Outcome in 104 pubovaginal slings using freeze-dried allograft fascia lata from a single tissue bank

Old wine into new wineskins: an update for female stress urinary incontinence

PURPOSE OF REVIEW

To review minimally invasive modifications of traditional surgeries for female stress urinary incontinence (SUI) in light of increased demand.

RECENT FINDINGS

Prior to the synthetic mid-urethral sling (MUS), traditional procedures were used to correct SUI. Often these were retropubic colposuspension procedures for a hypermobile urethra and fascial slings for sphincter deficiency but fell out of favor because of increased morbidity compared with synthetic MUS. As controversy rages over use of mesh in female pelvic reconstructive surgery, more women desire nonmesh alternatives. Traditional approaches have been modified to enable colposuspensions and fascial slings to be performed minimally invasively without minimizing efficacy.

SUMMARY

Minimally invasive modifications to traditional procedures for SUI have been available for about a decade but interest has been recently reignited in the setting of patient concern over mesh.

Treatment of mixed urinary incontinence

INTRODUCTION

Mixed urinary incontinence (MUI) is a prevalent condition and imposes a significant impact on a woman's quality of life. Treatment is often challenging, as a single modality may be inadequate for alleviating both the urge and stress component.

MATERIALS AND METHODS

A MEDLINE search was conducted regarding English-language literature pertaining to the pathophysiology, diagnosis of, and treatment for MUI. Non-English language articles were considered if they could be translated into English using GOOGLE translator.

RESULTS

The identification of an ideal single treatment has also been made more challenging by the poor characterization of the pathophysiology of MUI. Behavioral and lifestyle modification, as well as pelvic floor muscle therapy, should be considered first-line options for all women with MUI. Treatment of the urge component with anti-muscarinics is effective; however the stress component is likely to persist after therapy. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI, with emerging evidence suggesting that transobturator MUS may be associated with lower rates of de novo and persistent urge component compared to other procedures. The presence of concomitant, preoperative detrusor overactivity has not been consistently associated with postoperative outcomes.

CONCLUSIONS

The optimum treatment of MUI may often require multiple treatment modalities. While surgery may have a positive impact on both the urge and stress component, its implementation should be approached with caution and patients should be carefully selected. Detailed informed consent in women with MUI cannot be overstated.

Prevalence of urinary urgency symptoms decreases by mid-urethral sling procedures for treatment of stress incontinence

INTRODUCTION AND HYPOTHESIS

Conflicting opinions on the effect of incontinence surgery on the prevalence of postoperative urgency symptoms exists. Our aim was to evaluate the prevalence of urgency symptoms preoperatively and during 3-year of follow-up in women undergoing mid-urethral sling procedures for stress incontinence.

METHODS

Two hundred and sixty-seven women were randomly assigned to a retropubic or a transobturator operation. Detrusor instability score (DIS) and Urogenital Distress Inventory-6 (UDI-6) questionnaires were used to assess prevalence of urgency symptoms. The Incontinence Impact Questionnaire-7, visual analog scale, urinary incontinence severity score, and the EuroQol-5D assessed overall quality of life changes.

RESULTS

A significant decrease in the DIS and UDI-6 score was seen postoperatively. Signs of de novo urgency symptoms were low.

CONCLUSIONS

Mid-urethral sling procedures can be recommended in cases of mixed incontinence, and the procedures seems to decrease prevalence of urgency symptoms.

Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion

Introduction:

Various grafts have been used in the treatment of urinary incontinence and pelvic prolapse. Autologous materials such as muscle and fascia were first utilized to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. Complications such as infection and erosion or extrusion associated with these materials may be troublesome to manage. We review the literature and describe a brief overview of grafts used in pelvic floor reconstruction and focus on the management complications specifically related to synthetic materials.

Materials and Methods:

We performed a comprehensive review of the literature on grafts used in pelvic floor surgery using MEDLINE and resources cited in those peer-reviewed manuscripts. The results are presented.

Results:

Biologic materials provide adequate cure rates but have associated downfalls including potential complications from harvesting, variable tissue quality and cost. The use of synthetic materials as an alternative graft in pelvic floor repairs has become a popular option. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and fewer complication rates due to their structure and composition. Erosion and extrusion of mesh are common and troublesome complications that may be managed conservatively with observation with or without local hormone therapy, with transvaginal debridement or with surgical exploration and total mesh excision, dependent upon the location of the mesh and the mesh type utilized.

Conclusions:

The ideal graft would provide structural integrity and durability with minimal adverse reaction by the host tissue. Biologic materials in general tend to have fewer associated complications, however, the risks of harvesting, variable integrity of allografts, availability and high cost has led to the development and use of synthetic grafts. Synthetic grafts have a tendency to cause higher rates of erosion and extrusion; however, these complications can be managed successfully.

Urodynamic assessment of urinary incontinence

Context

Urodynamic evaluation in the assessment of women complaining of urinary incontinence remains controversial with recent UK National Institute of Health and Clinical Excellence guidance maintaining that it is unnecessary prior to surgery for women with a primarily stress leakage. Other experts contend it should be part of routine preoperative assessment since it establishes a diagnosis, allows more careful patient counseling and predicts surgical outcome.

Objectives

To summarize current literature to define the evidence level on which these conflicting opinions are based.

Materials and Methods

A systematic literature search was performed and retrieved publications summarized in a narrative evidence review using both original papers and previous reviews.

Results

Five hundred and one primary research papers and 65 previous reviews were retrieved. The findings were summarized in a narrative comprising overview, description of methods of bladder and urethral pressure measurement, and a summary of the literature concerning four key questions.

Conclusion

The level of evidence was low regarding answering each of the questions posed, preventing firm conclusions. Urodynamic findings do correlate with relevant symptoms and, to some extent, with symptom severity, giving reasonable diagnostic accuracy. There is no reliable evidence that preoperative urodynamic diagnosis improves outcome from surgery for stress incontinence although it is likely to facilitate preoperative discussion. Tests to differentiate sphincter deficiency and urethral hypermobility are not currently recommended due to poor validity and reproducibility. This along with the current use of mid-urethral tapes as the universal primary surgical procedure means differentiation is not a necessity. Preoperative diagnosis of detrusor overactivity does not appear to worsen surgical outcome in women with a primary symptom of stress leakage. Large, well-designed prospective studies are now underway to provide a definitive answer to these questions.

