FREE VAGINAL WALL SLING

Chapter 34 FREE VAGINAL WALL SLING



Dmitry U. Pushkar


Pubovaginal sling procedures are the main surgical operations used to correct stress urinary incontinence (SUI). These procedures provide for a tape insertion underneath the urethra or bladder neck. The American Urological Association guidelines panel studied the long-term efficacy of all anti-incontinence procedures and found that pubovaginal slings were among the most versatile and successful.1–14


Until the end of the 1990s in most cases autologous tissues were used to create a tape. However, by the late 1990s specialists began to make use of synthetic materials, mainly in the form of Prolene tapes.9,13


This chapter covers several aspects of the free vaginal wall sling procedure. At the same time, it touches on the technical particularities of the full-thickness, nonisolated vaginal wall flap, based on the bladder neck area. This procedure was first described in 1996 by the French group from Nice.11 The patient is placed in the lithotomy position with access to the suprapubic area, and an 18-Fr Foley catheter is inserted. After the vaginal cavity is exposed a ∪-shaped incision is made to create a rectangular flap based superiorly in the bladder neck (Fig. 34-1). During vaginal dissection, it is preferable to create a thin flap to preserve perivesical tissue for cystocele repair. After flap mobilization, the cystocele is repaired with a running double-layer 3-0 monofilament polyglyconate suture (Fig. 34-2). The rectangular vaginal flap is then rolled to form a tube and secured at each end with two 2-0 polypropylene sutures. Before being rolled, the vaginal flap must be de-epithelialized with a scalpel to prevent postoperative cyst formation. Then, the vaginal tube is positioned in the bladder neck and sutured to periurethral tissues or suspended subcutaneously with two 2-0 polypropylene sutures (Fig. 34-3). Cystoscopy is performed to rule out urethral or bladder perforation and confirm bladder neck suspension. Posterior colporrhaphy is performed, and a povidone-iodine–impregnated vaginal gauze is inserted; it is removed the following day. Normally, the Foley catheter is withdrawn after 48 hours.


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Figure 34-1 A U-shaped incision is performed to create a rectangular vaginal flap based on the bladder neck area.


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Figure 34-2 A full-thickness rectangular flap based on the bladder neck area is created from the anterior vaginal wall. This flap may be kept and used as a fixed flap based on the bladder neck suspended by two 1-0 Prolene sutures in the suprapubic area. Cystocele is repaired. This flap may also be isolated if a free vaginal wall sling by isolated flap is preferred.


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Figure 34-3 A vaginal flap is rolled to form a tube and is secured at each end with two 1-0 Prolene sutures, with subsequent passage and attachment of these sutures suprapubicly.


It is still questionable whether the vaginal wall sling procedure should remain in the surgical armamentarium. We believe that this textbook would not be complete without coverage of this procedure.


The desire to make use of autologous vaginal tissue for the treatment of SUI first surfaced at the beginning of the 20th century. This was motivated by patients experiencing a combination of incontinence and cystocele, which provided for the enlargement of the vaginal wall, with subsequent preparation of a viable vaginal flap. Previously, full-size flaps had been employed, which led to a high rate of morbidity.


The application of monofilament polypropylene materials, such as Prolene sutures, allowed for further minimization of the procedures, with shorter flap creation. These sutures were used for a wide variety of suspensions. The flap itself had to meet several requirements. The primary requirement was that the flap must be long enough to support the bladder neck, and it must be viable, providing for full thickness of the vaginal wall.


It remains to be asked whether the classification of type 1, 2, or 3 SUI is still useful. Sling procedures were in the past reserved for correction of ISD. Today, it has been shown that most female patients with SUI have some kind of ISD. In our department, we have edged away from a standard classification of SUI and now pay particular attention to the anatomy of the patient. We believe that SUI associated with either cystocele, rectocele, or pelvic floor dysfunction clearly calls for a change in accepted “textbook” treatment planning.


Why do patients choose free vaginal wall sling procedures? What are the long-term functional results of these procedures? What is the purpose of the patient-doctor conversation, and should we convince our patients to proceed with this type of surgery? Should the free vaginal wall procedure remain in the surgical armamentarium? Finally, should we make any comparison with synthetic tapes or other tension-free vaginal tape (TVT)-like procedures?



RATIONALE


The free vaginal wall procedure may have the following applications:


1. Mild to moderate SUI in elderly patients with cystocele

2. Patients unwilling to use any synthetic materials

3. Young patients with mild SUI, who are rarely scheduled for surgery. There is a lack of long-term follow-up of synthetic materials. These patients may develop recurrence in the distant future, which can dictate the use of synthetic materials such as TVT.

4. Patient desire to have a minimal operation with use of autologous tissue and no abdominal scar.


PREOPERATIVE CONSIDERATIONS


Preoperative considerations currently include the following requirements:


1. Mild to moderate SUI

2. Symptoms confirmed by signs is always preferable, which means demonstrable involuntary urine loss during physical examination while coughing or sneezing

3. No signs of vaginal atrophy

4. No signs of detrusor instability—cystometry must be performed if detrusor instability is suspected

5. Cystocele provides enlarged vaginal wall to create viable flap; surgeon may decide whether flap can be created from posterior part if rectocele is present

6. Urinary tract infection excluded

7. Cystoscopy, which is routinely performed in our department

8. Ultrasound examination, also a usual part of preoperative assessment

9. Informed consent and strong will of the patient to undergo surgery


SURGICAL TECHNIQUE

Related posts:

DEVELOPMENTAL ANATOMY AND UROGENITAL ABNORMALITIES USE OF CADAVERIC FASCIA FOR PUBOVAGINAL SLINGS EPIDEMIOLOGY OF INCONTINENCE AND VOIDING DYSFUNCTION IN THE ELDERLY TRANSVAGINAL CLOSURE OF THE BLADDER NECK IN THE TREATMENT OF URINARY INCONTINENCE FEMALE SEXUAL FUNCTION AND DYSFUNCTION FUNCTIONAL ANATOMY AND PATHOPHYSIOLOGY OF PELVIC ORGAN PROLAPSE

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Jun 4, 2016 | Posted by in ABDOMINAL MEDICINE | Comments Off on FREE VAGINAL WALL SLING

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