Editing Functional: Female SUI (section)

===== Pubovaginal Slings (PVS) =====

* '''Indicated for treatment of incontinence associated with''' 
**'''Deficiency in a portion of the midurethral complex'''
**'''Hypermobility'''
**'''ISD'''
**'''MUI'''
**'''Concomitant cystoceles'''
**'''Urethral diverticula'''
**'''Neurologic conditions'''

====== Anatomy and Mechanics of a PVS ======
* '''<span style="color:#ff0000">Positioned at the bladder neck (in contrast to MUS which is placed in the midurethra)</span> to provide urethral compression without obstruction during times of increased intraabdominal pressure.'''
**Pubovaginal slings are placed under mild tension at the bladder neck to reestablish the suburethral hammock and are able to improve SUI by providing a layer of tissue that compresses the urethra during times of increased intra-abdominal pressure.
** Unlike the PVS, the MUS should be placed loosely at the midportion of the urethra to prevent movement of the posterior urethral wall
* The current concept of PVS comes from using a shorter free graft of rectus fascia whose tension could be adjusted

====== Pubovaginal Sling Materials ======
* '''Options (4):'''
*#'''Autologous'''
*#'''Allograft'''
*#'''Xenograft'''
*#'''Synthetic''' 
*#* Although there is complete biocompatibility of the autologous sling and negligible urethral perforation, biologic graft and synthetic prosthetic materials have been increasingly used to decrease operative time, morbidity, pain, and hospital stay
* '''<span style="color:#ff0000">Autologous fascia PVS'''
** '''<span style="color:#ff0000">Gold standard for management of ALL forms of SUI'''
** '''Advantages compared to alternative sling materials (2):'''
**# '''Minimal tissue inflammation'''
**# '''Negligible risk of urethral erosion'''
** '''Disadvantages compared to alternative sling materials (4):'''
*** '''Increased operative time, hospital stay'''
***'''Postoperative pain'''
***'''Risk of suprapubic wound seroma'''
***'''Risk of incisional hernia'''
** '''<span style="color:#ff0000">Most commonly used autologous materials (2):'''
**# '''<span style="color:#ff0000">Rectus abdominis fascia harvested from the abdominal wall'''
**#* '''<span style="color:#ff0000">Most commonly used'''
**# '''<span style="color:#ff0000">Fascia lata harvested from the lateral thigh'''
**#* '''Fascia lata is the preferred autologous material for PVSs in patients with a history of prior ventral hernia repair;''' unlike rectus facia''',''' the recovery time is less and there is no risk of future abdominal hernia formation.
**#* Disadvantages of fascia lata compared to rectus abdominis:
**#*# Requires repositioning of the patient
**#*# Increased operative time
**#*# Operating in an area unfamiliar to most pelvic surgeons
**# '''Rectus abdominis fascia vs. fascia lata PVS: similar improvement of SUI'''
* '''Allograft PVS'''
** Were introduced in an effort to reduce overall morbidity, operative time, and pain related to graft procurement
** Currently derived from either cadaveric fascia lata or acellular human dermis
** Allografts from cadavers raise the concern of potentially transmitting illnesses such as HIV, hepatitis, and Creutzfeldt-Jakob prion disease
*** The estimated risk of HIV transmission from an allograft is 1 in 1,667,600.
*** The theoretical risk of developing Creutzfeldt-Jakob disease from a non-neural allograft is 1 in 3.5 million.
** '''Tissue-processing techniques for allografts may disrupt the microstructure and affect their strength properties'''
*** '''Maximum load to failure, maximum load/graft width, and stiffness are significantly lower for the allograft freeze-dried fascia lata group compared with the autologous, solvent-dehydrated, and dermal graft groups'''
* '''Xenograft PVS'''
** The forms of xenograft used are porcine dermis, porcine small intestinal submucosa, and bovine pericardium
** '''Less tensile strength''' than allograft in situ and '''highest propensity to encapsulate'''
* '''Synthetic PVS'''
** '''The most commonly used synthetic material for PVSs is polypropylene mesh.'''
** '''Advantages:'''
*** '''Almost unlimited supply''' of artificial graft material in various sizes and shapes, consistency in quality, '''elimination of harvest site complications''', and decreased operative time.
*** More uniform, consistent, and durable compared with biologic grafts
*** Sterile, biocompatible, and noncarcinogenic
*** '''Lowest amount of degradation or disruption and the highest amount of fibroblast ingrowth and tissue ingrowth into the specimen'''
** '''Disadvantages'''
*** '''Significant inflammatory and foreign body reactions'''
*** '''Higher rates of graft infection, urinary tract perforation, and vaginal exposure'''
**** '''No longer used to due risk of complications'''
'''Patient counselling'''
*If a synthetic prosthetic or biologic graft material is being used, surgeons should thoroughly counsel their patients about the permanent nature of these products and the unique and sometimes serious complications related to their use.
*'''Risk of''' '''transient and permanent voiding dysfunction after surgery, including''' '''postoperative difficulty emptying the bladder and de novo urgency and frequency'''
====== Technique ======
* '''Graft Harvest for Autologous Pubovaginal Sling'''
** '''Closure of the rectus fascia without tension is sometimes problematic. To prevent this difficulty, it is important to maintain a distance of ≥2 cm from the pubic symphysis'''
** If undermining the fascial edges does not adequately mobilize the fascia, than interposition of a segment of synthetic mesh or graft may be necessary.
* '''Pubovaginal Sling Placement and Fixation'''
** '''The bladder must be completely drained before passage of the Stamey needles to avoid inadvertent bladder injury'''
** '''Perform a cystoscopy after trocar passage to ensure integrity of the bladder and at the time of sling tensioning to visualize the bladder neck'''
** '''A sling should never be tensioned before the weighted speculum is removed and the vaginal incision is closed.''' 
***Tensioning before this may result in failure of the procedure due to too much or too little tension. The abdominal incision is closed after the sling is tensioned.
** No suture fixation to the underlying periurethral fascia is necessary to anchor the sling  

