Autologous Fascia Pubovaginal Sling Research Articles

This Month in Adult Urology.

This Month in Adult Urology.

Accreditation of an old surgical technique for stress urinary incontinence: long-term outcomes of modified autologous fascial pubovaginal sling.

To evaluate long-term outcomes of modified autologous fascial pubovaginal sling (AFPVS) in women with stress urinary incontinence (SUI). To evaluate long-term outcomes of modified AFPVS, we retrospectively reviewed the medical records of our patients from 2004 to 2015. From 2 decades ago, we have made modifications to classic surgical technique to make it simpler and faster. 199 patients were contacted with mean age of 52years. The mean follow-up period was 107months. According to Revised Urinary Incontinence Scale (RUIS) questionnaire, overall success rate was 83.9%. In patients with positive history for SUI surgery, success rate was 73% compared to 87% in those without it. Body mass index was negatively associated with cure rate. We did not encounter any major complications and most of the issues were managed conservatively. Recurrence of SUI occurred in 6 patients (3.5%) after initial improvement. Modified AFPVS is an effective surgical technique for treatment of SUI with high and durable success rate. At the present time with concerns regarding the use of transvaginal synthetic mesh, there is increasing interest and request for modified traditional procedures. It is likely that AFPVS may become more popular in upcoming years.

Autologous fascia pubovaginal slings in women with stress urinary incontinence at high risk of mesh/device-related complications

Very popular in many parts of the world, autologous fascial pubovaginal sling (AFPVS) remains marginally used in France. However, it may be of particular interest in patients carrying a high risk of mesh-related or device-related related complications. The aim of the present series was to report the outcomes of AFPVS in this high-risk population. The charts of all female patients who underwent a fascial sling for SUI at a single academic center between April 2019 and May 2021 were reviewed retrospectively. Only patients deemed at high-risk of device/mesh related complications were included in the present analysis: female with a neurological condition who were doing clean intermittent catheterization (CIC), female with SUI after radical cystectomy and ileal neobladder, female with urethral/bladder extrusion of any synthetic material placed for SUI. Success was defined as complete resolution of SUI at 3 months. Sixteen patients were included in this study: 13 rectus fascia slings and 3 fascia lata slings. The success rate was 56.3% (9/16 patients). Four patients were improved but not completely dry (25%). Two patients had major postoperative complications (i.e. Clavien grade 3 or higher, 11.2%). Two patients had a persisting significant post-void residual (PVR) postoperatively, managed by self-catheterization (transition to self-catheterization at 3 months: 2/8, 25%). The use of autologous fascia pubovaginal sling is an interesting option in female SUI patients with high risk of device/mesh related complications with satisfactory functional outcomes. 4.

"Risk Factor of De Novo Urgency and Urge Incontinence After Autologous Fascia Pubovaginal Sling"

Pei Shan Yang1,2*, Sophia Delpe2, Casey G Kowalik2, W Stuart Reynolds2, Melissa R Kaufman2 and Roger R Dmochowski2 Author Affiliations 1Department of Urologic Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan 2Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, USA Received: May 20, 2021 | Published: May 28, 2021 Corresponding author: Pei Shan Yang, Chang Gung Memorial Hospital and Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 333, Taiwan DOI: 10.26717/BJSTR.2021.36.005807

A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling

Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision withurethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling. The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling. This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05. We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups. This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was aconsiderable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group.

Development of a safety zone for rectus abdominis fascia graft harvest based on dissections of the ilioinguinal and iliohypogastric nerves

