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Functional: Female SUI: Difference between revisions

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#'''<span style="color:#ff0000">Restricts movement of the posterior urethral wall above the sling</span>''' , directing its motion in an anteroinferior or anterior direction.
#'''<span style="color:#ff0000">Restricts movement of the posterior urethral wall above the sling</span>''' , directing its motion in an anteroinferior or anterior direction.
#*'''<span style="color:#ff0000">Patients without urethral hypermobility do not respond as well to MUS surgery'''
#*'''<span style="color:#ff0000">Patients without urethral hypermobility do not respond as well to MUS surgery'''
#** '''Lack of urethral mobility is an indication that the patient has a fixed urethra and ISD'''
#** '''<span style="color:#ff0000">Lack of urethral mobility is an indication that the patient has a fixed urethra and ISD'''
#'''<span style="color:#ff0000">Narrows (compresses) the urethral lumen</span> due to inward movement of the posterior urethral wall after placement of a MUS'''
#'''<span style="color:#ff0000">Narrows (compresses) the urethral lumen</span> due to inward movement of the posterior urethral wall after placement of a MUS'''


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*#'''<span style="color:#ff0000">Immune suppression</span>'''
*#'''<span style="color:#ff0000">Immune suppression</span>'''
====== Technique ======
====== Technique ======
* '''Should be placed loosely at the midurethra''' because its function is not primarily related to compression.
* '''<span style="color:#ff0000">Should be placed loosely at the midurethra</span>''' because its function is not primarily related to compression.
**'''A loosely placed MUS combined with a mobile urethra may allow the sling to compress the urethra during times of Valsalva and stress while remaining nonobstructive when the urethra is at rest.'''
**'''A loosely placed MUS combined with a mobile urethra may allow the sling to compress the urethra during times of Valsalva and stress while remaining nonobstructive when the urethra is at rest.'''
***'''For single-incision MUSs, tension should be tighter than the classic retropubic or transobturator MUS surgeries to achieve the same result'''
***'''For single-incision MUSs, tension should be tighter than the classic retropubic or transobturator MUS surgeries to achieve the same result'''
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** As is the case with primary surgery, the failure rate is higher in females with immobile urethras.
** As is the case with primary surgery, the failure rate is higher in females with immobile urethras.
** '''No significant difference in subjective cure rates in patients after retropubic vs. transobturator MUS surgery for recurrent SUI.'''
** '''No significant difference in subjective cure rates in patients after retropubic vs. transobturator MUS surgery for recurrent SUI.'''
====== <span style="color:#ff0000">Adverse events ======
====== <span style="color:#ff0000">Adverse events ======
* '''Patient counselling'''
* '''Patient counselling'''
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* '''<span style="color:#ff0000">Vaginal Mesh Exposure'''
* '''<span style="color:#ff0000">Vaginal Mesh Exposure'''
** '''Most cases manifest within a few weeks to a few months after the MUS procedure'''
** '''Most cases manifest within a few weeks to a few months after the MUS procedure'''
** '''Risk factors (5):'''**#'''Diabetes'''
** '''Risk factors (5):'''
**#'''Diabetes'''
**#'''History of smoking'''
**#'''History of smoking'''
**#'''Older age'''
**#'''Older age'''
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****#'''Urinary incontinence'''
