Indications
The autologous pubovaginal sling is accepted as one of the gold-standard treatments for female stress urinary incontinence (SUI). The original indications for the pubovaginal sling include the correction of SUI as a result of intrinsic sphincter deficiency with or without associated urethral hypermobility. Although this indication certainly still holds true today, since the advent of the midurethral sling, the fascial sling has been used more and more for recurrent SUI after a failed midurethral sling or retropubic suspension. In addition, it has proven beneficial for patients with SUI with concomitant urethral diverticulum or fistula and can be used for urethral reconstruction in neurogenic patients with urethral loss secondary to catheter-associated erosion.
The procedure has evolved over time, and the current concept of the free graft of rectus fascia is a modification of the procedure described by McGuire and later popularized by Blavias. The sling is thought to provide the urethra with a hammock-like support, which is stabilized as a result of fibrosis and incorporation into the endopelvic fascia as the sling enters the space of Retzius. In addition to providing a backboard against urethral hypermobility, the sling can be tensioned to provide additional passive urethral compression when needed.
Patient Preparation
Perform a thorough history and physical, urinalysis, and postvoid residual assessment. Key components of the history include complete assessment of the voiding symptoms with emphasis placed on characterizing the incontinence and differentiating between stress and urge symptoms. Urge urinary incontinence (UUI) should be carefully explored, and the patient should be adequately counseled that the goal of the surgery is to improve the stress-related component of incontinence. It should be noted that 33% of patients will have persistent urge incontinence, and up to 9% may develop de novo UUI. Assessment of voiding symptoms is also recommended to identify any preexisting voiding problems. The physical examination should focus on a complete abdominal and pelvic examination. Evaluate for the presence of urethral hypermobility. Congruent with the American Urological Association’s SUI guidelines, demonstration of incontinence with the Valsalva or cough maneuver is performed. When necessary, a bladder stress test can be performed, including urethral catheterization for postvoid residual as well as for bladder filling, which enables assessment for SUI with a known bladder volume. The routine use of urodynamics is not indicated for patients with straightforward stress incontinence. However, given that the pubovaginal sling is often used for recurrent SUI or in complicated incontinence cases, the use of preoperative urodynamics is more commonly done before this procedure. Intrinsic sphincter deficiency can be confirmed with urodynamic studies, and patients with poor detrusor contractility and those with elevated residual urine should be counseled to be at higher risk for postoperative urinary retention. Although all patients are counseled about the risk of retention and voiding problems, selected patients should be taught clean intermittent catheterization preoperatively because of this risk.
Patient Positioning
Place the patient in a low lithotomy position with the legs in Allen or Yellofin stirrups. Ensure that there is no pressure on the calf or the lateral aspect of the leg and that all pressure points are padded. Prepare the lower abdomen, vagina, and perineum. Drape to provide access to the lower abdomen and vagina. A 5- to 10-mL balloon Foley catheter is placed at the beginning of the case to drain the bladder.
Operative Technique
Although the pubovaginal sling has traditionally been described using two surgeons dividing the retropubic and vaginal portions of the procedure, the surgery is commonly performed with one surgeon who alternates between the retropubic and vaginal approaches.
Retropubic Component
The authors usually begin with the suprapubic approach, and a 6- to 8-cm-long transverse lower abdominal incision is made above the pubic symphysis. The site of the incision may vary based on body habitus and previous incisions, especially because the goal of this incision is to access and harvest the rectus fascial graft. The incision is carried down to the rectus fascia, and the fascia is exposed by dissecting away any superficial soft tissue. Exposure of the rectus bed where the graft will be harvested can be accomplished using various self-retaining devices, but the authors have learned that the large Alexis disposable retractor often works well in this setting. Measure and mark out a 2-cm-wide by 8-cm-long segment of rectus fascia for the graft. The graft is harvested sharply with the goal of placing sutures at each end of the graft to suspend and tension the sling. Various techniques have been described for this, including placing sutures into the sling on the back table after the graft has been removed, doubling the thickness of the graft edges by folding the ends before suture placement, and running the suture along the edge. These authors prefer to preplace figure-of-8 stitches in each of the four corners of the graft before it has been harvested. Each figure-of-8 stitch is tied down with the suture tails kept long because these will be the sutures used for suspension and tensioning ( Fig. 98.1 ). The authors prefer a size 0 polypropylene suture. Incise the fascia along the premarked areas ( Fig. 98.2 ). Use the suture tails to pull up on the graft, thereby providing a handle to assist when freeing it up from the underlying rectus muscle. Wrap the graft in moistened gauze or place it in normal saline and set it aside. Inspect the harvest bed, maintain hemostasis using cautery, and then close the fascial defect with a running size 0 polydioxanone suture (PDS). In the ideal situation, the same suprapubic incision is used for placement of the sling sutures. However, if the lower rectus fascia is deemed suboptimal because of a previous fascial incision in the target area, the surgeon may choose to move cephalad to gain access to a nonviolated area of fascia. Access to the area just above the pubis should be maintained, or if needed, an additional small suprapubic incision can be made for placement of the sling sutures ( Fig. 98.3 ).
Alternative fascial harvest technique: When the abdominal fascia is unsatisfactory for use, a graft from the fascia lata may be harvested. A small longitudinal incision is made on the lateral aspect of the thigh, and a fascial stripper is used to avoid a large incision.
Alternative to autologous graft harvest: In certain situations when use of autologous fascia is not possible, the authors have used biologic grafts such as cadaveric fascia ( Fig. 98.4 ). Such situations are not common, but when necessary, the patient should be thoroughly counseled about the use and risks of non-native tissue along with possible risk of less optimal outcomes.
Vaginal component: Place a weighted speculum in the vagina. Submucosal injection of normal saline is performed to aid in the dissection of the vaginal epithelium (see Fig. 98.6 ). Some surgeons may prefer to use a local anesthetic for this portion with or without epinephrine to aid in hemostasis. Various vaginal incisions may be used, including a midline longitudinal vaginal incision as well as the inverted U incision. Location of the incision should allow access to the proximal urethra and bladder neck area. These authors prefer the inverted U incision especially in complicated cases ( Figs. 98.5 to 98.7 ). The juncture of the bladder neck and proximal urethra is identified with aid of the Foley balloon by gently tugging on it to assist with palpation of the area. The apex of the inverted U incision or a longitudinal vaginal incision is usually situated somewhere between the distal and mid urethra but will vary based on operative circumstances.
