High failure rate using allograft fascia lata in pubovaginal sling surgery for female stress urinary incontinence

Sacrocolpopexy using autologous rectus fascia: Cohort study of long-term outcomes and complications

OBJECTIVE

To evaluate objective and subjective outcomes of patients who underwent sacrocolpopexy using autologous rectus fascia to provide more data regarding non-mesh alternatives in pelvic organ prolapse surgery.

DESIGN

Ambispective cohort study with retrospective and prospective data.

SETTING

A single academic medical centre.

POPULATION

Women who underwent abdominal sacrocolpopexy using autologous rectus fascia between January 2010 and December 2019.

METHODS

Patients were recruited for a follow-up visit, including completing the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse Quantification (POP-Q) examination. Demographic and clinical characteristics were collected.

MAIN OUTCOME MEASURES

Composite failure, anatomic failure, symptomatic failure and retreatment.

RESULTS

During the study period, 132 women underwent sacrocolpopexy using autologous rectus fascia. The median follow-up time was 2.2 years. Survival analysis showed that composite failure was 0.8% (95% CI 0.1%-5.9%) at 12 months, 3.5% (95% CI 1.1%-10.7%) at 2 years, 13.2% (95% CI 7.0%-24.3%) at 3 years and 28.3% (95% CI 17.0%-44.8%) at 5 years. The anatomic failure rate was 0% at 12 months, 1.4% (95% CI 0.2%-9.2%) at 2 years, 3.1% (95% CI 0.8%-12.0%) at 3 years and 6.8% (95% CI 2.0%-22.0%) at 5 years. The symptomatic failure rate was 0% at 12 months, 1.3% (95% CI 0.2%-9.0%) at 2 years, 2.9% (95% CI 0.7%-11.3%) at 3 years and 13.1% (95% CI 5.3%-30.3%) at 5 years. The retreatment rate was 0.8% (95% CI 0.1%-5.9%) at 12 months and 2 years, 9.4% (95% CI 4.2%-20.3%) at 3 years and 13.0% (95% CI 6.0%-27.2%) at 5 years.

CONCLUSION

Autologous rectus fascia sacrocolpopexy may be considered a safe and effective alternative for patients who wish to avoid synthetic mesh.

Managing female pelvic floor disorders: a medical device review and appraisal

Pelvic floor disorders (PFDs) will affect most women during their lifetime. Sequelae such as pelvic organ prolapse, stress urinary incontinence, chronic pain and dyspareunia significantly impact overall quality of life. Interventions to manage or eliminate symptoms from PFDs aim to restore support of the pelvic floor. Pessaries have been used to mechanically counteract PFDs for thousands of years, but do not offer a cure. By contrast, surgically implanted grafts or mesh offer patients a more permanent resolution but have been in wide use within the pelvis for less than 30 years. In this perspective review, we provide an overview of the main theories underpinning PFD pathogenesis and the animal models used to investigate it. We highlight the clinical outcomes of mesh and grafts before exploring studies performed to elucidate tissue level effects and bioengineering considerations. Considering recent turmoil surrounding transvaginal mesh, the role of pessaries, an impermanent method, is examined as a means to address patients with PFDs.

Pubovaginal sling materials and their outcomes

Stress urinary incontinence (SUI) is the most common type of urinary incontinence, and approximately 200 different methods have been described for its surgical management. A better understanding of the pathophysiology of SUI has led to the development of surgical therapies focused on creating a strong suburethral supportive layer and urethral resistance. The most important advantage of the pubovaginal sling (PVS) procedure is that it restores urethral resistance during stress maneuvers to prevent incontinence, while improving urethral coaptation at rest and allowing for spontaneous micturition. Various autologous, allograft, xenograft and synthetic materials have been used for the PVS. The autologous PVS procedure for the treatment of SUI offers the highest success rate and is the most commonly used PVS surgical method. Unlike xenograft and allograft materials, the autologous procedure does not result in a tissue reaction and is associated with a low rate of material-related complications.

Demands and properties of alloplastic implants for the treatment of stress urinary incontinence

Surgical treatment of stress urinary incontinence changed dramatically with the introduction of the tension-free vaginal tape. Owing to its high efficacy and minimal patient discomfort this new minimally invasive procedure quickly obtained widespread acceptance and superseded the abdominal colposuspension as the gold standard. In the course of success of the original method a number of tension-free vaginal tapes flooded the market, varying in approach and material. These variations may strongly influence the safety, efficacy and long-term results of tension-free vaginal tape and its major modification, the transobturator technique. Therefore, it is the aim of this review to closely illuminate available materials and complications associated with this procedure. An extensive Medline search of the published literature up until 2006 on the subject of stress urinary incontinence was carried out. All sources identified were reviewed with particular attention to the method applied, the properties of the mesh materials and clinical complications. Apart from several technical variations, there are marked differences between the different vaginal sling materials, ranging from absorbable collagens over polypropylene to allografts. Although performed globally in substantial and increasing numbers, minimally invasive techniques for the surgical treatment of stress urinary incontinence are lacking sufficient safety data.

