163 Gopal H. Badlani1 & Joao P. Zambon2 1 Wake Forest University, Winston‐Salem, NC, USA 2 Department of Urology, Wake Forest University Baptist Medical Center, Winston‐Salem, NC, USA Urinary incontinence is a common symptom affecting almost a third of adult women [1]. It can occur due to hypermobility or intrinsic sphincter deficiency of the urethra (stress urinary incontinence (SUI)) and/or bladder dysfunction. Whatever its etiology, urinary incontinence is associated with poor quality of life and most incontinent women develop symptoms such as anxiety, depression, and social isolation over time [2, 3]. The American Urological Association (AUA) guidelines for SUI list several surgical options, of which the most common are pubovaginal and midurethral sling [4]. In 2010, approximately 560 000 women with SUI underwent surgical repair with mesh products; however, the use of various synthetic biomaterials from a variety of manufacturers gave rise to a wide range of mesh‐related complications [5]. For these reasons, despite the advantages of minimally invasive procedures for SUI, use of pubovaginal fascial slings has increased over the last few years [5]. This chapter addresses the following subjects regarding pubovaginal fascial slings: indications, surgical technique, postoperative complications, and surgical outcomes. In 1907, Von Giordano described the use of gracilis muscle wrapped around the urethra for the treatment of women with SUI [6]. Three years later, instead of gracilis muscle Goebell used the pyramidalis muscle to improve the urethral support [7]. Autologous fascial sling was first reported by Price in 1933 when he used a suburethral strip of fascia lata for the treatment of women with recurrent SUI [8]. In 1942, Aldridge used a rectus fascia segment placed inferiorly through the rectus abdominis muscle to provide urethral support [9]. Thirty years later, in 1978 McGuire and Lytton reintroduced the concept of fascial slings for women with SUI. They used an autologous rectus fascia segment to suspend the bladder neck and promote urinary continence [10]. In 1991 Blaivas and Jacobs described midurethral slings and outlined the importance of mid urethra in urinary continence control [11, 12]. Midurethral synthetic slings were first described in 1996, with the tension‐free vaginal tape (TVT) [13]. Since then, the development of different types of nonabsorbable biocompatible materials, minimal invasiveness, and availability of easy‐kits has resulted in an exponential increase in the number of mesh surgical procedures performed by both urologists and gynecologists [14, 15]. The hammock theory was described by DeLancey in 1995 [16]. According to his theory the urinary continence relies on urethra and bladder neck compression by a hammock‐like musculofascial layer. When this layer is deficient, funneling of the bladder neck during increased intra‐abdominal pressure can result in urinary incontinence. Thus, the placement of pubovaginal slings around the mid urethra aims to provide an additional support for the continence mechanism. By definition, SUI is an involuntary leakage of urine with effort or exertion, such as physical exercise, sneezing, or coughing. SUI is a clinical diagnosis based on a patient’s history and physical examination [4]. When urinary incontinence is not demonstrated on physical exam, additional tools such as a three‐day bladder diary and pad test can be helpful. The three‐day bladder diary assesses associated symptoms, such as urinary frequency and nocturia, and measures the functional bladder capacity, whereas the pad test can objectively demonstrate urinary leakage [17, 18]. Urogenital prolapse and postvoid residual volume (PVR) should be well documented prior to any therapeutic intervention. Women with prolapse can unmask occult SUI after prolapse reduction, and patients with high PVR are at risk of postoperative urinary voiding difficulty [19]. The role of urodynamic study (UDS) is still controversial in the literature. Overall, UDS is recommended by the AUA guidelines for women with mixed incontinence, significant anterior pelvic organ prolapse and SUI, recurrent SUI, patients with neurological diseases, diabetes mellitus, and those with high PVR [4, 20]. Pubovaginal fascial slings are indicated for patients with SUI due to intrinsic sphincter deficiency and/or urethral hypermobility. They are also recommended for the following conditions [21, 22]: Estrogen cream can be prescribed for 4–6 weeks preoperatively in postmenopausal women with vaginal epithelial atrophy if there are no contraindications. If the patient uses a pessary, it should be discontinued two weeks prior to surgery. Patients using only “baby” aspirin do not need to stop the medication prior to procedure. In the presence of urinary tract infection, coagulopathy, or other significant medical comorbidity, surgery should be postponed. All patients should be counseled about the risk of retention and recurrence. Laxative diet and fluid intake is advisable to avoid postoperative complications. Regarding antibiotic prophylaxis, first‐ or second‐generation cephalosporin is given intravenously at least 1 hour prior to the procedure and continued for the next 24 hours [23]. Autologous fascial tissue can be harvested from patient’s rectus fascia or fascia lata for sling