The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during increased abdominal pressure. 24 OBG Management | MarchNovember 2010 2012 | Vol. | Vol.22 No.24 No.3 11 obgmanagement.com SurgicAl tecHniqueS When and how to place an autologous rectus fascia pubovaginal sling Although synthetic midurethral slings remain the standard of care for most women with stress urinary incontinence, an autologous graft is a safe and effective alternative Mickey Karram, MD, and Dani Zoorob, MD cASe 1 recurrent SUI and mesh erosion vaginal tape (TVT), about 2 years earlier. A 50-year-old woman reports urinary incon- During physical examination, the patient tinence that is associated with activity and becomes incontinent when abdominal pres- exertion—stress urinary incontinence (SUI)— sure is increased, with some urethral mobility and says it has worsened over the past year. (cotton-swab deflection to 25˚ from the hori- She mentions that she underwent vaginal hys- In thIs zontal). She is also noted to have erosion of Article terectomy, with placement of a tension-free the TVT tape into the vaginal lumen. Urodynamic testing reveals easily demon- Who is a candidate? Dr. Karram is Director of the strable SUI at a volume of 150 mL when she page 26 fellowship Program in female is in the sitting position, with a Valsalva leak- Pelvic Medicine and reconstructive point pressure of 55 cm H O. Her bladder Pelvic surgery, university of 2 Step by step: How to Cincinnati/The Christ Hospital, remains stable to a capacity of 520 mL. Cys- harvest rectus fascia Cincinnati, Ohio; Co-editor in Chief toscopy yields unremarkable findings. of the international Academy of and create a sling When she is offered surgical correction of Pelvic surgery (iAPs); and Course page 28 Director of the Pelvic Anatomy and Gynecologic her SUI, the patient expresses a preference for surgery symposium (PAGs) and the female the use of her own tissues and says she does urology and urogynecology symposium (FUUS), both co-sponsored by OBG ManageMent. not want to have synthetic mesh placed. A few technical Dr. Zoorob is a fellow in Is this patient a candidate for a rectus fas- suggestions nt e urogynecology at the university cia pubovaginal sling? page 32 M e of Cincinnati/The Christ Hospital in Cincinnati, Ohio. s more patients express reservations manag about the placement of synthetic obg r mesh during sling procedures, the O f A The authors report no financial relationships relevant to this use of autologous rectus fascia pubovaginal article. man r slings has risen. The concept of using a pa- bo tient’s own tissue as a sling to support the lly DeVelOPeD iN PArTNersHiP wiTH O urethra dates to the early 20th century, but : M it was not until late in that century that the On the Web on i at procedure gained widespread appreciation r 2 intraoperative T and evolved into its current form. Initially, videos, at illus the procedure entailed mobilizing a strip of obgmanagement.com obgmanagement.com Vol. 24Vol. Vol. No. 22 24 11 No. No. | 3November 5| March| May 20102012 | OBG Management 25 SurgicAl tecHniqueS / rectuS fasciAl Sling Low transverse abdominal incision abdominal wall musculature or, more com- monly, tied to each other on the anterior sur- face of the abdominal wall. Long-term success depends on healing and fibrotic processes, which occur primar- ily where the sling passes through the endo- pelvic fascia. Mark 4 cm above pubic symphysis Who is a candidate? Although the pubovaginal sling procedure was pioneered as a surgical option for intrin- sic sphincter deficiency (ISD), its indications have broadened to encompass all types of SUI. Its reliable results and durable outcomes make it one of the main standards of treat- ment, and the pubovaginal sling has been used extensively as primary therapy for: • SUI related to ISD or urethral hyper- mobility • as a salvage procedure for recurrent SUI FIGURE 1 Skin incision • as an adjunct to urethral and bladder Before initiating the operation, delineate the location of the transverse skin incision, which reconstruction WAtcH A ViDeO! should measure 8 to 10 cm and be situated • as a way to functionally close the urethra to about 4 cm above the symphysis pubis. A vertical abandon urethral access to the bladder. Rectus fascia incision is also feasible, although it usually is less In our opinion, the autologous pubovag- aesthetic. pubovaginal sling inal sling is appropriate for patients with SUI by Mickey M. Karram, MD, who decline to have synthetic material im- and Dani Zoorob, MD abdominal muscle (either rectus or pyrami- planted because of concerns related to long- Courtesy of International dalis), freeing one end of the strip from its at- term placement of synthetic mesh. Other Academy of Pelvic Surgery tachment, passing that end under the bladder good candidates are women who experience neck, and reaffixing it to the abdominal mus- recurrent incontinence after placement