Update of AUA guideline on the surgical management of female stress urinary incontinence

PURPOSE

We updated the 1997 American Urological Association guideline on female stress incontinence.

MATERIALS AND METHODS

MEDLINE searches of English language publications from 1994 and new searches of the literature published between December 2002 and June 2005 were performed using identified MeSH terms. Articles were selected for the index patient defined as the otherwise healthy woman who elected to undergo surgery to correct stress urinary incontinence or the otherwise healthy woman with incontinence and prolapse who elected to undergo treatment for both conditions.

RESULTS

A total of 436 articles were identified as suitable for inclusion in the meta-analysis, and an additional 155 articles were suitable for complications data only due to insufficient followup of efficacy outcomes in the latter reports. Surgical efficacy was defined using outcomes pre-specified in the primary evidence articles. Urgency (resolution and de novo) was included as an efficacy outcome due to its significant impact on quality of life. The primary efficacy outcome was resolution of stress incontinence measured as completely dry (cured/dry) or improved (cured/improved). Complications were analyzed similarly to the efficacy outcomes. Subjective complications (pain, sexual dysfunction and voiding dysfunction) were also included as a separate category.

CONCLUSIONS

The surgical management of stress urinary incontinence with or without combined prolapse treatment continues to evolve. New technologies have emerged which have impacted surgical treatment algorithms. Cystoscopy has been added as a standard component of the procedure during surgical implantation of slings.

A comparative study evaluating the in vivo incorporation of biological sling materials

OBJECTIVES

To comparatively investigate biological tissues that are clinical products currently used for implantation in urological reconstruction. Specifically, we examined biological materials in vivo and evidence regarding the tissue response observed. Biological tissues are widely used in urological surgeries to treat conditions such as pelvic organ prolapse and stress urinary incontinence.

METHODS

Histologic data from 4 biological sling materials, that is, small intestinal submucosa (SIS), cadaveric fascia lata, cadaveric dermis, and porcine dermis, implanted within mice (n = 64) were evaluated at 2, 4, 8, and 12 weeks. Recovered tissue was assessed by several biocompatibility parameters such as capsule formation (collagen deposition), cellular number, cell morphology, and angiogenesis.

RESULTS

Data provide a scientific depiction of the cellular response to these biomaterials through a 12-week evaluation. SIS had a significantly higher level of angiogenesis and cell infiltrate as compared with all other material tested. Collectively, the data suggest that SIS has improved biocompatibility over other tested materials.

CONCLUSIONS

This study compared SIS with other biological tissues in an animal model and was found to have superior biocompatibility as seen in humans. This may be helpful for clinicians while selecting a particular biological material. The study provides evidence of the varying stages of remodeling each implant, with hopes to better understand the material response in vivo.

A comprehensive review of suburethral sling procedure complications

The study objective was to review the existing literature regarding complications of anti-incontinence sling procedures. PubMed listings using keywords related to slings and associated complications with no date or language restrictions through May 2007 and the Manufacturer and User Facility Device Experience Database were searched for specific device- and procedure-related complications. Where no information was available, published abstracts were cited. Published reports of complications for all types of anti-incontinence sling procedures are analyzed and reported. Sling-related complications are multiple but can be summarized from studies on 13737 cumulative patients as involving: voiding dysfunction (8 studies, 881 patients, 16.3% average overall incidence [OI]); detrusor overactivity (20 studies, 1950 patients, 15.4% OI); urinary retention (14 studies, 943 patients, 14.2% OI); erosion/extrusion (19 studies, 2197 patients, 6.03% OI); impact on quality of life-dyspareunia (2 studies, 175 patients, 4.3% OI); infections-most often urinary tract infections but severe infections such as abscess are reported (19 studies, 1487 patients, 5.5% OI); hematoma-most often pelvic or vaginal (4 studies, 3691 patients, 2% OI); pain (6 studies, 597 patients, 7.3% OI); abdominal and pelvic organ injury-bladder, urethra, vagina, and intestines (10 studies, 1816 patients, 3.3% OI); systemic complications-deep vein thrombosis, sepsis (case reports); and death (case reports). Cure rates for all slings are as follows: subjective (16 studies, 1541 patients, 95% OI, range 63%-99%), objective (15 studies, 1203 patients, 82% OI, range 51%-97%), and failure (8 studies, 599 patients, 11.5% OI, range 4%-37%). It is likely that sling-related complications are under-reported in the published medical literature and in the Manufacturer and User Facility Device Experience Database. This review reports on the incidence of known complications for all types of slings. Some complications are common to all sling techniques; however, with development of minimally invasive slings, device-related complications are reported and compared.