Histologic comparison of pubovaginal sling graft materials: a comparative study

OBJECTIVES

Little is known about the host response to the various biologic and synthetic graft materials used as substitutes for autologous fascia. We investigated the host response to sling graft materials in humans.

METHODS

A total of 24 women undergoing sling revision had a portion of the graft material removed for comparative analysis. At exploration, the degree of graft preservation (integrity), encapsulation, infection, and fibrosis was quantified. A histopathologic analysis was performed by systematically examining each specimen for the inflammatory response, neovascularity, and host fibroblast infiltration.

RESULTS

A total of 24 grafts were explanted at 2-34 months after implantation. The indications for removal were a lack of sling efficacy in 2, urinary retention in 9, and sling obstruction in 13. The types of graft material were polypropylene mesh (PPM) in 10, autologous fascia in 5, porcine dermis in 4, cadaveric dermis in 3, and cadaveric fascia in 2. No graft degradation had occurred in PPM material. Autologous and cadaveric fascia had the most demonstrable graft degradation. No encapsulation had occurred with autologous fascia or PPM. The porcine dermis was the most encapsulated. No host infiltration had occurred with the encapsulated porcine grafts, and only peripheral infiltration of fibroblasts had occurred in the cadaveric grafts. The PPM grafts had the greatest number of fibroblasts throughout the entire graft. Neovascularity was the most prevalent in mesh and was also present in the autologous fascia. Giant cells were seen in two mesh and two porcine grafts.

CONCLUSIONS

The results of our study have shown that porcine dermis has the potential to encapsulate. The degree of host tissue infiltration was greatest with PPM, and no degradation of the mesh material had occurred with time.

Urethral erosion after suburethral synthetic slings: risk factors, diagnosis, and functional outcome after surgical management

Urethral erosion (UE) is an uncommon but potentially severe complication after suburethral synthetic slings. We aimed to identify the risk factors and diagnostic modalities of UE and also functional outcome after UE surgical management. We retrospectively analyzed eight cases of UE managed in our department between 1997 and 2007. The main presumptive risk factors of UE were excessive sling tensioning (six of eight) and postoperative urethral dilation (four of eight). The most frequent symptoms included voiding difficulties (five of eight), storage symptoms (three of eight), pain (three of eight), and recurrent stress incontinence (three of eight). UE diagnosis was accessible to introital ultrasound (five of five) and confirmed by urethroscopy (eight of eight). Surgical management was performed in seven cases and included transvaginal sling removal with urethral repair (two of seven), endoscopic transurethral sling resection (four of seven), and combined approach (one of seven). All the approaches provided good functional outcomes. Transurethral endoscopy is a mini-invasive treatment of UE and should be tried first in selected cases.

Cadaveric fascia lata versus intravaginal slingplasty for the pubovaginal sling: surgical outcome, overall success and patient satisfaction rates

BACKGROUND

A wide variety of surgical procedures has been used to treat female stress urinary incontinence (SUI). The purpose of this study was to compare cadaveric fascia lata (CFL) sling with intravaginal slingplasty (IVS) in the surgical treatment of SUI.

METHODS

One hundred and thirty-nine women with SUI were randomly assigned to either CFL sling (n = 67) or IVS (n = 72). Concomitant urinary urge incontinence was present in 49 patients (73%) in the CFL sling and 44 patients (61%) in the IVS group. Daily mean pad usage was 4.1 +/- 3.5 in the CFL sling and 2.9 +/- 1.7 in the IVS group. The objective cure rate was evaluated by the pad test, and patient satisfaction rate was assessed by a subjective questionnaire.

RESULTS

The surgical results of both procedures with a follow-up 12 months were documented. The overall success rate was 79% in the CFL sling and 70.8% in the IVS (p = 0.261). In contrast patient satisfaction rates were 82 and 87.5%, respectively (p = 0.210). Comparison of the CFL sling with IVS showed persistent urinary urge incontinence in 67 and 25% (p = 0.0001) and de novo urinary urge incontinence in 22 and 6.9%, respectively (p = 0.009). The groups did not differ significantly with respect to intraoperative and postoperative complications.

CONCLUSIONS

There is no statistical difference in the overall success, satisfaction and complication rates in either group. In our series, both procedures were found to be effective, durable and significantly improved quality of life in patients with SUI but long-term results are awaited.

Long-term patient satisfaction following cadaveric pubovaginal sling incontinence surgery using the UDI and IIQ-7 questionnaires

AIMS

The goal of any incontinence surgery is overall long-term patient satisfaction. The purpose of our study was to assess long-term patient satisfaction following cadaveric fascia lata pubovaginal sling surgery using the urogenital distress inventory (UDI) and the short form of the incontinence impact questionnaire (IIQ-7).

MATERIALS AND METHODS

A total of 47 patients who underwent pubovaginal sling incontinence surgery with a minimum follow-up of 2 years were sent by mail the UDI (total score = 300) and the IIQ-7 (total score = 100). Thirty-seven responses (78.7%) were obtained, with a mean follow-up of 3.8 years (range 2.0-6.2).

RESULTS

Of the 37 patients who responded, the mean UDI score was 75.8 and the mean IIQ-7 score was 21.4. There was no difference in the mean IIQ-7 score for patients with more than 4 years follow-up as compared to the entire group (28.8, P = 0.22). In contrast, the mean UDI score for patients with more than 4 years follow-up was greater compared to the entire group (99.1, P = 0.04). UDI subscale analysis revealed that patients mainly complained of both irritative and stress symptoms as opposed to obstructive/discomfort symptoms (P < 0.01). Patients with pre-operative mixed incontinence had greater mean UDI and IIQ-7 scores compared to patients with pre-operative pure stress incontinence (96.7 vs. 58.0, P = 0.04; 32.5 vs. 11.9, P = 0.03).

CONCLUSIONS

Overall long-term scores assessing quality of life (IIQ-7) were good and those assessing symptom distress (UDI) were satisfactory following pubovaginal sling surgery. Patients with pre-operative mixed incontinence are at greatest risk for post-operative dissatisfaction.

