Introduction

The concept of using a patient’s own tissue as a “sling” to support under the urethra dates to the beginning of the twentieth century; however, it was not until the last quarter of the century that the procedure gained widespread appreciation and evolved into its current identity. 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, then reaffixed to the abdominal muscle wall, thus forming a U-shaped sling of muscle tissue 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 then tied to the abdominal wall directly or on top of the abdominal rectus sheath.

Despite its roots 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 of these attempts at substitution have been made in an effort to limit patient morbidity, as the procedure requires the additional morbidity of a sling tissue harvest site. Nevertheless, in its most popular variety, the pubovaginal sling remains associated with the use of 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, thus augmenting intraurethral pressure and deficient proximal sphincteric function.

The concept of the autologous pubovaginal sling involves supporting the proximal urethra and bladder neck with a piece of graft material, achieving continence 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 are attached either directly to the abdominal wall musculature or, more commonly, 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 remains an option as a procedure for stress urinary incontinence (SUI). Although pioneered as a surgical option for intrinsic sphincter deficiency (ISD), its indications have been broadened to encompass all types of SUI. Owing to its reliable results and durable outcomes, it is considered to be the one of the main standards of treatment of SUI and has been used extensively as a primary therapy for SUI, both for ISD and urethral hypermobility, as a salvage procedure for recurrent SUI, as an adjunct for urethral and bladder reconstruction, and even as a way to functionally “close” the urethra to abandon urethral access to the bladder altogether. In the authors’ opinion, other indications are in patients with SUI who decline to have a synthetic material implanted because of long-term concerns related to synthetic mesh. Moreover, 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 the autologous sling. Finally, the authors prefer to use an autologous sling in patients who have been radiated or who have had urethral injuries, and patients who are undergoing either simultaneous or prior urethrovaginal fistula or diverticulum repair.

Indications

The pubovaginal sling remains an option as a procedure for stress urinary incontinence (SUI). Although pioneered as a surgical option for intrinsic sphincter deficiency (ISD), its indications have been broadened to encompass all types of SUI. Owing to its reliable results and durable outcomes, it is considered to be the one of the main standards of treatment of SUI and has been used extensively as a primary therapy for SUI, both for ISD and urethral hypermobility, as a salvage procedure for recurrent SUI, as an adjunct for urethral and bladder reconstruction, and even as a way to functionally “close” the urethra to abandon urethral access to the bladder altogether. In the authors’ opinion, other indications are in patients with SUI who decline to have a synthetic material implanted because of long-term concerns related to synthetic mesh. Moreover, 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 the autologous sling. Finally, the authors prefer to use an autologous sling in patients who have been radiated 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 proved to be efficacious and reliable. Of the two, most surgeons prefer rectus fascia as an autologous material because it is easier and quicker to harvest.

Other biological materials that have been used include allogenic (ie, cadaveric) and xenogenic tissues. Cadaveric fascia lata and cadaveric dermis provide reasonable efficacy; however, durability of results remains an issue, as high failure rates have been reported in some studies. Bovine and porcine dermis as well as porcine small intestine submucosa (SIS) have also demonstrated acceptable efficacy for SUI but, again, durability 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, this 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.

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, for example, a cephalosporin or fluoroquinolone. (This 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 used to facilitate vaginal exposure.

  
  
• 3.
  

  Abdominal incision. An 8- to 10-cm Pfannensteil incision is made (approximately 3–5 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 tissue.

  
  
• 4.
  

  Fascial harvest. Harvest of the rectus abdominis fascia can be performed 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, then incised sharply with a scalpel, scissors, or electrocautery along the drawn lines. Although virgin fascia is preferred, the presence of fibrotic rectus fascia does not prohibit its use. If resecting the fascia close and parallel to the symphysis pubis, it is advisable to leave at least 0.5 to 1 cm attached, so as to facilitate closure and approximation to the superior fascial edge. Use of small Army/Navy retractors permits aggressive retraction of skin edges, thus allowing access through a smaller skin incision.

  
  
• 5.
  

  Fascial defect closure. The fascial defect is closed using a heavy-gauge (#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 that adequate anesthesia with muscular relaxation/paralysis are present when the closure is being done.

  
  
• 6.
  

  Preparation of fascia. To prepare the fascial sling for use, a #1 permanent (eg, polypropylene) suture is affixed to each end using a running stitch to secure the suture to the sling. Defatting of the sling may be done if necessary.

  
  
• 7.
  

  Vaginal dissection. Vaginal dissection proceeds with a midline or inverted “U” incision. Injectable-grade saline or local analgesic, such as 1% lidocaine, may be used to hydrodissect the subepithelial tissues. Vaginal flaps are created with sufficient mobility so as to ensure tension-free closure over the sling. Dissection is carried laterally and anteriorly until the endopelvic fascia is encountered. The endopelvic fascia is incised and dissected from the posterior surface of the pubis to enter the retropubic space. This dissection can at times be done bluntly but often, especially in recurrent cases, requires sharp dissection with Mayo scissors.

  
  
• 8.
  

  Passing retropubic needles or clamp. Stamey needles or long clamps are passed through the retropubic space from the open abdominal wound immediately posterior to the pubic bone, approximately 4 cm apart. Distal control of the needles is maintained by finger guidance through the vaginal incision, and the tip of the needle is advanced adjacent to the posterior surface of the pubic bone so as to avoid inadvertent bladder injury. Proper bladder drainage must be assured to minimize injury to the bladder, which may be closely adherent to the pubis, especially if a prior retropubic procedure, as in the case presented, has been previously performed.

  
  
• 9.
  

  Cystoscopy to rule out injury. Careful cystoscopic examination of the bladder after passing the needles is mandatory to rule out inadvertent bladder injury. As the injuries to the bladder typically occur at the 1 o’clock and 11 o’clock positions, use of the 70° lens is warranted, and the bladder must be completely filled to expand any mucosal redundancy. Wiggling the needles or clamps can help to localize their position relative to the bladder wall.

  
  
• 10.
  

  Deploying the sling. The free ends of the sutures affixed to the sling are threaded into the ends of the Stamey needles or grasped with the clamp, and each suture is pulled up to the anterior abdominal wall through the retropubic space. Care is taken to maintain the orientation of the sling so that it is centered and flat at the bladder-neck area.

  
  
• 11.
  

  Some surgeons prefer to fix the sling in the midline to the underlying periurethral tissue with numerous delayed absorbable sutures. The authors, however, prefer to leave the sling unattached to the underlying urethra and bladder neck.

  
  
• 12.
  

  Tensioning of the sling. Various techniques for tensioning are applicable. To ensure adequate “looseness,” the authors prefer to tie the sutures across the midline while holding a right-angled clamp between the sling material and the posterior urethral surface. Tensioning of the sling may also be accomplished by direct vision of proximal/bladder-neck coaptation with rigid cystoscopy while gently pulling up on the free ends of the sling sutures.

  
  
• 13.
  

  The abdominal skin incision is closed with 3-0 and 4-0 absorbable sutures. The vaginal mucosa is closed with 3-0 absorbable sutures. The authors prefer to close the vagina after the tensioning procedure has been completed, whereas some surgeons complete this step before the tensioning.

  
  
• 14.
  

  A bladder catheter is left indwelling and a vaginal gauze packing is placed. The catheter and vaginal packing may be removed after 24 hours. If the patient is unable to void, she is taught intermittent self-catheterization or an indwelling Foley is left in place for 1 week.