As a result of the vaginal mesh controversy, surgeons are performing more nonmesh, autologous fascia pubovaginal slings to treat stress urinary incontinence in women. The rectus abdominis fascia is the most commonly harvested site for autologous pubovaginal slings, so it is crucial that surgeons are familiar with the relationship between this graft harvest site and the ilioinguinal and iliohypogastric nerves, which can be injured during this procedure. The aims of this study were as follows: (1) to estimate the safest area between the bilateral courses of the ilioinguinal and iliohypogastric nerves in which a rectus abdominis fascia graft could be harvested with minimal risk of injury to these nerves and (2) to determine the location and dimensions of a graft harvest site that maximized graft length while remaining close to the pubic symphysis. The ilioinguinal and iliohypogastric nerves were dissected bilaterally in 12 unembalmed female anatomical donors. The distances of these nerves to a 10× 2 cm rectus abdominis fascia graft site located 4 cm above the pubic symphysis were measured. Nerve courses inferior to the graft site were determined for each donor by linearly extrapolating measurement points; analysis was performed with and without extrapolation. Average nerve trajectories were estimated assuming a linear regression function to predict the horizontal measurement as a quadratic function of the vertical distance; 95% confidence bands were also estimated. An estimated safety zone was determined to be the region between all credible nerve bounds. The largest safety zone that was closest to the pubic symphysis was located at 5.4 cm superior to the pubic symphysis. At this location, the inferior border of the graft could measure 9.4 cm in length (4.7 cm bilaterally from the midline). Extrapolated nerve courses below the study graft site yielded a smaller safety zone located 2.7 cm superior to the pubic symphysis, allowing for the inferior border of the graft to be 4.8 cm (2.4 cm bilaterally from the midline). A rectus abdominis fascia graft harvested 5.4 cm superior to the pubic symphysis with the inferior border of the graft measuring 9.4 cm in length should minimize injury to the ilioinguinal and iliohypogastric nerves. These dimensions allow for the longest graft while remaining relatively close to the pubic symphysis. The closer a graft is harvested to the pubic symphysis, the smaller in length the graft must be to avoid injury to the ilioinguinal and iliohypogastric nerves.

Trends in Stress Urinary Incontinence Surgery at a Tertiary Center: Midurethral Sling Use Following the AUGS/SUFU Position Statement

ObjectiveTo investigate trends in stress urinary incontinence (SUI) surgery before and after the 2011 Foods and Drug Administration notification and the 2014 (American Urogynecologic Society [AUGS]/Society for Urodynamics Female Pelvic Medicine and Urogenital Reconstruction [SUFU]) position statement. MethodsA retrospective chart review was performed to identify patients presenting for evaluation of SUI by 2 Female Pelvic Medicine and Reconstructive Surgery specialists between June 1, 2010 and May 31, 2017. Rates of surgical treatment modality (synthetic midurethral slings [MUS] versus autologous fascial pubovaginal sling versus bulking agents) were analyzed at 6-month intervals. ResultsOver fourteen 6-month intervals, the number of new patients presenting for evaluation of SUI increased consistently. There was a decrease in the proportion of new patients who underwent antiincontinence surgical procedures, specifically MUS, between December 2011 and December 2013. After the integration of the 2014 AUGS/SUFU position statement in patient counseling, this trend reverted and we noted a sustained increase in the proportion of patients electing surgical management. This paralleled an increase in new patient visits for SUI and MUS. The number autologous fascial pubovaginal sling remained stable throughout the study period. Conversely, MUS composed the highest proportion of procedures performed, accounting for 60 %-87.2% off all antiincontinence procedures. ConclusionAfter the Foods and Drug Administration Public Health Notification in 2011, we observed a decline in the number of new patients presenting with SUI electing surgical management, specifically MUS. However, after the AUGS/SUFU position statement publication and integration into counseling, we observed a reversal in the previous year's trends, noting a resurgence of MUS utilization.

Exploring stress urinary incontinence outcomes after sling excision for perforation or exposure.

This study assessed stress urinary incontinence (SUI) outcomes after sling excision for urinary tract perforation or vaginal exposure, and compared the outcomes of concomitant versus staged autologous fascia pubovaginal sling (AFPVS). A retrospective chart review of all patients who underwent midurethral sling (MUS) excision for urinary tract perforation or vaginal exposure at a tertiary referral center between 2010 and 2015 was performed. Therapeutic strategies were categorized as concomitant AFPVS, staged AFPVS, and no anti-incontinence procedure. In all, 32 patients were included for analysis: 13 with vaginal tape exposure (40.6%) and 19 with urinary tract tape exposure (59.4%). In patients who had SUI prior to sling excision (43.8%), the rate of resolved or improved SUI postoperatively was higher in the concomitant AFPVS group than in those who underwent sling excision alone (83.3% vs 12.5%, respectively; P = 0.03). Of 18 patients with no SUI prior to sling excision, 12 experienced recurrent SUI after sling removal (66.7%). The rate of recurrent SUI was lower in patients with vaginal MUS exposure than urinary tract MUS perforation, but this did not reach statistical significance (57.1% vs 72.7%, respectively; P = 0.63). The rates of resolved SUI after AFPVS were comparable in patients with concomitant and staged AFPVS (66.7% vs 71.4%, respectively; P = 0.99). Many patients with MUS perforations or exposures will have SUI at initial presentation or develop SUI after removal of the synthetic sling. The decision to perform a concomitant AFPVS or to stage the surgical management of SUI can be individualized.

