Pubovaginal slings: a review of the technical variables

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.

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.

Success of Pubovaginal Sling in Patients With Stress Urinary Incontinence and Efficacy of Vaginal Sling Release in Patients With Post-Sling Voiding Dysfunction

OBJECTIVE

To assess the overall success of sling procedures and surgical sling release in achieving urinary continence and voiding function in women with stress urinary incontinence.

METHODS

We reviewed the charts of 107 patients with stress urinary incontinence who had a two-team abdominal-vaginal fascial sling procedure performed between January 2000 and December 2003. Data reviewed included the patients' medical history, demographic data, findings on physical examination, urodynamic studies, operative report, and findings at visits 6 weeks, 6 months, and 12 months after surgery. Patients with sling releases were followed up to assess pelvic organ prolapse, uroflowmetry, and post-void residual urine volume, and to complete the quality of life questionnaire IIQ-7.

RESULTS

At one year after pubovaginal sling surgery, 82.1% of patients were cured of stress urinary incontinence. The majority (85.1%) of patients did not develop postoperative voiding dysfunction. Only 5.6% of those who did develop postoperative voiding dysfunction required surgical sling release. Sling release resolved the post-sling voiding dysfunction in three out of five patients.

CONCLUSION

Pubovaginal sling surgery is a highly successful strategy for the management of stress urinary incontinence and has a low rate of postoperative voiding dysfunction. Surgical sling release may resolve post-sling voiding dysfunction.