of a cle wall, forming a “U”-shaped sling around synthetic sling or who develop a complica- the bladder outlet. Subsequently, overlying tion, such as vaginal erosion (ViDeO 1), after abdominal fascia was included in the sling, placement of a synthetic sling. We also prefer eventually replacing the muscle altogether. to use an autologous sling in patients who The final innovation: An isolated strip of fas- have been radiated or who have sustained 4 ways to watch this video: cia was suspended by free sutures that were urethral injuries, as well as in patients who 1. go to the Video Library at tied to the abdominal wall or attached on top are undergoing simultaneous repair of ure- www.obgmanagement.com of the abdominal rectus sheath. throvaginal fistula or diverticulum—or those 2. use the QR code to download the video to your The autologous pubovaginal sling sup- who have already undergone such repair. Smartphone* ports the proximal urethra and bladder neck 3. text RFPVS to 25827 to achieve continence by providing a direct 4. visit www.OBGmobile compressive force on the urethra and blad- What is the optimal sling .com/RFPVS der outlet, or by reestablishing a reinforcing material? *By scanning the QR code with a platform or hammock against which the ure- rectus abdominis fascia versus fas- QR reader, the video will download to your Smartphone. Free QR thra is compressed during the transmission cia lata. The two most commonly used readers are available at the iPhone of increased abdominal pressure. autologous tissues are rectus abdominus App Store, Android Market, and The sling is suspended on each end by fascia and fascia lata. Both of these materi- BlackBerry App World. free sutures that are attached directly to the als have been studied extensively and proven continUeD On pAge 28 26 OBG Management | November 2012 | Vol. 24 No. 11 obgmanagement.com SurgicAl tecHniqueS / rectuS fasciAl Sling continUeD from pAge 26 dermis provide reasonable efficacy, but -du Rectus rability remains an issue, as high failure muscle rates have been reported. Bovine and Cut line porcine dermis, as well as porcine small- Army-navy intestine submucosa, are also effective for retractor used for Cut line aggressive exposure SUI, although durability remains a concern. of underlying fascia Synthetic materials. Synthetic graft mate- Rectus fascia 1–2 cm rials of various designs and substances also have been used as sling material. Mono- filament, large-pore weave grafts (Type 1 8–10 cm mesh) are recommended for implantation in the vagina. Although good efficacy can be achieved with synthetic mesh, the material also may increase the risk of serious compli- cations, such as infection, vaginal extrusion, and genitourinary erosion, and is not recom- mended for use beneath the proximal ure- thra or bladder neck. How to harvest rectus fascia and create a sling 1 choose anesthesia and perioperative antibiotics Pubovaginal sling procedures are generally Perioperative carried out under general anesthesia, but antibiotics (such spinal or epidural anesthesia also is possible. as a cephalosporin Full-patient paralysis is not warranted but or fluoroquinolone) may facilitate closure of the rectus fascia af- ensure appropriate ter fascial harvesting. coverage against Perioperative antibiotics usually are given to ensure appropriate coverage against skin and vaginal flora skin and vaginal flora (for example, a cepha- losporin or fluoroquinolone). In fact, periop- erative antibiotics have become a mandated quality of care measure in the United States. FIGURE 2 resect the fascial strip After choosing the optimal location for excision, 2 mark the area using electrocautery or a surgical Position the patient marking pen. Then resect the strip using a scalpel for optimal access or electrocautery. The strip should measure Place the patient in the low lithotomy posi- 8 to 10 cm in length and 1 to 2 cm in width. if the tion with her legs in stirrups. The abdomen skin incision is small, Army/Navy retractors may enhance exposure. and perineum should be sterilely prepared and draped to provide access to the vagina and lower abdomen. to be effective and reliable. Most surgeons After the bladder is drained with a Foley prefer rectus fascia because it is easier and catheter, place a weighted vaginal specu- quicker to harvest. lum and use either lateral labial retraction Allogenic and xenogenic tissues. Allo- sutures or a self-retaining retractor system to genic (cadaveric) fascia lata and cadaveric facilitate vaginal exposure. 28 OBG Management | November 2012 | Vol. 24 No. 11 obgmanagement.com 3 Make an abdominal incision Make an 8- to 10-cm Pfannenstiel incision approximately 3 to 5 cm above the pubic bone, carry the dissection down to the level of the rectus fascia using a combination of electrocautery and blunt dissection, and sweep the fat and subcutaneous tissue clear of the rectus tissue (FIGURE 1, page 26).