Time-dependent variations in inflammation and scar formation of six different pubovaginal sling materials in the rabbit model

OBJECTIVES

To provide pathologic evidence, using six different sling materials, of the findings from rabbit model studies demonstrating loss of tensile strength and stiffness in porcine and cadaveric sling materials.

METHODS

Ten rabbits randomized into two survival groups (6 and 12 weeks of age) each had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh, and autologous fascia implanted on their anterior rectus fascia. At harvest, hematoxylin-eosin and immunohistochemical staining for CD3, CD20, and MIB-I were performed. A pathologist unaware of the content of the slides quantified the degree of inflammation and fibrosis of each.

RESULTS

Significant differences were found for inflammation (P = 0.016), eosinophil infiltrate (P = 0.035), and inflammatory rind (P = 0.027) at 12 weeks, with polypropylene mesh having the lowest degree. At 12 weeks, differences were found in the presence of fibrosis/scar formation (P = 0.010) and degree of fibrosis/scar (P = 0.009). Although polypropylene mesh, cadaveric fascia, and porcine dermis all demonstrated a high presence of fibrosis/scar, polypropylene mesh had the greatest overall degree of scar formation at 12 weeks.

CONCLUSIONS

The inflammation with the cadaveric fascia and porcine materials may cause rapid clinical deterioration compared with autologous fascia and polypropylene mesh. These data provide a possible explanation for prior biomechanical studies demonstrating variations in tensile strength and stiffness of the different materials. The fibrosis and scarring noted with polypropylene mesh may also contribute to a more lasting repair.

Use of rectus fascia graft for corporeal reconstruction during placement of penile implant

OBJECTIVES

To report on the technique of using autologous rectus fascia graft for corporeal and tunica reconstruction during placement of an inflatable penile prosthesis. Reconstructing the corpora cavernosa and closing the tunica albuginea over an inflatable penile prosthesis can be challenging when severe fibrosis is encountered.

METHODS

Fifteen patients with severe fibrosis of the corpora or tunica were included in this study. Eight patients had severe corporeal fibrosis secondary to an infected or malfunctioned penile prosthesis that had been previously removed, and seven had severe penile curvature secondary to tunical fibrosis with concomitant erectile dysfunction. All patients underwent corporeal or tunica reconstruction using autologous rectus fascia after placement of an inflatable penile prosthesis. Postoperatively, patients were evaluated at 1, 6, 12, and 24 months. Data on patient satisfaction, graft function, and complications were recorded.

RESULTS

At a mean follow-up of 18 months (range 12 to 64), augmentation of the tunica or corporeal defect using autologous rectus fascia graft was successful in all patients. The penile prostheses were functioning properly with no evidence of graft infection, erosion, or abdominal wall hematoma. Patients demonstrated good results, with return to sexual intercourse at a mean of 9 weeks postoperatively (range 8 to 10).

CONCLUSIONS

Use of an autologous rectus fascia graft for coverage of a tunical or corporeal defect during penile prosthesis placement in patients with corporeal or tunica fibrosis is surgically feasible, safe, and efficacious. Long-term follow-up of this reconstructive technique has demonstrated excellent clinical results with no morbidity related to the rectus fascia graft harvesting.

Minimally invasive surgical techniques for stress incontinence surgery

Minimally invasive techniques for surgical correction of stress incontinence date back to the late 1950s. Since that time there have been many developments to attempt to emulate the good results achieved by open surgery with less surgical morbidity. Needle suspensions have attempted to reposition the bladder neck in the same way as a colposuspension. However, although numerous variations have been described, they do not have the long-term outcomes of colposuspension. These variations, their complications and long-term outcome are discussed. Sling surgery, especially the tension-free vaginal tape (TVT), has probably had the largest impact on incontinence surgery in recent years, offering a procedure with low morbidity and, thus far in the medium term, outcomes comparable with those of more invasive procedures. This has led the TVT procedure to become the most common procedure performed worldwide for stress incontinence. With the benefit of lessons learnt from the use of synthetic material in the genitourinary tract, some worries remain with regard to the long-term complications of TVT. Other non-synthetic material should not be forgotten, and the advantages and disadvantages of various sling materials are compared. Injectables have an established place in the treatment of sphincter deficiency, though long-term results are poor compared to those of other procedures. Various materials used and the technique for their injection are discussed.