====== Outcomes ======
* '''Predominantly SUI'''
**'''No risk factors that consistently predict outcomes'''
** '''<span style="color:#ff0000">PVS are particularly helpful in treating ISD (in contrast to midurethral sling)'''
** '''The reported cure rate of PVS surgery for recurrent SUI is excellent'''
** '''Autologous PVS'''
*** '''Continence rate after PVS ranges from 61-97%'''; wide range due to variation in outcome definition
*** Postoperative de novo or urgency incontinence rates range from 2-21%
**** '''Most common reason for failure/patient dissatisfaction relates to urgency symptoms and urgency incontinence at follow-up'''
** '''Allograft PVS'''
*** Limited outcome data, and the '''efficacy and durability of these slings are questionable'''
*** Previously reported failures coupled with the consistent success and rapid adoption of synthetic MUSs has led to abandonment of all types of cadaveric allograft at most centers.
** '''Xenograft PVS'''
*** Because of the morbidity of autologous fascial harvest, high failure rates of allograft materials, and high exposure and perforation rates with synthetic PVSs, xenografts are an attractive option.
*** In general, they are associated with a low rate of infection, exposure, and perforation owing to their incorporation into host tissue cure rates comparable to those of the autologous sling.
*** '''In RCTs, porcine dermis was associated with significantly inferior long-term cure rates compared with the autologous PVS'''

* '''Autologous PVS for Mixed Urinary Incontinence'''
** '''Overall, PVS remains an effective treatment option for MUI with cure rates similar to those of simple SUI.'''
*** '''The treatment of patients with mixed urgency and SUI is complicated and often involves a combination of anticholinergic therapy and surgery'''
*** PVS is an effective treatment option for stress-induced DO with cure rates similar to those of simple DO.
*** '''Anti-incontinence surgery may cure or aggravate urgency symptoms or lead to de novo urgency. This aspect of anti-incontinence surgery is unpredictable and a major cause of patient dissatisfaction'''
*** '''The presence of residual urgency is similar to de novo urgency with a PVS.'''

* '''Autologous PVS for Urethral Reconstruction'''
** '''<span style="color:#ff0000">Autologous PVSs in the setting of urethral reconstruction (urethral fistula, urethral diverticulum, destroyed urethra) has excellent results when compared with other surgeries for incontinence'''

====== Adverse Events ======
* '''Pubovaginal Sling Perforation and Exposure'''
** '''Incidence is partially dependent on the composition of sling material'''
*** Synthetic slings perforate 15x more often into the urethra and are exposed 14x more often in the vagina than autologous, allograft, and xenograft slings. 
***'''<span style="color:#ff0000">Perforation or exposure of autologous pubovaginal slings is rare'''
**** Urethral perforation rate was 0.02% and the vaginal exposure rate was 0.007% in 1515 patients who received synthetic slings.
**** Urethral perforation incidence of 0.003% and a vaginal exposure incidence of 0.0001% in 1715 patients undergoing autologous and allograft sling procedures.
***'''Because urinary tract perforation and vaginal exposure of synthetic PVSs are more common and associated with significant morbidity, synthetic material is no longer used for bladder neck slings'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''Urethral perforations present at ≈9 months'''
*** '''<span style="color:#ff0000">History and Physical Exam'''
****'''<span style="color:#ff0000">Presenting symptoms often include urinary retention, urgency, and mixed incontinence.''' 
****'''<span style="color:#ff0000">In addition, synthetic sling perforations and exposures are also associated with vaginal discharge, vaginal pain, suprapubic pain, and recurrent UTIs.'''
** '''<span style="color:#ff0000">Management''' 
***'''<span style="color:#ff0000">Management of autologous and allograft PVS urethral perforation usually involves incision or excision of the part of the sling that has perforated and simple closure of the urethra'''
*** The incidence of recurrent SUI after synthetic PVS urethral perforation is 44-100%, and treatment often involves a second PVS