The impact of detrusor overactivity on the management of stress urinary incontinence in women

The presence of overactive bladder symptoms, urodynamic detrusor overactivity, and urge incontinence can complicate the diagnosis and management of stress urinary incontinence in women. The exact pathophysiology of mixed incontinence is not well characterized; in some patients, the stress and urge etiology may be pathologically linked. The role of urodynamics in evaluating patients with mixed incontinence remains controversial. Conservative therapies, such as bladder training, pelvic floor exercise, biofeedback, and electrical stimulation, offer moderate success in women with mixed incontinence. Surgery (colposuspension, bladder neck pubovaginal slings, and midurethral slings) offers excellent subjective and objective cure rates in patients with mixed incontinence. Preoperative detrusor overactivity is cured consistently 50%of the time with colposuspension and slings. Overall, the presence of preoperative detrusor overactivity does not appear to significantly worsen the outcome of conservative and surgical treatments for stress urinary incontinence in women.

Suitability of different sling materials for the treatment of female stress urinary incontinence

Stress urinary incontinence (SUI) is defined as leakage of urine with a sudden increase in intra-abdominal pressure, such as that seen with laughing, lifting, or changing position, without a concomitant rise in detrusor (bladder-generated) pressure. The proposed mechanism of SUI is that an increase in intra-abdominal pressure resulting from various activities causes the bladder pressure to rise above the urethral pressure. The pubovaginal sling remains the standard treatment for female SUI in the US. The market has been flooded with innumerable sling materials. This review discusses the currently available sling materials, surgical approaches, and clinical outcomes data. Long-term data on efficacy is lacking, but early results with new materials and delivery techniques indicate that excellent cure rates with minimal morbidity and high patient satisfaction may be achievable.

Sacral neuromodulation for the treatment of refractory urinary urge incontinence after stress incontinence surgery

OBJECTIVE

This study was undertaken to evaluate the response to sacral neuromodulation in women with refractory, nonobstructive urinary urge incontinence after stress incontinence surgery.

STUDY DESIGN

We reviewed the medical records of women in whom sacral neuromodulation was performed for worsening or de novo urinary urge incontinence after a stress incontinence procedure. All patients had undergone preliminary test stimulation. Demographics, surgical and urogynecologic history, including bladder diary and pad weight test, and urodynamic parameters were evaluated.

RESULTS

Of 34 women, 22 (65%) responded to the test stimulation and underwent permanent lead implant. There was no difference between responders and nonresponders with respect to type of stress incontinence surgery. Incontinence or urodynamic parameters were not different between responders and nonresponders. Factors that were predictive of a positive response were women aged less than 55 years (P = .01), the test stimulation performed within 4 years of the stress incontinence procedure (P = .01), and evidence of pelvic floor muscle activity (P = .03).

CONCLUSION

Sacral neuromodulation is a viable option for the treatment of refractory urinary urge incontinence that occurs after stress urinary incontinence surgery. Older women with no pelvic floor activity who are remote from their incontinence surgery may have a suboptimal response.

Detrusor overactivity and urge urinary incontinence [corrected] following midurethral versus bladder sling procedures

OBJECTIVE

The objective of the study was to compare detrusor overactivity and urge urinary incontinence rates after midurethral slings versus bladder neck slings.

STUDY DESIGN

Three hundred forty subjects underwent midurethral slings or bladder neck slings. Comparisons were made using Student's t test and chi2 test. Multivariate analysis was performed to detect confounding factors.

RESULTS

More patients in the midurethral sling group resolved detrusor overactivity than in the bladder neck sling group (38% versus 15%, P < .001). In addition, subjects in the midurethral sling group had significantly lower rates of de novo detrusor overactivity than subjects in the bladder neck sling group (29% versus 62%, P = .002). The only significant predictors of postoperative detrusor overactivity were preoperative detrusor overactivity (P < .001) and sling type (P < .001). After adjusting for preoperative detrusor overactivity, bladder neck slings significantly increased the risk for persistent detrusor overactivity (odds ratio 3.9).

CONCLUSION

Midurethral slings have increased rates of resolution of detrusor overactivity and lower rates of de novo detrusor overactivity than transvaginal bladder neck sling procedures.

Solvent-dehydrated cadaveric dermis: a new allograft for pubovaginal sling surgery

AIM

The aim of this study was to evaluate the efficacy of solvent-dehydrated cadaveric dermis in pubovaginal sling surgery for the first time in the literature.

METHODS

Twenty-five women with stress urinary incontinence underwent pubovaginal sling surgery using 2 x 12 cm allograft dermis. Preoperatively, all patients were evaluated by a detailed urogynecologic evaluation, voiding diary, pelvic examination and urodynamic investigation. Outcome was assessed by the Urogenital Distress Inventory short form and standardized follow-up questionnaires.

RESULTS

Twenty (80%) patients were cured of stress incontinence symptoms. Seventeen wore no pad and three reported occasional stress urinary incontinence and used no or one pad at a mean follow up of 12 months. Five (20%) patients in our series experienced the same amount of leakage as before the surgery. Seventy-six percent of the patients indicated that urinary incontinence was no longer negatively affecting their daily life and were satisfied with the procedure.

CONCLUSIONS

Questionnaire-based assessment of outcome suggests that solvent-dehydrated cadaveric dermis is effective in the treatment of stress urinary incontinence. However, larger and comparative prospective studies with long-term results and randomized comparison of tissue preparation techniques are warranted.

Histopathologic changes of porcine dermis xenografts for transvaginal suburethral slings

OBJECTIVE

The purpose of this study was to examine the histopathologic changes of HMDI (Hexamethylene di-isocyanate) cross-linked porcine dermis grafts used for suburethral sling surgery.

STUDY DESIGN

Twelve patients underwent reoperation with graft removal for urinary retention or recurrent stress urinary incontinence after transvaginal sling surgery. Tissue specimens were available for pathologic evaluation in 7 patients. Graft specimens underwent histologic preparation including hematoxylin and eosin staining. A single pathologist reviewed the slides blinded to clinical outcomes.

RESULTS

Histopathologic analyses revealed only limited collagen remodeling, and evidence of a foreign body type reaction was present in some specimens. In cases of recurrent stress incontinence, implants appeared to be completely replaced by dense fibroconnective tissue and moderate neovascularization without evidence of inflammation or graft remnants.

