URINARY INCONTINENCE PUBOVAGINAL SLINGS
Category: Urology
Abstract : urinary incontinence pubovaginal slings Indications Sling procedures are mainly used for female stress incontinence associated with poor urethral function (type III or ISD), or when previous surgical procedures have failed. Also used for incontinence due to urethral damage (following radical pelvic surgery or radiotherapy), and for neurological urethral dysfunction (e.g. myelodysplasia) in b
urinary incontinence pubovaginal slings
Indications
Sling procedures are mainly used for female stress incontinence associated with poor urethral function (type III or ISD), or when previous surgical procedures have failed. Also used for incontinence due to urethral damage (following radical pelvic surgery or radiotherapy), and for neurological urethral dysfunction (e.g. myelodysplasia) in both sexes.
It is essential that urethral and bladder function is evaluated prior to surgical repair.
Types of sling
- Autologous rectus fascia, fascia lata (from the thigh), vaginal wall slings.
- Non-autologous allograft fascia lata from donated cadaveric tissue.
- Synthetic monofilament polypropylene tape (TVT or tension-free vaginal tape).
Autologous and allograft slings
The tissue strip is inserted via an abdominal incision, and tunnelled through the endopelvic fascia on one side, behind the proximal urethra and into the anterior vagina, and then guided out the other side. The two ends are sutured to rectus fascia, using the minimal amount of tension needed to prevent urethral movement. In men, the sling is placed around the bulbourethra. Alternative methods of fixation include bone anchoring; however, this is associated with increased risk of osteitis pubis.
Synthetic slings
The TVT is a popular procedure as it is less invasive, it can be inserted under local anaesthetic as a day case, and it has few complications. The tape has long trocars on each end, which are inserted either side of the urethra through a vaginal approach. They perforate the endopelvic fascia, and are pushed out onto the lower abdominal wall. Once the tape is positioned loosely behind the mid-urethra, its covering is removed, and the ends cut flush to the abdomen.
Both techniques use cystoscopy to assist prevention of bladder perforation during sling placement. Post-operatively, patients may temporarily require ISC until post-void residuals are less than 100ml.
Outcomes
Overall, long-term cure rates for slings are 80%, with improvement seen in 90%.8 Complication rates are low but include voiding disorders (urinary retention, de novo bladder overactivity); vaginal, urethral, and bladder erosions; bowel and bladder perforation; and pelvic bleeding.
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