Stress urinary incontinence surgery trends in academic female pelvic medicine and reconstructive surgery urology practice in the setting of the food and drug administration public health notifications.

To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States. Surgical volume for procedures performed primarily by FPMRS surgeons at eight academic institutions across the US was collected using Current Procedural Terminology (CPT) codes for stress urinary incontinence repair and revision surgeries from 2007 to 2013. SAS statistical software was used to assess for trends in the data. There was a decrease in the use of synthetic mesh sling for the treatment of SUI at academic tertiary care centers over the past 7 years; however, this was not statistically significant. While the total number of surgical interventions for SUI remained stable, there was an increase in the utilization of autologous fascia pubovaginal slings (AFPVS). The number of mesh sling revision surgeries, including urethrolysis and removal or revision of slings, increased almost three-fold at these centers. These observed trends suggest a possible effect of the FDA Public Health Notifications regarding TVM on surgical practice for SUI in academic centers, even though they did not specifically warn against the use of synthetic mesh for this indication. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study. However, such data may provide alternative insights into reasons for the observed trends. Neurourol. Urodynam. 36:1155-1160, 2017. © 2016 Wiley Periodicals, Inc.

MP65-18 FEMALE URETHRAL DIVERTICULA: CORRELATION OF MRI FINDINGS WITH PRE-OPERATIVE SIGNS AND SYMPTOMS OR POST-OPERATIVE OUTCOMES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy II1 Apr 2016MP65-18 FEMALE URETHRAL DIVERTICULA: CORRELATION OF MRI FINDINGS WITH PRE-OPERATIVE SIGNS AND SYMPTOMS OR POST-OPERATIVE OUTCOMES Nima Baradaran, Leah Chiles, Drew Freilich, William Rawls, Lindsey Cox, Ross Rames, and Eric Rovner Nima BaradaranNima Baradaran More articles by this author , Leah ChilesLeah Chiles More articles by this author , Drew FreilichDrew Freilich More articles by this author , William RawlsWilliam Rawls More articles by this author , Lindsey CoxLindsey Cox More articles by this author , Ross RamesRoss Rames More articles by this author , and Eric RovnerEric Rovner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1229AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pelvic MRI (pMRI) provides excellent anatomic delineation of urethral diverticula (UD) and is routinely utilized for preoperative planning and patient counselling. Determining whether preoperative pMRI findings are correlated with severity of the condition or postoperative success is the objective of this study. METHODS After IRB approval, records of adult females who underwent transvaginal excision of UD (TVUD) at our institution between 2004 and 2014 were retrospectively reviewed. Clinical characteristics before and after TVUD including lower urinary tract symptoms, incontinence status, dyspareunia, postvoid dribbling, and urinary tract infections were reviewed and correlated with preoperative pMRI findings. MRI characteristics included UD configuration (simple, saddlebag, or circumferential), size, location (proximal, mid, or distal urethra), and number of UD. An autologous fascia pubovaginal sling was placed at the time of UD excision if stress urinary incontinence was present preoperatively. RESULTS 58 patients underwent TVUD of which 49 patients had available data on preoperative pMRI. Three patients had a previous TVUD at other institutions. UD was located in the proximal urethra in 36%, midurethra in 43%, and distal urethra in 6%. Four (8%) patients had panurethral involvement. Median (range) size of the UD on largest dimension was 2.5cm (0.5-6.7). UD configuration was simple in 37%, saddlebag in 37%, and circumferential in 24% of cases. Size, configuration, and location of UD on pMRI were not predictive of symptoms at presentation or symptom severity. However, distal and pan-urethral UD were correlated with presence of vaginal mass on physical examination (p=0.04). Larger UD size (>3 cm) was associated with higher intraoperative blood loss (450cc vs. 200cc, p<0.001) as was placement of a concomitant sling at the time of TVUD (275cc vs. 200cc, p=0.03). Complete resolution of UD on voiding cystourethrogram was achieved postoperatively in 65% of patients however only 3 (5%) patients required subsequent surgical intervention for persistent UD. There was no correlation with preoperative pMRI characteristics and resolution of UD on postoperative imaging. CONCLUSIONS Although pMRI provides valuable anatomical information for surgical planning, preoperative pMRI findings are not correlated with patients’ presenting symptoms, signs, or postoperative outcomes. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e871 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Nima Baradaran More articles by this author Leah Chiles More articles by this author Drew Freilich More articles by this author William Rawls More articles by this author Lindsey Cox More articles by this author Ross Rames More articles by this author Eric Rovner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes of Autologous Fascia Pubovaginal Sling for Patients with Transvaginal Mesh Related Complications Requiring Mesh Removal

