Editing Functional: Female SUI (section)

====== 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)'''