Bladder neck pubovaginal slings

Over the past 30 years, the pubovaginal sling has surpassed retropubic and transvaginal suspensions as the most common surgical operation for correcting stress urinary incontinence. This resurgence has been due in part to innovative technological advances that have shortened operative times and expedited postoperative recovery. The introduction of novel allografts, xenografts and synthetic materials has also been accompanied by unique complications, previously not encountered with autologous materials. The aim of this review is to compare the available sling materials in the context of biocompatibility and efficacy.

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.

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.

Abdominal sacral colpopexy with allograft fascia lata: one-year outcomes

OBJECTIVE

The purpose of this study was to assess 1-year outcomes of sacral colpopexy with the use of allograft fascia lata.

STUDY DESIGN

Records of all subjects who underwent sacral colpopexy with allograft fascia lata from May 1, 2001, to April 30, 2003, were reviewed. Subjects underwent pre- and postoperative evaluation of prolapse with the pelvic organ prolapse quantification system. The Fisher's exact test was used to analyze the results.

RESULTS

Allograft fascia lata was used for 24 colpopexies during this period. No significant intraoperative or postoperative complications or graft erosions occurred. Five subjects were lost to follow-up after 3 months. Analysis was performed on the remaining 19 subjects. Prolapse of stage 2 or more in compartments Aa, Ba, Ap, Bp, and C was preoperatively 50%, 74%, 78%, 84%, and 68% and postoperatively 11%, 16%, 21%, 26%, and 5%, respectively.

CONCLUSION

Allograft fascia lata may be a suitable alternative to permanent mesh for sacral colpopexy, but longer-term outcomes and larger studies are needed.

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.

Assessing outcome after a modified vaginal wall sling for stress incontinence with intrinsic sphincter deficiency

Forty women with stress incontinence, intrinsic sphincter deficiency (ISD), associated or not with urethral hypermobility, a Valsalva leak point pressure (VLLP)<60 cmH(2)0 and a maximum urethral closure pressure<30 cmH(2)0 underwent in situ vaginal wall sling. The main modification to the technique was the use of two small Marlex meshes placed at the lateral edges of the sling. Outcome was assessed by pad use, surgical results and patients' satisfaction. Data of 39/40 patients were analyzed after a minimum follow-up of 1 year. After surgery 30/39 patients were completely dry (no pads), stress incontinence disappeared in 22/39, and 30/39 patients were satisfied with outcome. Reasons for dissatisfaction included recurrence of stress incontinence in three, infections in one and urge incontinence in five. Overall results are good given this category of patients. The vaginal wall sling can be recommended for patients with ISD because the results are promising, it corrects urethral hypermobility and, in our experience, it does not cause obstruction if correctly performed.

Time Dependent Variations in Biomechanical Properties of Cadaveric Fascia, Porcine Dermis, Porcine Small Intestine Submucosa, Polypropylene Mesh and Autologous Fascia in the Rabbit Model: Implications for Sling Surgery

PURPOSE

We investigated time dependent variations in tensile strength, stiffness, shrinkage and distortion in 6 materials commonly used for transvaginal anti-incontinence surgery.

MATERIALS AND METHODS

A total of 15 rabbits were randomized into 3 survival groups (2, 6 and 12 weeks, respectively). Each rabbit had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia implanted on the anterior rectus fascia. At harvest tensiometry and image analysis were performed on each sling. Results were compared to baseline for each sling type and the percent decrease from baseline was compared among sling types.

RESULTS

Each type of human cadaveric fascia and porcine allografts showed a marked decrease (60% to 89%) in tensile strength and stiffness from baseline. Polypropylene mesh and autologous fascia did not differ in tensile strength from baseline. Polypropylene mesh increased in stiffness from baseline. Autologous fascia and small intestinal submucosa demonstrated a 41% and 50% decrease in surface area, respectively, at 12 weeks.

CONCLUSIONS

To our knowledge the relative contribution of biomechanical properties of sling material to the success of anti-incontinence surgery is unknown. However, rapid loss of tensile strength and stiffness in porcine and cadaveric materials may contribute to the early re-emergence of symptoms following successful sling surgery. The results of this study add scientific validity to the increasing use of synthetics in anti-incontinence surgery. Urologists selecting a sling material should be aware of its time dependent biomechanical fate relative to other sling materials.

Efficacy and morbidity of autologous fascia lata sling cystourethropexy

PURPOSE

Sling cystourethropexy for intrinsic sphincter deficiency has more recently been accepted as effective surgical treatment for all types of stress urinary incontinence. We report our experience using autologous fascia lata for sling cystourethropexy, regarding treatment efficacy, harvest site morbidity and patient satisfaction.