****#'''Urinary incontinence'''
** '''<span style="color:#ff0000">Management'''
** '''<span style="color:#ff0000">Management'''
*** '''Options (2)'''
*** '''<span style="color:#ff0000">Observation should never be considered when there is intravesical perforation'''
***'''Options (2)'''
***#'''If small area of mesh perforation: endoscopic management (excision with scissors or ablation with the holmium laser) is an appropriate initial step if complete excision of all exposed material can be achieved'''
***#'''If small area of mesh perforation: endoscopic management (excision with scissors or ablation with the holmium laser) is an appropriate initial step if complete excision of all exposed material can be achieved'''
***# '''If endoscopic excision fails or as initial treatment for large areas of mesh perforation, transvaginal or retropubic excision'''
***# '''If endoscopic excision fails or as initial treatment for large areas of mesh perforation, transvaginal or retropubic excision'''
***## Reconstruction should involve nonoverlapping suture lines and interposition of tissue such as a labial fat pad or greater omentum.
***## Reconstruction should involve nonoverlapping suture lines and interposition of tissue such as a labial fat pad or greater omentum.
***## An autologous fascial sling can be placed at the time of surgery to augment the repair or in a delayed fashion to treat recurrent SUI.
***## An autologous fascial sling can be placed at the time of surgery to augment the repair or in a delayed fashion to treat recurrent SUI.
***'''<span style="color:#ff0000">Observation should never be considered when there is intravesical perforation'''
* '''Pain and Infection after MUS Surgery'''
* '''Pain and Infection after MUS Surgery'''
** '''Groin and suprapubic pain are potential problems after MUS placement.'''  
** '''Groin and suprapubic pain are potential problems after MUS placement.'''  
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**'''Pathogenesis'''
**'''Pathogenesis'''
***'''Typically the result of obstruction'''
***'''Typically the result of obstruction'''
****From the sling being placed too tightly or in the wrong location (too proximally)
****'''From the sling being placed too tightly or in the wrong location (too proximally)'''
****Associated with pelvic organ prolapse (unrecognized preoperatively or de novo)
****'''Associated with pelvic organ prolapse (unrecognized preoperatively or de novo)'''
*****Some patients may have voiding dysfunction without evidence of obstruction
*****Some patients may have voiding dysfunction without evidence of obstruction
** '''Risk factors'''
** '''Risk factors'''
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**** In addition, the rate of urinary retention (catheter for longer than 6 weeks) was also higher in the retropubic MUS group (3.7% vs. 0.7%).
**** In addition, the rate of urinary retention (catheter for longer than 6 weeks) was also higher in the retropubic MUS group (3.7% vs. 0.7%).
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''History and Physical Exam'''
***'''<span style="color:#ff0000">History and Physical Exam'''
****'''<span style="color:#ff0000">History'''
****'''<span style="color:#ff0000">History'''
*****'''<span style="color:#ff0000">Most common symptoms of obstruction are'''  
*****'''<span style="color:#ff0000">Most common symptoms of obstruction are'''  
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******'''<span style="color:#ff0000">De novo urgency and frequency'''
******'''<span style="color:#ff0000">De novo urgency and frequency'''
*****Over several weeks to a month, the storage symptoms (urgency and frequency) and pain become more prevalent as the bladder attempts to adjust to the obstruction.
*****Over several weeks to a month, the storage symptoms (urgency and frequency) and pain become more prevalent as the bladder attempts to adjust to the obstruction.
****'''<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'''
***'''<span style="color:#ff0000">Cystoscopy'''
****'''<span style="color:#ff0000">Useful to rule out bladder pathology, urethral mesh perforation, and a hypersuspended bladder neck'''
****'''<span style="color:#ff0000">Useful to rule out bladder pathology, urethral mesh perforation, and a hypersuspended bladder neck'''
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*** '''Higher rates of graft infection, urinary tract perforation, and vaginal exposure'''
*** '''Higher rates of graft infection, urinary tract perforation, and vaginal exposure'''
**** '''No longer used to due risk of complications'''
**** '''No longer used to due risk of complications'''
 
