5 Biologic Bladder Neck Pubovaginal Slings

Mickey Karram, M.D.

Dani Zoorob, M.D.

W. Stuart Reynolds, M.D.

Melissa R. Kaufman, M.D.

Roger Dmochowski, M.D.

 Videos

5-1. Rectus Fascia Pubovaginal Sling Procedure

5-2. Urethral Reconstruction with Martius Fat Pad Transposition and Cadaveric Fascia Lata Pubovaginal Sling

Introduction

The concept of using a patient’s own tissue as a “sling” to support the urethra dates back to the beginning of the 20th century; however, it was not until the last quarter of the 20th century that the procedure gained widespread popularity and evolved into its current state. Initially, the procedure was described as using a strip of mobilized abdominal muscle (either rectus or pyramidalis). One end of the strip was freed from its attachment, passed under the bladder neck, and then reaffixed to the abdominal muscle wall, forming a “U”-shaped sling of muscle around the bladder outlet. Subsequently, overlying abdominal fascia was also included in the sling and eventually replaced the muscle altogether. The final innovation involved using an isolated strip of fascia suspended by free sutures that were tied to the abdominal wall directly or on top of the abdominal rectus sheath.

Despite originating as an autologous procedure, many different types of materials have been used as sling substitutions, including various sources of autologous tissue, allograft tissue, xenograft tissue, and synthetic material. Almost all these substitutions have been made in an attempt to limit patient morbidity by alleviating the additional morbidity created by the harvesting of the sling material. Nevertheless, the most popular pubovaginal sling still uses autologous rectus abdominis fascia. Regardless of the material used, the pubovaginal sling is meant to be placed at the junction of the proximal urethra and bladder neck for purposes of supporting the urethra, as well as augmenting intraurethral pressure and deficient proximal sphincteric function.

Continence is achieved either by providing a direct compressive force on the urethra/bladder outlet or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during transmission of increased abdominal pressure. The sling is suspended with free sutures on each end that either are attached directly to the abdominal wall musculature or more commonly are tied to each other on the anterior surface of the abdominal wall. The long-term success of the procedure relies not on the integrity of the suspensory sutures, but rather on the healing and fibrotic process involving the sling, which occurs primarily where the sling passes through the endopelvic fascia.

Indications

The pubovaginal sling is a treatment option for stress urinary incontinence (SUI). Although pioneered as a surgical option for intrinsic sphincter deficiency, the indications have been broadened to encompass all types of SUI. Because of its reliable results and durable outcomes, it is considered to be one of the main standards of treatment of SUI and has been used extensively as a primary therapy of SUI both for intrinsic sphincter deficiency and for urethral hypermobility, as a salvage procedure for recurrent SUI, as an adjunct for urethral and bladder reconstruction, and even as a way to “close” the urethra functionally to abandon urethral access to the bladder altogether. In our opinion, other indications are in patients with SUI who decline to have a synthetic material implanted because of concerns related to the long-term presence of synthetic mesh. Also, women who have recurrent incontinence after a synthetic sling or have had a complication after a synthetic sling such as a vaginal erosion may be good candidates for a biologic sling. Finally, we prefer to use a biologic sling in patients who have undergone radiation or who have had urethral injuries and patients who are undergoing either simultaneous or prior urethrovaginal fistula or diverticulum repair.

Sling Materials

Several different types of materials have been tried and investigated for use as a pubovaginal sling. The two most common autologous tissues are rectus abdominis fascia and fascia lata. Both have been extensively studied and have proven to be efficacious and reliable. Of the two, most surgeons prefer rectus abdominis fascia as an autologous material because it is easier and quicker to harvest.

Other biologic materials that have been used include allogeneic (i.e., cadaveric) and xenogeneic tissues. Cadaveric fascia lata and cadaveric dermis provide reasonable efficacy; however, durability of results remains an issue because high failure rates have been reported in some studies. Bovine and porcine dermis and porcine small intestine submucosa have also demonstrated acceptable efficacy for SUI, but durability again remains a concern.