* '''Voiding Dysfunction Secondary to Bladder Outlet Obstruction after PVS'''
** '''PVS is associated with higher success rate but increased risk of post-operative voiding dysfunction compared to the Burch colposuspension'''
*** '''<span style="color:#ff00ff">SISTEr (NEJM 2007)</span>'''
****Population: 655 women with SUI
****Randomized to autologous rectus fascia PVS vs. Burch colposuspension
****Results
*****Success rates higher for PVS
*****Voiding dysfunction (63% vs. 47%, ''P'' < .001), UTI, difficulty voiding, and postoperative urgency incontinence higher for PVS
****[https://pubmed.ncbi.nlm.nih.gov/17517855/ Albo, Michael E., et al. "Burch colposuspension versus fascial sling to reduce urinary stress incontinence." ''New England Journal of Medicine'' 356.21 (2007): 2143-2155.]
** '''Risk Factors'''
***'''No well-established risk factors for patients who are likely to experience voiding dysfunction after PVS surgery.''' 
***Although urodynamic studies are useful in understanding the voiding dynamics of incontinent women, low detrusor pressure and Valsalva voiding preoperatively should not exclude patients from having an anti-incontinence procedure.
**'''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''<span style="color:#ff0000">History and Physical Exam'''
****'''Presentation of patients with obstruction by a PVS is variable'''
****'''<span style="color:#ff0000">Symptoms range from complete urinary retention, impaired detrusor, detrusor overactivity contractility and urgency incontinence to the less obvious irritative symptoms.'''
***** '''Persistent/increasing urgency incontinence and urgency (8-25%) are more common presenting symptoms in bladder outlet obstruction after a PVS procedure than frank retention'''
***** '''The incidence of permanent retention is usually ≤ 5%;''' the majority of patients who require clean intermittent catheterization after PVS placement had a neurogenic bladder preoperatively
****'''<span style="color:#ff0000">Physical Exam'''
*****'''<span style="color:#ff0000">Pelvic organ prolapse'''
******'''A key factor in assessing voiding dysfunction is the presence of prolapse that was either uncorrected at time of surgery or that occurred postoperatively.''' Prolapse of sufficient size may kink or angulate and externally compress the urethra. '''After surgery, apical, anterior, and posterior prolapse must be ruled out as a cause of the urethral obstruction.'''
*** '''<span style="color:#ff0000">Cystoscopy'''
****Useful to rule out bladder pathology, sling perforation, and a hypersuspended urethra
*** '''Urodynamics'''
****'''The most important criterion for a sling incision or urethrolysis remains the temporal relationship between the symptoms and the surgical procedure. Urodynamic studies are essential in these cases to diagnose and make an appropriate treatment plan.'''
** '''<span style="color:#ff0000">Management'''
*** '''See 2017 AUA Female SUI Guidelines Notes'''
*** '''<span style="color:#ff0000">Although transient urinary retention is common, most patients return to spontaneous voiding within the first 10 days'''
****Obstruction after an autologous PVS procedure usually improves or resolves with time
*** '''<span style="color:#ff0000">If symptoms persist, loosening the sling in the operating room can be attempted In the first 6 weeks after autologous PVS surgery.''' 
****Technique
*****Using spinal or general anesthesia, this is done by first inserting a cystoscope into the bladder and then gently applying caudal pressure to the urethra
****'''This procedure is not advised with synthetic slings'''
*** '''<span style="color:#ff0000">After 6 weeks or when conservative measures fail, a sling incision or formal urethrolysis is indicated'''
**** '''Sling incision has comparable success rates and shorter operative time and less morbidity than formal urethrolysis'''
****Recurrent SUI after formal urethrolysis is reported as 0-19% and 34% after sling incision
****Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach
**** Reported success rates of the surgical management of bladder outlet obstruction after a PVS procedure are 65-93%
****There are no preoperative or urodynamic parameters that consistently predict success or failure of urethrolysis.
*** '''Failure of urethrolysis''' 
****'''Causes''' 
*****'''Persistent or recurrent obstruction'''
*****'''Detrusor overactivity'''
*****'''Impaired detrusor contractility'''
*****'''Learned voiding dysfunction'''
****'''Management'''
*****'''The most common reason for failure is likely insufficient dissection and lysis of the urethra. This supports the use of repeat urethrolysis in the face of initial failure or in cases wherein the aggressiveness of the initial dissection is unknown.'''
*** '''Refractory storage symptoms after urethrolysis'''
****OAB symptoms are refractory in 50% of affected patients after urethrolysis and contribute to a significant portion of the reported failures. 
****Can be challenging to treat. 
*****In addition to anticholinergics, SNM should be considered as an option for de novo or refractory urgency and urgency incontinence after urethrolysis.
* '''Non-urologic Complications of PVS'''
** '''Most commonly pulmonary, cardiovascular, neurologic, and gastrointestinal (bowel injury)'''