VAGINAL WALL SLING

Chapter 33 VAGINAL WALL SLING



Rodney A. Appell


There are a plethora of surgical procedures for the treatment of female stress urinary incontinence (SUI). More than 200 procedures currently exist, and the list is still growing. Sincere attempts to overcome imperfect results and to avoid complications, as well as pressures from industry and patients, have all taken part in this evolution, or perhaps revolution, with innovative, creative attempts over the last decade aimed at performing less invasive surgery for SUI, to decrease morbidity, hospital stay, postoperative discomfort, and perhaps even the cost of surgery. There are nonlaparoscopic procedures available for SUI that are minimally invasive and share many of these qualities just described; in the carefully chosen patient, they provide a reasonable surgical option for the treatment of SUI. This chapter reviews the surgical techniques and results of vaginal wall slings.


Surgical procedures in this category are really modifications of transvaginal suspensions that were designed to support the proximal urethra and bladder neck into a high retropubic position transvaginally, presumably in a less invasive way than with retropubic suspensions. A midline or inverted ∪-shaped incision was created at the anterior vaginal wall. The periurethral ligaments and, in some procedures, the deep part of the vaginal epithelium were included in a helical suture. The suture was then transferred, using a long needle passer, to a small suprapubic incision. This step was then repeated on the contralateral side. Tying the sutures in the suprapubic area resulted in suspension of the bladder neck and the proximal urethra into a high retropubic position. Variations on these themes included modifications by Pereyra in 1959,1 Stamey in 19732 and 1981,3 and Gittes in 1987.4 These variations differed in the shape of the vaginal incision (midline, T-shaped, inverted U), the way the needle was passed (direct finger guidance or blindly), the anchoring tissue, and the use of cystoscopy (to rule out injury or to confirm suture placement). As a group, these procedures have been less efficacious than retropubic suspensions or sling procedures. They carry a success rate of 67% with 4 or more years of follow-up.5 A possible explanation for their lesser efficacy may include pull-through of the sutures through the supporting anchoring structures and eventual failure of the supporting mechanism at the level of the bladder neck and proximal urethra. Future applications for these procedures seem to be limited unless they can be used in conjunction with the “sling concept.”



MINIMALLY INVASIVE SLING PROCEDURES


Sling procedures have been used for almost a century in efforts to correct SUI and are constantly evolving. In recent years, several observations have helped direct innovations. In the past, SUI was separated into urethral hypermobility (type I and II) and intrinsic sphincter deficiency or ISD (type III). Now it is believed that, if SUI is present, there must be some component of sphincteric deficiency. Sling procedures were originally designed for the treatment of the ISD type of urinary SUI and for recurrent SUI when prior surgical treatments had failed. Now, however, sling procedures are used also in the treatment of primary SUI.


If a sling procedure is chosen, there are many technical options available for placement and choice of sling material: in situ vaginal wall, free vaginal wall graft, synthetic material, cadaveric fascia lata, autologous rectus fascia, and autologous fascia lata. Despite the success of synthetic slings placed at the mid-urethra, there are many patients and surgeons for whom the placement of a foreign body through the vagina is not acceptable. For such patients, and especially for those with abdominal (Valsalva) leak point pressure (VLLP) greater than 50 cm H2O, an acceptable alternative is an in situ vaginal wall sling.6 Through the use of the vaginal wall, the time and morbidity of the sling procedure can be decreased, and the use of any foreign material is avoided. Furthermore, regardless of the sling material, preservation of the endopelvic fascia may help to prevent recurrent paravaginal defects may decrease the operative morbidity by reducing the surgical dissection and adverse side effects such as detrusor instability. The sling should then be fixed in position and tied without tension.



PREOPERATIVE ASSESSMENT


Every patient undergoes a careful pelvic examination, measurement of postvoid residual volume, and a supine stress test. Patients with mixed incontinence or an elevated postvoid residual volume always undergo urodynamic testing. Patients with pure SUI, on the other hand, should have urodynamic testing with determination of VLLP to help determine whether the type of sling material to be used is in question. Cystoscopy can be reserved preoperatively for the patient with complaints of significant urgency. Any pelvic organ prolapse noted on physical examination should be addressed at the time of the proposed incontinence surgery.



METHOD: IN SITU VAGINAL WALL SLING WITH PRESERVATION OF THE ENDOPELVIC FASCIA

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DEVELOPMENTAL ANATOMY AND UROGENITAL ABNORMALITIES USE OF CADAVERIC FASCIA FOR PUBOVAGINAL SLINGS ANTERIOR COLPORRHAPHY FOR CYSTOCELE REPAIR 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 VAGINAL WALL SLING

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