CONCLUSION

HMDI cross-linked porcine dermal collagen implants result in variable tissue reactions that may have unpredictable clinical outcomes in different patients, raising questions about the overall tolerability and efficacy of these grafts in pelvic reconstructive surgery.

Comparison of long-term outcomes of autologous fascia lata slings with Suspend Tutoplast fascia lata allograft slings for stress incontinence

OBJECTIVE

This study was undertaken to compare the objective and subjective long-term surgical outcomes in patients receiving Tutoplast fascia lata allograft slings with those receiving autograft slings for the treatment of stress urinary incontinence (SUI).

STUDY DESIGN

We reviewed all patients (n = 71) undergoing suburethral sling with either autologous fascia lata (n = 39) or Tutoplast fascia lata (n = 32) for urodynamic stress incontinence (USI) from October 1, 1998, to August 1, 2001.

RESULTS

Of the original 71 patients, 47 were evaluated by objective and/or subjective means at a minimum of 2 years after surgery. Subjective quality of life measures, subjective continence, maximum urethral closure pressure, and bladder neck mobility were not different between the 2 groups. USI was demonstrated in 41.7% of allograft patients compared with no autograft patients (P = .007).

CONCLUSION

Although patient reported cure of SUI is high for both sling types, USI recurs at a significantly higher rate in Tutoplast slings compared with autologous slings.

Synthetic sling options for stress urinary incontinence

In the past decade, sling surgery has become the preferred technique for the management of female stress urinary incontinence. A greater understanding of the pathogenesis of stress urinary incontinence and a greater durability and effectiveness for sling surgery has allowed this technique to become the benchmark for treatment of female stress urinary incontinence. As a consequence, a multitude of products have been developed using various techniques and materials to perform sling surgery. This article reviews the materials and techniques available and the complications associated with each. Most importantly, the outcomes are discussed so that the readers can best understand the impact of these surgeries on our patients.

Surgical outcome of abdominal sacrocolpopexy with synthetic mesh versus abdominal sacrocolpopexy with cadaveric fascia lata

Nineteen women who had an abdominal sacrocolpopexy (ASC) with synthetic mesh and 18 women who had an ASC with freeze-dried, irradiated cadaveric fascia lata returned for blinded pelvic organ prolapse quantification (POPQ) examinations. The mean relative vaginal descent (delta) from perfect total vaginal length in the mesh group was 1.1 (0.3) cm, and the delta in the fascia group was 2.8 (0.8) cm (p=0.02, Mann-Whitney U). The proportion of women with "optimal" surgical outcome in the mesh group was 89% and 61% in the fascia group (p=0.06, Fischer's exact test). This study suggests that cadaveric fascia lata may not be a good choice for ASC.

The completely dry rate: A critical re-evaluation of the outcomes of slings

OBJECTIVE

To critically evaluate sling outcomes and revisit the realistic goals of anti-incontinence surgery.

MATERIALS AND METHODS

A review of an Institutional Review Board-approved prospective database revealed the outcomes of four different sling techniques that are utilized at our institution.

RESULTS

Four hundred ninety-eight patients had a mean follow-up varying from 9 to 24 months (range 6-50) after undergoing one of four different sling techniques utilized at our institution. The techniques had similar results with regard to completely dry rate, overall success rate, and rate of urgency regardless of the variation in follow-up time. Success was defined as completely dry or leakage = 1/week or = 70% improved by questionnaire in those patients who leaked 1/week. Success, by this definition, varied from 74.9% to 85.7%, but the completely dry rate varied from 36.1% to 45.2%. An additional 31.0% to 33.3% leaked = 1/week, and of the remaining patients, 24.5% to 44.4% considered themselves = 70% improved despite leakage > 1/week. Urge incontinence was reported by 24.4% to 33.3% of patients.

CONCLUSION

As surgeons, we must constantly reevaluate the outcomes and purposes of the procedures we perform on our patients.

Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures

The aim of this study was to document longer-term follow-up of patients in a previously reported series who underwent either sacrocolpopexy (SCP) or suburethral sling procedures utilizing freeze-dried, irradiated donor fascia. Subjects from the initial series of 67 SCPs and 35 slings were included in this retrospective chart review of postoperative follow-up where surgical follow-up longer than 3 months from the procedure was available. Subjects undergoing SCP were examined at the time of any clinical visit and their pelvic organ support evaluated utilizing the POP-Q system. The SCP procedure was considered to be unsuccessful if any anterior vaginal wall point (Aa or Ba) was at the hymen or beyond, or if the vaginal apical point (C or D) descended to a point at least halfway to the hymen from a position of perfect apical support. Subjects who did not return for clinical examination after their 3-month postoperative visit but who had been in telephone contact with the clinic stating that they had experienced symptomatic recurrence of their POP were also included as having unsuccessful SCP procedures. Those similarly in contact with the office by telephone, but not clinically examined, who indicated no subjective return of their POP, were coded as successful. The outcome of the sling procedure was primarily evaluated subjectively, with the patient indicating that stress incontinence symptoms were present or absent. Follow-up was available for 75 patients, who had undergone 54 SCP and 27 sling procedures (6 patients had undergone both SCP and sling procedures). When failure was defined according to any of the criteria listed in the methods section, 45 (83%) patients experienced SCP failure at a median of 12 months after surgery. A total of 14 (52%) sling procedures were failures, with recurrent SUI symptoms experienced from 2 weeks to 24 months (median 3 months) after the procedure. One year after surgery, 23 (43%) SCPs were known to be failures, and 11 (41%) slings were known to be failures. The remaining 13 (48%) slings were subjectively successful when last seen 7-51 months after surgery. We reoperated on 21 (40%) patients. At the time of repeat SCP (chosen by 16 patients) we found graft between the sacrum and vagina in just 3 patients (19%). The use of freeze-dried, irradiated donor fascia for both SCP and sling procedures was associated with an unacceptably high failure rate in our series.