procedures, so there is no risk of rejection. Nevertheless, the quality and strength of the tissue will depend on the patient’s age and previous surgical manipulation [24, 25]. Overall, autologous fascial slings have better long‐term outcomes than Burch procedure and are comparable to synthetic slings but are associated with postoperative morbidity and convalescence [26]. Rectus fascia is the most common autologous tissue used in pubovaginal fascial slings. Tissue is obtained through a low transverse abdominal incision. Then dissection is carried out down to the level of the anterior rectus fascia. Following the dissection, a 1 cm × 12–16 cm fascial segment at least 5 cm above the pubic symphysis is marked with a marker pen. Two sutures are placed at either end of the fascia, perpendicular to the fascial fibers. The fascial strip is mobilized and removed carefully. Then the fascial defect is closed in a running fashion with delayed absorbable or nonabsorbable sutures. The main advantages of fascia lata are the lower risk of abdominal wall hernias, greater tensile strength than rectal fascia, and no previous surgical tissue manipulation. The disdvantages are that for tissue harvesting the patient needs to be repositioned, the procedure carries a risk of pain/disability, and most urologists are not familiar with the surgical field [27, 28]. The fascia lata can be harvested using different surgical approaches. We have used the technique described by Govier et al. [27]. The patient is placed in the full lateral position with the entire thigh, from the iliac crest to the tibial plateau, being prepped and draped into the surgical field. A vertical line is drawn from the greater trochanter of the femur to the lateral condyle of the knee. A 3 cm perpendicular incision is made at the midpoint of this line. Two additional perpendicular incisions of 3 cm in length are made, flanking the first incision 9 cm superior and inferior. Then the fascia lata is cleared off from the overlying subcutaneous fat. At the three skin incision sites, incisions parallel to the direction of the fascial fibers are made 2.5 cm apart. At the distal and proximal ends of the fascia, two stay sutures are placed perpendicular to the fibers of the fascia and the fascial incisions are connected to a free segment of fascia lata approximately 24 cm in length and 2.5 cm in width. After a careful hemostasis, the fascia lata is not approximated, and the skin is closed with a stapler. The leg is then wrapped with an elastic dressing, which is removed 8 hours postoperatively. Early ambulation is required for all patients (Figure 163.1). Figure 163.1 Fascia lata – skin incisions. Source: Govier FE, Gibbons RP, Correa RJ et al. Pubovaginal slings using fasica lata for the treatment of intrinsic sphincter deficiency. J Urol 1997;157:117–121. Reproduced with permission of Elsevier. In the last decade there has been widespread use of synthetic slings. The main advantages when compared to autologous fascial slings are: (i) lower operating time; (ii) minimal invasiveness; (iii) no risk of disease transmission; and (iv) strength maintenance over time [29–31]. Monofilament polypropylene mesh with large pore size (>75 μm) is the “gold standard” synthetic biomaterial for slings. The monofilament polypropylene decreases bacterial adherence and reduces the risk of infection and foreign‐body response, and the large pore size promotes mesh flexibility, facilitates host tissue integration, and allows immune cells to scavenge bacteria [31–33]. The incorporation of mesh into the sling surgical setting has decreased patient’s morbidity. However, and not less important, vaginal mesh placement is associated with unique potential risks such as vaginal mesh exposure, infection, dyspareunia, and chronic pelvic pain. All of these postoperative complications should be addressed with the patient prior to the procedure [34–36]. Several types of allogenic and xenogenic materials have been used as fascial sling substitutes aiming to provide readily available biomaterial without additional morbidity associated with fascia harvesting [37]. Xenografts for pubovaginal sling include material derived from porcine dermis (Pelvicol, C.R. Bard Inc., Murray Hill, NJ, USA), porcine small bowel (SIS™, C.R. Bard Inc.), and, more recently, bladder extracellular matrix. These are available as off‐the‐shelf biomaterials and are not used routinely for pubovaginal sling procedures. Some xenograft‐related issues are the higher product costs, biomechanical variability, risk of rejection, and disease transmission [38, 39]. Like xenografts, allografts have the advantage of not requiring fascial harvesting and have similarly decreased operative times, less postoperative pain, and shorter convalescence. They are also available as an off‐the‐shelf material that can be used as needed. Allograft materials have lower erosion rates compared to synthetic meshes, but these advantages must be weighed against the higher cost and the risk of disease transmission [40].
Maxi/Pubovaginal Sling
Introduction
Historical landmarks
Hammock theory
Diagnosis
Indications
Preoperative preparation
Choice of tissue/biomaterial
Autologous fascial tissue
Rectus fascia
Fascia lata
Synthetic slings
Synthetic mesh substitutes
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