrent sui (sui resolved, but then recurred) - MC due to pt associated factors,
such as age, obesity, concomitant preoperative uui, and postop POP.
• What surgery?
• Repeat MUS- certainly an option for primary MUS failure, success rates are 62%
to 89%.
• Appealing because of minimal morbidity and high success rates, even as a
secondary procedure.
• Autologous PVS is an option for recurrent and persistent SUI.
• PVS places the sling in a location/vector that is distinctly different from that of the
MUS.
• Disadvantage- greater chance for postop voiding dysfunction and harvest site
morbidity.
118. • As synthetic mesh use becomes more restricted and controversial,
there may be a change in practice toward autologous sling material
and colpo-suspension in the future.