'''Patient counselling'''
====== PVS Operative Procedure ======
*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.
* '''Patient Counseling'''
*'''Risk of''' '''transient and permanent voiding dysfunction after surgery, including''' '''postoperative difficulty emptying the bladder and de novo urgency and frequency'''
** 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.
====== Technique ======
** '''Patients should also be counseled about the risk of transient and permanent voiding dysfunction after surgery, including (2):'''
**# '''Postoperative difficulty emptying the bladder'''
**# '''De novo urgency and frequency'''
* '''Graft Harvest for Autologous Pubovaginal Sling'''
* '''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'''
** '''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.
** 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 Vaginal Approach
* '''Pubovaginal Sling Placement and Fixation'''
* Pubovaginal Sling Placement and Fixation
** '''The bladder must be completely drained before passage of the Stamey needles to avoid inadvertent bladder injury'''
** '''The bladder must be completely drained before passage of the Stamey needles to avoid inadvertent bladder injury'''
** '''It is recommended to perform a cystoscopy after trocar passage to ensure integrity of the bladder and at the time of sling tensioning to visualize the bladder neck'''
** '''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.
** '''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  
** No suture fixation to the underlying periurethral fascia is necessary to anchor the sling  
* Pubovaginal Sling Postoperative Care


====== Outcomes ======
====== Outcomes ======
* '''Predominantly SUI'''
* '''Predominantly SUI'''
**'''No risk factors that consistently predict outcomes'''
**'''No risk factors that consistently predict outcomes'''
** '''PVS are particularly helpful in treating ISD'''
** '''<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'''
** '''The reported cure rate of PVS surgery for recurrent SUI is excellent'''
** '''Autologous PVS'''
** '''Autologous PVS'''
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* '''Autologous PVS for Urethral Reconstruction'''
* '''Autologous PVS for Urethral Reconstruction'''
** '''Autologous PVSs in the setting of urethral reconstruction (urethral fistula, urethral diverticulum, destroyed urethra) has excellent results when compared with other surgeries for incontinence'''
** '''<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'''
 
====== 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.]
* '''The presentation of patients with obstruction by a PVS is variable and the 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
* '''There are 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.'''
* '''Although postoperative urgency and urgency incontinence (voiding dysfunction) are strongly related to failure, there are no preoperative risk factors that consistently predict these outcomes after PVS surgery.'''
* Cystoscopy is useful to rule out bladder pathology, sling perforation, and a hypersuspended urethra.
* '''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.'''
* '''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.'''
* '''Surgical Management of Voiding Dysfunction after PVS'''
** '''See 2017 AUA Female SUI Guidelines Notes'''
** Obstruction after an autologous PVS procedure usually improves or resolves with time; '''although transient urinary retention is common, most patients return to spontaneous voiding within the first 10 days'''
** '''In the first 6 weeks after autologous PVS surgery, loosening the sling in the operating room''' (using spinal or general anesthesia) '''can be attempted.''' 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'''
** '''After 6 weeks or when conservative measures fail, a formal urethrolysis''' by a retropubic, transvaginal, or suprameatal approach '''or sling incision is indicated.'''
*** '''Sling incision has comparable success rates and shorter operative time and less morbidity than formal urethrolysis'''
*** Reported success rates of the surgical management of bladder outlet obstruction after a PVS procedure are 65-93%
*** Recurrent SUI after formal urethrolysis is reported as 0-19% and 34% after sling incision
** There are no preoperative or urodynamic parameters that consistently predict success or failure of urethrolysis.
** '''Failure of urethrolysis may be caused by persistent or recurrent obstruction, DO, impaired detrusor contractility, or learned voiding dysfunction. 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.'''
** OAB symptoms are refractory in 50% of affected patients after urethrolysis and contribute to a significant portion of the reported failures. Refractory storage symptoms after urethrolysis 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.


====== Adverse Events ======
====== Adverse Events ======
* '''Pubovaginal Sling Perforation and Exposure'''
* '''Pubovaginal Sling Perforation and Exposure'''
** The incidence of PVS perforation and exposure is partially dependent on the composition of sling material.
** '''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. '''The perforation or exposure of autologous PVSs is rare'''
*** 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 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.
**** Urethral perforation incidence of 0.003% and a vaginal exposure incidence of 0.0001% in 1715 patients undergoing autologous and allograft sling procedures.
** '''Urethral perforations present at ≈9 months'''
***'''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'''
** '''Presenting symptoms often include urinary retention, urgency, and mixed incontinence. In addition, synthetic sling perforations and exposures are also associated with vaginal discharge, vaginal pain, suprapubic pain, and recurrent UTIs.'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
** '''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'''
***'''Urethral perforations present at ≈9 months'''
** The incidence of recurrent SUI after synthetic PVS urethral perforation is 44-100%, and treatment often involves a second PVS
*** '''<span style="color:#ff0000">History and Physical Exam'''
** '''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">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'''
* '''Non-urologic Complications of PVS'''
** '''Most commonly pulmonary, cardiovascular, neurologic, and gastrointestinal (bowel injury)'''
** '''Most commonly pulmonary, cardiovascular, neurologic, and gastrointestinal (bowel injury)'''
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* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 84
* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 84
*[https://pubmed.ncbi.nlm.nih.gov/37096580/ Kobashi, Kathleen C., et al. "Updates to surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline (2023)." ''The Journal of Urology'' 209.6 (2023): 1091-1098.]
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