Paper 27: Autologous Rectus Fascia is Superior to Cadaveric Fascia in Pubovaginal Sling Continence Outcomes

Abstract

OBJECTIVE: To compare patient subjective and objective outcomes of autologous rectus fascia versus cadaveric fascia lata in pubovaginal slings using survival analysis. METHODS: This study was IRB-approved, and women provided written informed consent. Without otherwise altering technique, in 1998, study surgeons changed from autologous rectus fascia to cadaveric fascia lata for virtually all patients. Women who had a pubovaginal sling with an autologous or cadaveric graft from 1994 to 2003, to allow at least 1 postoperative year, were contacted by mail and invited to participate. Fifty-nine percent of women responded, and 49% were enrolled. Subjects completed a focused medical history, questionnaires (MESA, PFDI, PFIQ), physical exam for pelvic organ prolapse (POP-Q), and office cystometry. Cystometrics included bladder filling to 300cc or maximum capacity, whichever came first, and provocative stress testing in the supine and standing positions; prolapse was not reduced. Subjects' hospital charts were reviewed for information regarding the index sling hospitalization. Subjective failure was defined as a positive answer to the question, “Do you leak regularly since your sling?” Women who answered “yes” estimated the month and year when regular leaking first recurred. Objective failure was defined as the date of any reoperation for recurrent stress incontinence. Group differences were evaluated using Student t-test or chi-square test as appropriate. The log rank test was used to determine whether time from initial sling surgery to subjective or objective failure differed between the 2 groups. All statistical tests were evaluated at the 0.05 significance level. RESULTS: A total of 303 women were enrolled, 153 with autologous grafts and 150 with cadaveric grafts. Demographic data between the 2 groups were similar. Mean age was 62.9 ± 10.4 years. Mean BMI was 28.7 ± 5.3 kg/m2. The median time from index sling surgery to subject enrollment was 5.6 years overall, with 7.1 years in the autologous group, and 3.5 years in the cadaveric group. Subjective failures occurred in a higher proportion of the cadaveric group (39.6%) compared to the autologous group (28.3%) (P<0.04). Objective failures occurred in a higher proportion of the cadaveric group (12.7%) compared to the autologous group (3.3%) (P<0.003). By survival analysis, the autologous group experienced fewer subjective failures compared to the cadaveric group (5 vs. 16 per 100 women-years, P<0.0001). It took 6.2 years for 25% of the autologous group to reach subjective failure, compared to only 1 year in the cadaveric group. By survival analysis, the autologous group also experienced fewer objective failures compared to the cadaveric group (1 vs. 4 per 100 women-years, P<0.0003). CONCLUSIONS: Autologous grafts used in pubovaginal slings have superior subjective and objective continence outcomes, compared to cadaveric fascia. The use of cadaveric fascia for pubovaginal slings should be restricted to cases in which autologous tissue is not available.