We reviewed the outcomes of the autologous fascial pubovaginal sling as a salvage procedure for recurrent stress incontinence after intervention for polypropylene mesh erosion/exposure and/or bladder outlet obstruction in patients treated with prior transvaginal synthetic mesh for stress urinary incontinence. In a review of surgical databases at 2 institutions between January 2007 and June 2013 we identified 46 patients who underwent autologous fascial pubovaginal sling following removal of transvaginal synthetic mesh in simultaneous or staged fashion. This cohort of patients was evaluated for outcomes, including subjective and objective success, change in quality of life and complications between those who underwent staged vs concomitant synthetic mesh removal with autologous fascial pubovaginal sling placement. All 46 patients had received at least 1 prior mesh sling for incontinence and 8 (17%) had received prior transvaginal polypropylene mesh for pelvic organ prolapse repair. A total of 30 patients underwent concomitant mesh incision with or without partial excision and autologous sling placement while 16 underwent staged autologous sling placement. Mean followup was 16 months. Of the patients 22% required a mean of 1.8 subsequent interventions an average of 6.5months after autologous sling placement with no difference in median quality of life at final followup. At last followup 42 of 46 patients (91%) and 35 of 46 (76%) had achieved objective and subjective success, respectively. There was no difference in subjective success between patients treated with a staged vs a concomitant approach (69% vs 80%, p = 0.48). Autologous fascial pubovaginal sling placement after synthetic mesh removal can be performed successfully in patients with stress urinary incontinence as a single or staged procedure.

Female Urethral Diverticulum: Current Diagnosis and Management.

While urethral diverticulum (UD) affects less than 20 per 1,000,000 women overall, it is thought to represent 1.4% of women with incontinence presenting to urology practices. It is hypothesized to evolve from periurethral glands that become obstructed, infected, and dilated over time, and patients typically present with dyspareunia, bothersome lower urinary tract symptoms (LUTS), and/or recurrent UTIs. In many patients, a periurethral mass can be appreciated on exam. In recent years, magnetic resonance imaging (MRI) has become the imaging test of choice for diagnosis of UD, but ultrasound (US) is a readily available alternative and provides good specificity at a lower cost. Surgical excision of the diverticulum with tension-free, water-tight, three-layer closure continues to be the mainstay of treatment of UD with most studies reporting cure rates of >90%. Concomitant treatment of preexisting stress incontinence with autologous fascial pubovaginal sling can be used at the time of diverticulectomy to avoid a secondary procedure. However, since secondary anti-incontinence procedures are needed in only a small number of patients, up-front stress incontinence treatment may result in significant overtreatment, and staged anti-incontinence procedures continue to be a reasonable option for patients with persistent bothersome stress urinary incontinence (SUI) after diverticulectomy.

Long-term outcomes of autologous pubovaginal fascia slings: Is there a difference between primary and secondary slings?

To report our long-term pubovaginal slings (PVS) outcomes between primary (PVS1) and secondary (PVS2) autologous fascia PVS, with the hypothesis that outcomes in PVS1 will be better than in PVS2. IRB approved retrospective study of women undergoing PVS between 1996 and 2011 with minimum 6 months follow-up. Data reviewed included demographics, questionnaires that is, UDI-6, IIQ-7, QOL, prior anti-incontinence procedure, associated repairs, urodynamic findings and repeat procedures. Primary outcome and surgical success defined by: (1) QOL ≤ 3, (2) UDI question 3 on SUI ≤ 1, and (3) no SUI re-treatment/operation. Secondary outcomes included all other patient reported outcome measures (PROM). Of 110 patients, 84 had follow-up. Mean age was 61 years (38-88) and median follow-up was 89 months (7-189). Demographic findings and type of fascia used were similar between the two groups. Mean postoperative scores were not statistically significant for total UDI-6 score (P = 0.62), IIQ-7 (P = 0.30) and QOL (P = 0.35) between groups, but was statistically significant compared to baseline (P = 0.001) as expected. Twelve patients, 3 in PVS1 and 9 in PVS2 underwent subsequent procedures. Surgical success rate was 76% in PVS1 and 52% in PVS2 for those with completed questionnaires. Overall, 78% (28) in PVS1 and 69% (33) in PVS 2 required no further surgical intervention at last follow-up. At long-term follow-up of average 7.4 years, primary and secondary PVS patients had comparable favourable functional outcomes with low morbidity. However, secondary PVS patients had lower success rates as per our definition with higher rate of additional procedures.