Mixed incontinence: Stressing about urge

Urgency and urinary urge incontinence are troublesome and complex symptoms that can complicate the diagnosis and treatment of stress urinary incontinence. Despite this fact, first-line intervention frequently is directed toward the incompetent bladder neck using surgical approaches. Persistent urgency or detrusor instability following anti-incontinence surgery reduces patient satisfaction and overall continence in most series. This article discusses current theories explaining the etiology of mixed incontinence. It also reviews the results of anti-incontinence surgery for mixed incontinence and discusses management strategies. Possible predictors of outcome after sling surgery in this complex group of patients also are presented.

Pubovaginal sling using cadaveric allograft fascia for the treatment of female urinary incontinence

OBJECTIVES

The technique and outcomes of patients treated with allografts or autografts as pubovaginal sling are compared.

METHODS

Fascia lata was included among the tissues harvested from brain-dead patients considered for multiple organ donation. After informed consent, segments of allograft (group A) cadaveric fascia lata autografts (group B) were compared with used for sling operations in 60 women from 37 to 73 years of age (mean 53.4 years), who presented with stress incontinence requiring a pubovaginal sling.

RESULTS

At a mean follow-up of 36 months (range = 22 to 44 months), 40% of group A patients were cured and 28% were improved. At a mean follow-up of 33 months (range = 24 to 41) 70% of group B patients were cured and 20% improved (P <.05). There were no adverse outcomes of sling erosion or infection in either group. Placement of allograft sling took an average of 62 minutes while the mean duration of sling placement requiring fascial harvest was 81 minutes (P <.05). The mean duration of hospital stay was shorter in the allograft (1.25 days) than the autograft (2.48 days) group (P <.05).

CONCLUSION

Use of allografts was associated with a shorter operative time and duration of hospital stay compared to an autograft, but the 3-year continence rate was lower in the autograft group.

Sling procedures for urinary incontinence in women

There are many different techniques of sling surgery for female incontinence and numerous materials are available for use as a suburethral sling. Autologous materials are associated with more success and fewer complications than cadaveric material. The objectives of this review are to identity the benefits and adverse effects of suburethral sling procedures. There is no evidence that suburethral slings are better or worse than other surgical or conservative management because no trials have addressed this comparison.

8-ply small intestinal submucosa tension-free sling: spectrum of postoperative inflammation

PURPOSE

We report a series of postoperative inflammatory reactions of a tension-free pubourethral sling procedure using an 8-ply small intestinal submucosa (SIS) and review the literature regarding inflammatory reactions with this material in genitourinary reconstruction.

MATERIALS AND METHODS

Between August 2002 and June 2003, 6 of 10 patients treated for stress urinary incontinence with 8-ply SIS had postoperative inflammatory reactions. Patients underwent a thorough evaluation, including history, physical examination and urodynamic studies, before surgical intervention.

RESULTS

All patients presented with induration and erythema at the abdominal incision site(s) and pain 10 to 39 days postoperatively. Pelvic examinations were negative. In 3 patients the inflammatory reaction resolved with minimal or no intervention. Incision and drainage of a sterile abscess were required in 1 patient. Despite 7 days of prophylactic postoperative antibiotics and anti-inflammatory drugs, 2 patients had delayed inflammatory reactions. One patient had resolution with conservative treatment, while the other had an abscess that spontaneously drained. With short-term followup (mean 7 months, range 4 to 10), 8 patients are dry, 1 is improved and 1 is incontinent.

CONCLUSIONS

While the results with the 8-ply SIS tension-free sling in the short term are encouraging, the additional morbidity is alarming and caution is warranted. It is essential that patients be made aware of potential risks and possible delayed presentation of morbidity with the use of this material. The human to 8-ply SIS interaction needs further investigation to ensure that long-term safety and efficacy will not be jeopardized. Until then we will continue to use other sling materials.

Cadaveric fascia lata sling for stress urinary incontinence: a prospective quality-of-life analysis

OBJECTIVE

The purpose of this study was to describe the effects of full-length cadaveric fascia lata (CFL) sling on quality-of-life outcomes.

STUDY DESIGN

Patients were 102 women (aged 29 to 87 years) who underwent the sling procedure for stress incontinence associated with intrinsic sphincter deficiency. They were followed up at 12, 24, 36, and 48 months with the Incontinence Impact Questionnaire (IIQ-7), Urogenital Distress Inventory (UDI-6), and a patient satisfaction questionnaire.

RESULTS

Mean IIQ score declined from 55.1 before surgery to 11.0 at 12 months (P<.001). Mean UDI score declined from 67.1 to 28.0 at 12 months (P<.01). At 12 months, 79.7% of patients reported that leakage was better or much better, and 90.2% reported that they were somewhat or completely satisfied with their progress. Results were maintained throughout the 48-month follow-up period.

CONCLUSION

The CFL sling procedure has an enduring beneficial effect on lower urinary tract symptoms and quality of life.

Prospective analysis of patients treated with a distal urethral polypropylene sling for symptoms of stress urinary incontinence: surgical outcome and satisfaction determined by patient driven questionnaires

PURPOSE

We evaluated the safety and efficacy of the distal urethral polypropylene sling for stress urinary incontinence using patient self-assessment by questionnaires.

MATERIALS AND METHODS

We performed a prospective study of all consecutive patients who underwent a mid distal urethral sling procedure between November 1999 and February 2002. Surgical outcome was determined by symptom, bother and quality of life questionnaires completed by the patients. The physicians were blinded to patient responses. These outcomes were compared to the SEAPI determined by the physician and to physical examination findings.

RESULTS

There were 301 patients, of whom 2.3% required treatment for persistent stress urinary incontinence (SUI) after the polypropylene sling procedure. In the 92 patients with a minimum followup of 12 months the objective cure rate was 92%. The patient determined subjective success rate (cure and improved greater than 50%) was 89%. On questionnaires only 69% of the patients reported no symptoms of SUI under any circumstance and the same number reported never being bothered by SUI. The physician determined SEAPI overestimated patient self-reported symptoms by 10% to 50% depending on the symptom.

CONCLUSIONS

The polypropylene sling represents an inexpensive, safe and simple alternative treatment for patients with stress urinary incontinence. The procedure provides high objective and physician determined cure rates but a lower patient self-reported subjective cure rate. Patient self-assessment of symptoms, bother and quality of life should be an integral part of the outcome of stress urinary incontinence surgery.

Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome

PURPOSE

We present a series of urethral erosion following a pubovaginal sling procedure due to synthetic and nonsynthetic materials and discuss their management and continence outcome.

MATERIALS AND METHODS

During a 3-year period 57 patients underwent urethrolysis for urethral obstruction after receiving a pubovaginal sling. Urethral erosion, defined as sling material entering the urethral lumen, was present in 9 patients and this cohort comprises the focus of our review. In 3 patients the eroded material was synthetic, that is ProteGen (Boston Scientific, Natick, Massachusetts) in 2 and polypropylene in 1. This condition was treated with removal of the whole sling, multilayer closure of the erosion and selective use of a Martius flap. In 6 patients the eroded material was nonsynthetic, that is allograft fascia in 5 and autograft fascia in 1. This condition was treated with sling incision and multilayer closure of the urethra. Preoperative assessment included a urogynecologic questionnaire, measurement of pad use, a voiding diary, cystourethroscopy and videourodynamics. Postoperatively similar parameters were used to assess continence outcomes and the need for subsequent procedures.

RESULTS

Nine patients were followed 30 months after urethrolysis. All 9 women had some manifestation of voiding dysfunction following the pubovaginal sling procedure, including urinary retention in 4, urge incontinence in 3 and mixed incontinence in 2. Urinary retention resolved in 3 patients and urge incontinence resolved in 4. Stress urinary incontinence (SUI) persisted in 2 of the 3 patients in the synthetic group, while no patient in the nonsynthetic group had recurrent SUI. There were no recurrent urethral erosions or fistulas in either group.

CONCLUSIONS

Urethral erosion after a pubovaginal sling procedure can occur irrespective of the sling material. However, recurrent SUI is not an invariable outcome of the management of urethral erosion following the pubovaginal sling procedure.

Management of intrinsic sphincteric deficiency in women

PURPOSE

We reviewed treatment options for intrinsic sphincteric deficiency in women with an emphasis on safety and efficacy.

MATERIALS AND METHODS

Using MEDLINE, we comprehensively reviewed literature relevant to management of intrinsic sphincteric deficiency. We focused on peer reviewed articles from 1995 through December 2001 with older articles included for historical purposes.

RESULTS

Past and current treatment options for intrinsic sphincteric deficiency fall into the 3 categories of urethral bulking agents, slings and artificial urinary sphincter. The autologous fascial pubovaginal sling continues to be the gold standard but newer sling materials are promising. Less invasive therapies with acceptable efficacy and safety profiles are still needed.

CONCLUSIONS

Improved understanding of the continence mechanism may lead to new and improved treatment modalities for intrinsic sphincteric deficiency. However, it will be impossible to compare these treatment options with past treatment unless long-term, randomized, multicenter trials with specific definitions of cure and failure are conducted.

Anatomical correction of vaginal vault prolapse by uterosacral ligament fixation in women who also require a pubovaginal sling

PURPOSE

We describe the anatomical and functional outcome in patients who underwent vaginal vault fixation to the proximal uterosacral ligaments for the treatment of vault prolapse and who also required a concomitant pubovaginal sling for associated stress urinary incontinence as well as the repair of other sector defects.

MATERIALS AND METHODS

We retrospectively analyzed the records of 33 patients who underwent such repairs between November 1998 and December 2001. Endopelvic fascial defects were described using the pelvic organ prolapse quantitative system (POPQ). Outcome measures included anatomical and functional assessment of pelvic floor defects and urinary incontinence.

RESULTS

Preoperatively all patients complained of a vaginal bulge and stress urinary incontinence, while 17 of the 33 had urge incontinence, and 24 and 9 had POPQ stage III or IV and stage II prolapse, respectively. Mean followup was 28 months (range 6 to 43). There was significant improvement in all POPQ measurements (p <0.05). Most notably vaginal cuff support improved by a mean of 7 cm. Stages IIAp (rectocele) and IIC (cuff) prolapse developed in 4 and 2 failed cases, respectively. Stress urinary incontinence was cured in all 33 patients and urge incontinence was cured in 14 of 17, while in 27 vaginal prolapse symptoms resolved and most had improved defecation dysfunction. No patients had urinary obstructive symptoms. There were no ureteral, bladder or rectal complications but 1 patient required blood transfusion.

CONCLUSIONS

Suspension of the vaginal cuff to the proximal uterosacral ligaments with site specific repair of other associated endopelvic fascial defects provides excellent anatomical and functional correction of vault prolapse. Furthermore, a concomitant pubovaginal sling is a compatible repair for associated stress urinary incontinence. It did not compromise vaginal repair and prolapse repair did not jeopardize the outcome of the sling.

Continued multicenter followup of cadaveric prolapse repair with sling

PURPOSE

Since our initial description of the technique of combining a transvaginal sling with a cystocele repair using solvent dehydrated cadaveric fascia lata and bone anchors we have continued to follow our outcomes closely to determine long-term results. We present the updated, multicenter results of the cadaveric prolapse repair with sling.

MATERIALS AND METHODS

A total of 172 patients 35 to 90 years old (mean age 62.1) have undergone cadaveric prolapse repair with sling with a mean followup of 12.4 months (range 6 to 28). Of these patients 132 (76.7%) completed followup. Repair was performed for grade 2 cystoceles in 73 cases, grade 3 cystoceles in 43 and grade 4 cystoceles in 16. Followup included physical examination (degree of pelvic prolapse), SEAPI scores, complications, patient reported continence, perceived improvement and satisfaction. The latter 2 parameters were obtained using a validated questionnaire.