Synthetic graft materials of various designs and substances have also been used as sling material. As with other types of synthetic graft materials, monofilament, large-pore weave grafts (type 1 mesh) are recommended for implantation in the vagina. Good efficacy can be achieved with synthetic mesh; however, synthetic mesh also poses risks of serious complications, including infection, vaginal extrusion, and genitourinary erosion, and is currently not recommended for use underneath the proximal urethra or bladder neck.

Case 1: Recurrent SUI in a Patient Who Refuses a Synthetic Sling

A 58-year-old woman complains of urinary incontinence associated with activity and exertion (stress incontinence) that has been worsening over the last 3 years. She previously had undergone a “bladder lift” (most likely a retropubic urethropexy) at the time of abdominal hysterectomy 15 years ago for similar complaints. On physical examination, the patient demonstrates incontinence with increases in abdominal pressure with some mobility of the urethra (Q-tip deflection to 25 degrees from the horizontal). Urodynamics showed easily demonstrable stress incontinence at a volume of 150 mL in the sitting position with a Valsalva leak point pressure of 55 cm H₂O. Her bladder remained stable to a maximum capacity of 520 mL. Cystoscopy was unremarkable. When offered surgical correction, the patient expresses a preference for using “her own tissues” and does not wish to have synthetic mesh placed. She consents to a rectus fascia pubovaginal sling.

Technique for Harvest of Rectus Fascia and Placement of Pubovaginal Sling

1. Preoperative considerations. Pubovaginal sling procedures are generally performed under general anesthesia, but spinal or epidural anesthesia is also possible. Full patient paralysis is not warranted but may facilitate rectus fascia closure after fascial harvest. Perioperative antibiotics are usually administered with appropriate skin and vaginal floral coverage (e.g., a cephalosporin or fluoroquinolone). (Antibiotic prophylaxis has now become a mandated quality of care measure in the United States.)

2. Positioning. The patient is placed in the low lithotomy position with legs in stirrups, and the abdomen and perineum are sterilely prepared and draped to provide access to the vagina and the lower abdomen. The bladder is drained with a Foley catheter. A weighted vaginal speculum is placed, and either lateral labial retraction sutures are placed or a self-retaining retractor system is employed to facilitate vaginal exposure.

3. Abdominal incision. An 8- to 10-cm Pfannenstiel incision is made (approximately 3 to 5 cm above the pubic bone), and the dissection is carried down to the level of the rectus fascia with a combination of electrocautery and blunt dissection, sweeping the fat and subcutaneous tissue clear of the rectus abdominus fascia (Figure 5-1).

4. Fascial harvest. Harvest of the rectus abdominis fascia can be carried out in a transverse or vertical orientation. Typically, a fascial segment measuring at least 8 cm in length and 1.5 to 2 cm in width is harvested. The fascial segment to be resected is delineated with a surgical marking pen or electrocautery and incised sharply with a scalpel, scissors, or electrocautery along the drawn lines. Although virgin fascia is preferred, fibrotic rectus fascia can also be used. If resecting the fascia close and parallel to the symphysis pubis, it is advisable to leave at least 2 to 3 cm of fascia attached to the bone to facilitate closure and approximation to the superior fascial edge. Use of small Army-Navy retractors permits aggressive retraction of skin edges, allowing access through a smaller skin incision (Figure 5-2).

5. Fascial defect closure. The fascial defect is closed using a heavy gauge (No. 1 or 0), delayed absorbable suture in a running fashion. Mobilization of the rectus abdominis fascial edges may be required to ensure appropriate tension-free approximation. It is important to ensure adequate anesthesia with muscular relaxation or paralysis when the closure is being done.

6. Preparation of fascia. To prepare the fascial sling for use, a No. 1 permanent (e.g., polypropylene) suture is affixed to each end using a figure-of-eight stitch to secure the suture to the sling. Defatting of the sling may be done if necessary (Figure 5-3).

7. Vaginal dissection.

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