The autologous fascia pubovaginal sling for complicated female

Introduction: The purpose of this study is to review our contemporary experience with autologous fascia pubovaginal slings (AF-PVS) in the era of the midurethral sling.Methods: A retrospective review was completed to identify allpatients who underwent an AF-PVS between 2002 and 2009. Across-sectional questionnaire was used to assess postoperative urinary- specific quality of life (consisting of the Urogenital Distress Inventory [UDI-6] and the Incontinence Impact Questionnaires [IIQ-7]).Results: We identified 33 patients. They had failed a median oftwo previous incontinence treatments. Of these patients, 16 (48%) had failed a previous midurethral sling, and of these half had experienced a significant mesh erosion necessitating mesh removal. Preoperative median incontinence pad usage was 5/day. After a median follow-up of 16 months from the time of AF-PVS, the median pad usage had decreased to 1/day (p = 0.003). A third of the patients had postoperative urgency, and only 1 patient continues to use intermittent catheterization. The median IIQ-7 score was 19/100, and the median UDI-6 score was 44/100. Overall quality of life was mixed-to-delighted in 62% of patients.Conclusions: The AF-PVS has reasonable outcomes in a diversepopulation of patients, despite failure of other treatment modalities.

1555 PUBOVAGINAL SLING IN THE TREATMENT OF CONCOMITANT FEMALE URETHRAL DIVERTICULA AND STRESS URINARY INCONTINENCE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology I1 Apr 20121555 PUBOVAGINAL SLING IN THE TREATMENT OF CONCOMITANT FEMALE URETHRAL DIVERTICULA AND STRESS URINARY INCONTINENCE Ekene Enemchukwu, W. Stuart Reynolds, Harriette Scarpero, Melissa Kaufman, and Roger Dmochowski Ekene EnemchukwuEkene Enemchukwu Nashville, TN More articles by this author , W. Stuart ReynoldsW. Stuart Reynolds Nashville, TN More articles by this author , Harriette ScarperoHarriette Scarpero Nashville, TN More articles by this author , Melissa KaufmanMelissa Kaufman Nashville, TN More articles by this author , and Roger DmochowskiRoger Dmochowski Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1325AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Female urethral diverticulum is a rare condition with nonspecific symptoms. Consequently, diagnosis is often delayed. There is a paucity of data on the management and outcomes. Surgical management of female urethral diverticula and concomitant stress urinary incontinence (SUI) with pubovaginal sling (PVS) has been shown to be safe and effective in small series. We present our experience with concomitant repair. METHODS Retrospective chart review from 2006 to 2009 identified 22 women undergoing concomitant diverticulectomy and autologous fascia PVS. Demographics, symptoms, urodynamics (UDS), prior treatments, concomitant procedures, pads per day (PPD), outcomes and complications were evaluated. RESULTS Mean age was 50.2. Mean duration of symptoms was 71.2 months. Follow up was 307 days. Magnetic resonance imaging was utilized in 19 patients and 3 were evaluated with voiding cystourethrogram. Seven patients presented with recurrent diverticula status post >1 repairs. All women had demonstrable SUI on exam or UDS. Two patients experienced post-operative retention, one requiring short term intermittent catheterization. Pre and post-operative PPD were 2.6 and 0, respectively. 60% patients reported mixed urinary symptoms prior to repair. Of these, 8 had complete resolution while 5 had significant improvement. Overall, 16 (73%) patients reported cure, while 5 (22%) were improved. One patient experienced recurrence of her urethral diverticulum with SUI after 23 months. No de novo detrusor overactivity, perioperative complications, including hemorrhage, vaginal erosion, fistula or hernias were observed. CONCLUSIONS To our knowledge, this represents the largest series of concomitant repair of SUI and urethral diverticulum. In this series, autologous fascia PVS is a safe and effective in women undergoing primary as well as repeat diverticulectomy. In addition to treatment of SUI symptoms, placement of a PVS may provide tissue interposition to reduce erosion, fistula, and additional post-operative complications. Future directions include determining the prevalence of SUI in those with recurrent urethral diverticula, as this population may be at higher risk and require more preoperative evaluation. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e630-e631 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ekene Enemchukwu Nashville, TN More articles by this author W. Stuart Reynolds Nashville, TN More articles by this author Harriette Scarpero Nashville, TN More articles by this author Melissa Kaufman Nashville, TN More articles by this author Roger Dmochowski Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1553 OUTCOMES OF URETHRAL TRANSECTION FOR RECONSTRUCTION OF CIRCUMFERENTIAL URETHRAL DIVERTICULA