RESULTS

Of the 132 patients 15 (11.4%) had grade 1 and 2 (1.5%) had grade 2 cystocele recurrence, which required no further treatment, and 13 (9.8%) had recurrent or de novo apical vaginal prolapse. Preoperative and postoperative SEAPI scores were 5.58 and 0.9, respectively (p <0.001). A total of 90 patients (68.2%) do not use any pads for protection. Of the 132 patients 24 (18.2%) have stress incontinence of any degree, including 14 (10.6%) with pure stress urinary incontinence, 8 (6.0%) report de novo urge incontinence, 26 (19.7%) have persistent urge incontinence, 21 (15.9%) have any degree of urgency without urge incontinence, 28 (21.2%) report resolution of preoperative urgency or urge incontinence symptoms, 7 (5.3%) have mixed incontinence and 1 had prolonged urinary retention requiring urethrolysis. There has been 1 case of osteitis pubis and no osteomyelitis. Of the patients 94 (71.2%) reported greater than or equal to 70% subjective improvement overall, including 12 who were dry preoperatively, 99 (75.0%) were greater than or equal to 70% satisfied, 105 (79.9%) would repeat the surgery and 102 (77.4%) would recommend the surgery to a friend. With regard to continence 31 (23.8%) patients were less than or equal to 50% improved. A total of 108 (81.8%) patients have no stress urinary incontinence, and patient improvement, satisfaction and complication rates have been acceptable. We have been particularly impressed by the results of the cystocele repair. Surgeons must consider that patient perceived improvement and satisfaction level are essential components of the measure of success or failure of a given therapy.

CONCLUSIONS

With a maximum of 28 months of followup of the cadaveric prolapse repair with sling procedure, we continue to be satisfied with the success of the cystocele repair and the competitive stress urinary incontinence cure rate.

Autologous and synthetic urethral slings for female incontinence

Over the past decade, urethral slings have emerged as the procedure of choice for the surgical correction of most types of female urinary stress incontinence. A variety of materials, autologous, alloplastic, and synthetic, have been used successfully as urethral slings. In the next decade, it is hoped that a better understanding of the factors that influence surgical success will translate into continued refinement of surgical technique.

Surgical management of the apical vaginal defect

PURPOSE OF REVIEW

To review the etiology, presentation, imaging techniques and current surgical management of the apical vaginal defect.

RECENT FINDINGS

Urologists are increasingly managing urinary incontinence and prolapse of the anterior and posterior compartment but most refer the management of the apical defect to gynecologists. A variety of abdominal and vaginal repairs are commonly utilized to repair the apical defect, often based on the surgeon's preference. Of the abdominal repairs, abdominal sacral colpopexy with mesh remains the gold standard. Laparoscopic techniques, although feasible, have not gained widespread acceptance. Of the vaginal restorative procedures there are proponents for uterosacral ligament vault suspension, iliococcygeus and sacrospinous ligament fixation. The uterosacral ligament vault suspension is the most anatomic of the repairs and hence least likely to create a predisposition to future anterior or posterior vaginal wall defects or compromise vaginal function. In rare instances where restorative procedures are discouraged and sexual function is no longer desired, obliterative procedures, which are better tolerated, may be more appropriate.

SUMMARY

The best approach for restoration of vaginal apical support remains controversial with abdominal and vaginal routes commonly utilized. A single approach or procedure based on the surgeon's preference is not always optimal. Procedure selection should be individualized based on the patient's age, comorbidities, prior surgical history and level of physical and sexual activity. The transvaginal uterosacral ligament vaginal vault suspension is increasingly our procedure of choice for management of the apical defect due to its versatility, reduced postoperative morbidity and excellent short-term results.

Technique of combined pubovaginal sling and cystocele repair using a single piece of cadaveric dermal graft

OBJECTIVES

To investigate the feasibility of using a single piece of cadaveric dermal allograft for the repair of stress urinary incontinence (SUI) with concurrent cystocele.

METHODS

Nineteen patients with combined SUI and symptomatic grade III cystoceles were treated. Eleven of 19 patients had undergone prior repairs for SUI. All patients underwent a combined pubovaginal sling procedure and cystocele repair using a single piece of cadaveric dermal allograft (3 x 7 cm). The single strip of dermal graft was placed in a longitudinal direction along the anterior vagina. The distal segment of the allograft supported the urethra, and the proximal portion supported the central cystocele defect and was sutured to the pubocervical fascia. The mean follow-up was 28 +/- 4 months and patients were monitored by physical examination, videourodynamic studies, and completion of the bladder bothersome visual analog scale.

RESULTS

Of the 19 patients, 1 developed an acute infection and failure of the graft after presenting with fever, discharge, dysuria, and incontinence. The autolysed graft was removed, and she subsequently underwent successful autologous fascial repair. Of the remaining 18 patients, 17 were cured of their SUI, including 10 who had had prior repairs, and 16 had no recurrence of cystocele and 2 had asymptomatic grade I and II cystoceles. One patient developed de novo detrusor instability that was successfully treated with anticholinergic medication. No cases of urethral obstruction occurred.

CONCLUSIONS

Although the follow-up was short, the use of a single piece of cadaveric dermal graft slings for concomitant pubovaginal sling and cystocele repair is feasible and simple to perform. At more than 2 years of follow-up, documented by videourodynamic studies, neither urethral obstruction nor symptomatic cystocele recurrence was found.

Intermediate term failure of pubovaginal slings using cadaveric fascia lata: a case series

PURPOSE

The pubovaginal sling procedure using autologous fascia has become the gold standard for treating intrinsic sphincter deficiency and stress urinary incontinence in women. A recent modification has been the use of cadaveric fascia as the sling material. We recently reported similar results for cadaveric fascia lata in 121 women and autologous fascia lata in 46 at a mean followup of 12 months. We have now identified 8 patients who experienced intermediate term failure at 4 to 13 months using cadaveric fascia lata.

MATERIALS AND METHODS

We retrospectively reviewed the records of 8 of 121 patients who received a pubovaginal sling using cadaveric fascia lata between February 1997 and June 1999 and had recurrent stress incontinence after 4 to 13 months. We reviewed the type of fascia, surgical technique, preoperative and postoperative urodynamics, surgical history and medical co-morbidities.

RESULTS

We identified 8 patients who underwent a pubovaginal sling using cadaveric fascia lata and had recurrent stress urinary incontinence at a mean of 6.5 months (range 4 to 13) after the procedure. Fresh frozen fascia from a local tissue bank was used and the surgical technique was identical in all cases. Postoperatively urodynamics confirmed recurrent intrinsic sphincter deficiency. Previous incontinence surgery had been done in 7 of the 8 patients. Patient co-morbidities included neurological disease, diabetes mellitus, previous pelvic irradiation and previous pelvic surgery.

CONCLUSIONS

We identified a higher than expected intermediate term failure rate using fresh frozen cadaveric fascia lata. This risk must be weighed against the advantages of decreased operative time and patient morbidity. Longer followup and larger numbers are necessary to determine how much of a problem exists and what patient characteristics are relevant when selecting cadaveric grafts.

