Flawed methodology in the few randomized, controlled trials that have compared the pubovaginal sling with the tension-free vaginal tape (TVT) has cast doubt on their findings.3 Basok and colleagues found an increased rate of de novo urgency in the women treated with a pubovaginal sling, compared with those who underwent intravaginal slingplasty,4 whereas Sharifiaghdas and Mortazavi found equal efficacy between pubovaginal and retropubic midurethral synthetic slings.5 The most scientifically valid randomized, controlled trial found equal subjective cure rates and complication rates when a biologic pubovaginal sling was compared with the TVT.6 In that study, the pubovaginal sling was of porcine origin.
In a comparison of autologous and autograft slings, Flynn found equal control of SUI over 2 years, with reduced postoperative discomfort in the allograft group.7
When autologous pubovaginal slings were compared with Burch colposuspension in a randomized, controlled trial, fascial slings were better at controlling incontinence despite an increased morbidity profile.8
A meta-analysis found equal subjective cure rates and overall efficacy between pubovaginal and midurethral synthetic slings.9
Voiding dysfunction is the most common complication
Transient urinary retention may occur in as many as 20% of patients and requires intermittent self-catheterization until resolution (typically 2–4 weeks). Prolonged postoperative voiding dysfunction (lasting more than 4–6 weeks), including de novo urgency, urgency incontinence, and obstructive symptoms, may occur to some degree in as many as 25% of patients. However, fewer than 3% of women require subsequent urethrolysis for treatment of prolonged retention or obstructive voiding symptoms.
Synthetic full-length midurethral slings remain the standard of care
for SUI
Charles W. Nager, MD (November 2012)
Harvest the fascia first. Because substantial bleeding can occur during vaginal dissection, it is advisable to harvest the autologous fascia and prepare the sling by affixing sutures to it before dissecting the vagina. This facilitates timely insertion of the sling and minimal blood loss. Retropubic bleeding from high in the space that occurs during dissection almost always resolves upon placement of the sling. We recommend against prolonged attempts at hemostasis.
In urethral reconstruction, tension the sling after reconstruction. When placing an autologous pubovaginal sling in the setting of urethral reconstruction or as tissue interposition, harvest the fascia and prepare and deploy the sling (with passage of the retropubic sutures) before reconstructing the urethra—but refrain from tensioning until after the reconstruction is completed. Then affix the sling in the appropriate location and tension it. When the sling is placed after reconstruction, it can damage the reconstruction through traction or direct injury.
Don’t worry about surface orientation. During placement of the autologous sling material, surface orientation does not matter. Conventionally, however, the “body-side” or underside of the graft is placed on the body-side of the patient.
Tensioning varies between patients. For most women, sling tensioning can be accomplished by tying the sutures over one or two fingers placed across the fascia. In patients who have undergone multiple procedures and who have a nonmobile urethra, however, tension should be tighter and must be individualized, based on the patient’s anatomy, lower urinary tract function, and willingness to perform intermittent self-catheterization for a prolonged period of time.
CASE 1: Resolved
After you advise the patient of the risks and benefits of the rectus fascia pubovaginal sling, in comparison with a repeat synthetic midurethral sling, she continues to insist on the use of autologous tissue. She undergoes the pubovaginal sling operation with excision of eroded mesh without complication.
A 35-year-old woman reports continuous urinary leakage that is not associated with movement. She was previously told that she had an ectopic ureter implanted into a congenitally short urethra, and she underwent repair of the problem, including reimplantation of the ureter and placement of a cadaveric fascia lata sling. A congenital remnant—observed as a blind pouch via cystoscopy—was left attached to the urethra. Two years have passed since that operation.
Physical findings: A pelvic examination reveals complete loss of the posterior urethra. One possible explanation: The remnant became infected and caused a breakdown of the posterior urethra, with complete disappearance of the cadaveric fascia lata.
Recommended management: Complete urethral reconstruction, with transposition of a martius fat pad and repeat placement of a cadaveric fascia pubovaginal sling.
Technique: See Video 2, Urethral reconstruction.
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