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology I1 Apr 20121553 OUTCOMES OF URETHRAL TRANSECTION FOR RECONSTRUCTION OF CIRCUMFERENTIAL URETHRAL DIVERTICULA Ahmed El-Zawahry, Ross Rames, and Eric Rovner Ahmed El-ZawahryAhmed El-Zawahry Charleston, SC More articles by this author , Ross RamesRoss Rames Charleston, SC More articles by this author , and Eric RovnerEric Rovner Charleston, SC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1323AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Circumferential urethral diverticula (cUD) extending around the urethra represent a particular reconstructive challenge as the repair of such lesions may leave a large gap in the urethra. It is unclear whether such a configuration presents differently or confers a worse prognosis as compared to simple UD (sUD). This unusual configuration has only rarely been reported on in the literature. We present our experience with the clinical findings and reconstruction of these complex UD. METHODS Following IRB approval, a retrospective review of patients who underwent transvaginal urethral diverticulectomy (TVUD) at a single institution from 2004 to 2009 was performed. 9/34 TVUD were circumferential. Repair of these lesions was performed using a previously described technique utilizing complete division of the urethra to access the dorsally located UD, and reconstruction of the urethra with an end-to-end anastomosis. Martius flap and autologous fascial pubovaginal sling (PVS) were performed as needed. Presenting symptoms and post-operative results were reviewed and outcomes assessed based on patient (pt) questionnaires, chart review, and imaging including, VCUG, CT and/or MRI. RESULTS Mean age was 53 yo in the cUD vs. 51 yo in the sUD. Presenting symptoms in the cUD vs. sUD groups included: stress urinary incontinence (SUI) in 8 (89%) vs 14 (56%), urgency was present in 4 (44%) vs. 13 (52%), pelvic pain and/ or dyspareunia in 8 (89%) vs. 15 (60%), recurrent urinary tract infections (UTI) in 6 (67%) vs. 17 (68%) and vaginal mass in 5 (56%) vs. 17 (68%) and tender anterior vaginal wall was present in 6 pts (67%) vs. 12 (48%). These were not statistically significantly different between groups. Three pts presented with dysuria and one pt had bladder outlet obstruction and high post void residuals secondary to previous sling surgery. The incidence of postoperative complications in the 2 groups were similar (p=0.4). PVS was performed in the 8 pts with SUI and Martius flap in 4 in the cUD group. All patients reported subjective improvement of symptoms. Postoperative SUI was noted by history, physical examination or on urodynamics in 0 vs. 5 pts (cUD vs sUD respectively, p=0.085). Recurrent UD was seen in 1 pt in the cUD group. CONCLUSIONS Patients with cUD have a similar presentation and similar prognosis as compared to those with sUD. Surgical reconstruction and removal may be technically demanding at times however results are similar as compared to sUD. Urethral transection and end-to-end anastomosis is a feasible approach in experienced hands and can result in satisfactory clinical outcomes. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e629-e630 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed El-Zawahry Charleston, SC More articles by this author Ross Rames Charleston, SC More articles by this author Eric Rovner Charleston, SC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The autologous fascia pubovaginal sling for complicated female stress incontinence.