Pubovaginal sling using allograft fascia lata versus autograft fascia for all types of stress urinary incontinence: 2-year minimum followup

PURPOSE

Allografts have been substituted for autografts as a pubovaginal sling to decrease postoperative morbidity, although to our knowledge their long-term durability is unknown. Since 1997, we have offered allograft fascia lata as an alternative to autograft fascia in women undergoing the pubovaginal sling procedure. We describe our continued experience with those with a minimum 2-year followup.

MATERIALS AND METHODS

We retrospectively reviewed the records of 134 consecutive women with all types of stress urinary incontinence but without neurovesical voiding dysfunction or a significant degree of pelvic prolapse who underwent pubovaginal sling (allografts in 63 and autografts in 71) performed by a single surgeon. Rectus abdominis or fascia lata autograft and freeze-dried, gamma irradiated allograft slings were placed using identical techniques and a 2 x 12 cm. piece of fascia. Outcome analysis included a chart review, third party telephone interview and selective videourodynamics. Surgical outcome was categorized by daily pad use as cured-0, improved-1 or failed-greater than 1 pad.

RESULTS

Of 140 women who received a pubovaginal sling 134 were still evaluable. Preoperative parameters were similar in each group. Mean followup plus or minus standard deviation was less in the allograft group (29 +/- 3 versus 44 +/- 7 months, p < 0.05). There was no statistical difference in the overall stress and urge incontinence cure rate in the allograft and autograft groups (45 of 63 cases and 55 of 71, p = 0.42), nor was there a difference in the total number with recurrent stress urinary incontinence (8 and 7, respectively, p = 0.58). In 24% and 16% of cases postoperative incontinence was due to urge incontinence in the allograft and autograft groups, respectively. Using allografts instead of autografts resulted in a significantly decreased postoperative pain and disability (p < 0.05).

CONCLUSIONS

Using allograft fascia lata as an alternative to autologous fascia for a pubovaginal sling significantly decreases postoperative pain and disability without compromising efficacy at 2 years. Therefore, we believe that allograft fascia should remain a suitable alternative to autografts for pubovaginal slings.

Early results of pubovaginal sling lysis by midline sling incision

OBJECTIVES

To describe a simplified technique and results of pubovaginal sling lysis by incision of the sling in the midline by way of a transvaginal approach.

METHODS

We reviewed the charts of 19 women who underwent pubovaginal sling lysis for obstruction. Patients presenting with retention, incomplete emptying or storage, or voiding symptoms suggesting obstruction after pubovaginal sling placement were evaluated with videourodynamic studies and cystourethroscopy. The diagnosis of obstruction was made on the basis of a combination of clinical, urodynamic, and endoscopic findings. All patients underwent a midline incision of the sling by way of a transvaginal approach without formal urethrolysis.

RESULTS

The mean patient age was 57 years. Fifteen women (79%) had an autologous rectus fascial sling, 3 (16%) an allographic fascia lata sling, and 1 (5%) a polypropylene sling. Twelve women (63%) presented with urinary retention and required catheterization to empty. The other 7 women presented with obstructive and/or irritative symptoms without the need to catheterize. The mean time to sling lysis was 10.6 months from the initial surgery. The mean follow-up was 12 months (range 1 to 55). Overall, sling lysis was successful in 84% of the women. Stress incontinence recurred in 17%. No significant perioperative complications occurred.

CONCLUSIONS

Pubovaginal sling lysis without formal urethrolysis appears to be a safe and effective method of relieving obstruction. The success and recurrent stress incontinence rates are comparable to those with formal urethrolysis.

Polypropylene sling for the treatment of stress urinary incontinence

INTRODUCTION

Sling procedures have been used successfully for the treatment of stress urinary incontinence. Using similar surgical principles to the cadaveric fascia sling, we describe the placement of a thinly woven Prolene mesh under the mid to distal urethra. We describe our technique and report our initial early results. Technical Considerations. A total of 98 consecutive patients were evaluated. All patients had clinical evidence of stress urinary incontinence. The patients underwent a preoperative evaluation with video- urodynamic studies, symptom questionnaire, and cystoscopy. A 1 x 10-cm Prolene mesh was placed under the mid to distal urethra. Postoperatively, the patients were evaluated at 3-month intervals with a symptom questionnaire, physical examination, and postvoid residual volume determination.

CONCLUSIONS

We describe a new, simple, quick, inexpensive, and effective method to correct stress urinary incontinence by placing a Prolene mesh under the distal urethra.

Comparison of the durability of cadaveric and autologous fascia using an in vivo model

OBJECTIVES

To assess the durability of both autologous and cadaveric fascia using an animal model. The pubovaginal sling procedure can be performed using autologous, cadaveric, or synthetic materials. Few data are available about the strength and durability of these materials.

METHODS

Rectus abdominus fascia harvested from 6 female Sprague-Dawley rats was processed by Tutogen Medical. In 20 female Sprague-Dawley rats, three different types of fascia were implanted subcutaneously into each animal: autologous rectus abdominus fascia harvested at the time of surgery; rat cadaveric fascia processed by Tutogen; and human cadaveric fascia (Tutogen). The rats were killed at 2 months (10 rats) and 4 months (10 rats) after implantation. The mechanical properties of the tissue were assessed using the trouser tear test, and the fracture toughness was calculated.

RESULTS

Compared with the fracture toughness before implantation, the implanted rat autologous fascia decreased in toughness from 1763 to 1243 J/m(2) (P = 0.12), the implanted rat cadaveric fascia decreased in toughness from 1539 to 1022 J/m(2) (P = 0.02), and the implanted human cadaveric fascia decreased in toughness from 2120 to 1145 J/m(2) (P = 0.09). The fracture toughness of the implanted rat cadaveric fascia and rat autologous fascia did not differ significantly (P = 0.29).

CONCLUSIONS

The changes in strength or elasticity can be detected using the trouser tear test to calculate the fracture toughness. Both cadaveric and autologous fascial grafts may decrease in toughness with time. The long-term durability of the graft may only be a minor factor in determining the success of the pubovaginal sling procedure.