MATERIALS AND METHODS

A retrospective data base review identified all women who underwent sling cystourethropexy using autologous fascia lata for stress urinary incontinence. A followup survey study using questionnaires (Black and Urogenic Distress Inventory-6) combined with questions regarding pad use, satisfaction and leg morbidity was done.

RESULTS

A total of 100 women who could be contacted and who had undergone autologous fascia lata sling cystourethropexy performed by a single surgeon between 1993 and 2002 were surveyed. Mean patient followup was 4.4 years (range 0.8 to 9.3). Of the women 85% stated that they were dry or improved and 93% were pain-free at the harvest site by 7 days. There was no harvest site infection and no lower extremity thrombotic complication. Of the patients 83% indicated that the procedure had a positive effect on their life with only 4% stating that it had a negative effect, while 77% were satisfied with the procedure, 82% would recommend the procedure to a friend with incontinence and 83% would undergo the procedure if making the decision again.

CONCLUSIONS

Autologous fascia lata sling cystourethropexy is associated with high patient satisfaction and treatment efficacy comparable to that of other sling cystourethropexy materials, as determined by questionnaire. Harvest site morbidity is low. Sling cystourethropexy using autologous fascia lata should be considered as a primary surgical approach in women with stress urinary incontinence.

The tensile properties of tension-free vaginal tape and cadaveric fascia lata in an in vivo rat model

OBJECTIVE

To examine the tensile properties (break load and maximum average load), after in vivo implantation in a rat animal model, of tension-free vaginal tape (TVT) and cadaveric fascia lata (CFL), as pubovaginal slings of these materials have become popular for treating stress urinary incontinence.

MATERIALS AND METHODS

Twenty Sprague-Dawley rats (300-400 g) had 1 x 2 cm strips of commercially available TVT and CFL implanted on the right and left anterior abdominal wall, respectively. Half of the animals were then killed at 6 weeks and the remainder at 12 weeks, after which the strips of TVT and CFL were removed and their tensile properties measured using a tensiometer. The tensile strength of TVT and CFL strips maintained only in normal saline served as controls.

RESULTS

The TVT strips had a mean break load of 0.740 kg in the control and only 0.390 kg for CFL (P < 0.05). At 6 weeks the TVT material had a mean (sd) maximum average load of 0.634 (0.096) kg and a mean break load of 0.589 (0.249) kg, whereas the respective values for the CFL were 0.323 (0.198) and 0.167 (0.063) kg (P < 0.05). Similarly at 12 weeks, TVT had a greater mean maximum average and break load than CFL, at 0.742 (0.052) and 0.274 (0.126), and 0.737 (0.056) and 0.185 (0.128) kg, respectively.

CONCLUSION

This is the first study to assess the tensile properties of the currently used sling materials, TVT and CFL, in an in vivo model. TVT has a greater break load and maximum average load than CFL; the tensile strength of these materials does not decrease with time.

Pubovaginal sling using Duraderm? graft: Intermediate follow-up and patient satisfaction

AIM

To assess outcome and patient satisfaction utilizing Duraderm allograft as sling material.

METHODS

Twenty five patients undergoing the Duraderm sling procedure were evaluated by pelvic examination, post-void residual urine, and multi-channel urodynamics. Follow-up included repeat examination, stress test, and chart review. Patient satisfaction was assessed by phone interview with an independent examiner. Outcome was defined as dry (no leaking at all and patient perception of satisfaction), improved (minimal leak requiring < or =1 pad daily and patient perception of satisfaction), or failure.

RESULTS

Average age was 62.0 years (30-83); average daily preoperative pad usage was 3.5 (2-8). Duraderm allograft measuring 2 x 12 cm was used. Mean postoperative catheter time was 7.7 days (3-37 days). At 6 months, 17/25 (68%) were dry, 6 (24%) improved, and 2 (8%) failed. Mean intermediate follow-up at 14.8 months (8-23 months) revealed 8/25 (32%) patients were dry, 9 (36%) were improved, and 8 (32%) failed Duraderm sling. Mean pad use after surgery was 1.4 (0-6). Of the 25, 19 (76%) were satisfied with the surgical outcome, 17 (68%) noted they would have surgery again, and 17 (68%) would recommend the procedure.

CONCLUSIONS

Initial results of pubovaginal sling using Duraderm graft are satisfactory; however, longer term follow-up is disappointing. Graft degeneration previously described after utilization of cadaveric fascia lata may be possible following implantation of cadaveric dermis.

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.

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.