The purpose of this study is to review our contemporary experience with autologous fascia pubovaginal slings (AF-PVS) in the era of the midurethral sling. A retrospective review was completed to identify all patients who underwent an AF-PVS between 2002 and 2009. A cross-sectional questionnaire was used to assess postoperative urinary-specific quality of life (consisting of the Urogenital Distress Inventory [UDI-6] and the Incontinence Impact Questionnaires [IIQ-7]). We identified 33 patients. They had failed a median of two previous incontinence treatments. Of these patients, 16 (48%) had failed a previous midurethral sling, and of these half had experienced a significant mesh erosion necessitating mesh removal. Preoperative median incontinence pad usage was 5/day. After a median follow-up of 16 months from the time of AF-PVS, the median pad usage had decreased to 1/day (p = 0.003). A third of the patients had postoperative urgency, and only 1 patient continues to use intermittent catheterization. The median IIQ-7 score was 19/100, and the median UDI-6 score was 44/100. Overall quality of life was mixed-to-delighted in 62% of patients. The AF-PVS has reasonable outcomes in a diverse population of patients, despite failure of other treatment modalities.

Safety and Efficacy of Sling for Persistent Stress Urinary Incontinence After Bulking Injection

To evaluate the impact of injectable agents on subsequent incontinence surgery outcomes to assess safety and efficacy of this treatment combination. Periurethral bulking agents are a minimally invasive treatment option for stress urinary incontinence (SUI), but often lack durability necessitating further surgical intervention. Retrospective review of 43 patients with SUI following bulking agent who underwent subsequent sling placement from November 2000 to September 2009 were evaluated for demographics, symptoms, urodynamics (UDS), bulking agent characteristics, concomitant procedures, pad requirements per day (PPD), subjective outcomes, and complications. Mean patient age was 67 years, with mean follow-up of 37.3 months. All demonstrated SUI, and mixed urinary incontinence (MUI) was noted in 81.4%. Almost half (48.8%) had undergone a prior antiincontinence procedure. Mean number of injections was 3. After a bulking injection, 25 autologous fascia pubovaginal slings, 13 midurethral slings, and 5 biological pubovaginal slings were placed. Concomitant pelvic surgery was performed in 37.2%. Postoperatively, mean PPD decreased from 5.3 to 0.65, with a 60.5% subjective cure rate (no pads or leakage under any circumstances). No association was seen between number or type of injection, or type of sling with regards to patient outcomes. Results were significantly related to concomitant surgery (P = .007). SUI recurred in 8 patients (18.6%), which was not statistically associated with other parameters. Complications included urinary retention (8 patients) de novo urgency (1 patient), UTI (4 patients), abdominal wound infection (3 patients), and cystotomy (1 patient). Prior treatment with bulking agents does not appear to negatively affect outcomes for future antiincontinence surgery in our patient population.

Comparative Analysis of Urinary Incontinence Severity After Autologous Fascia Pubovaginal Sling, Pubovaginal Sling and Tension-Free Vaginal Tape

Autologous fascia, Pelvicol implant and polypropylene are common materials used in suburethral anti-incontinence procedures. We explored the relative effectiveness of the autologous fascia pubovaginal sling, Pelvicol pubovaginal sling and Gynecare TVT on self-reported postoperative urinary incontinence. The study was a mailed cross-sectional survey of health related quality of life 1 to 3 years after suburethral anti-incontinence surgery performed at our institution. The Incontinence Symptom Index was used to assess the presence and severity of urinary incontinence symptoms and the Incontinence Impact Questionnaire-7 was used to assess impairment. Regression models were developed to identify factors with an independent effect on the presence, severity and impairment of urinary incontinence symptoms. The questionnaire was returned by 69% of eligible respondents (173 of 250). Those with previous incontinence surgery (OR 11.0, 95% CI 2.3-51.4) and medical comorbidities (OR 1.6, 95% CI 1.1-2.2) were more likely to report urinary incontinence symptoms, ie incontinence symptom index greater than 0. Symptom severity, which was analyzed only in respondents with urinary incontinence symptoms, was greater in the Pelvicol than in the autologous fascia pubovaginal sling and TVT groups (each p <0.01). No significant difference was observed between the TVT and autologous fascia pubovaginal sling groups (p = 0.15). Also associated with higher urinary incontinence symptom severity scores were body mass index (p = 0.03), a history of incontinence surgery (p = 0.01) and lower education (p <0.01). Impairment from urinary incontinence, as assessed by the Incontinence Impact Questionnaire-7, was associated with body mass index, severe depression and current smoking (each p = 0.01) but not with surgical treatment group. Women who received an autologous fascia pubovaginal sling or TVT reported lower symptom severity scores than those who had a Pelvicol pubovaginal sling. Impairment was not associated with procedure type. These findings suggest better outcomes with autologous fascia pubovaginal sling and TVT. Randomized, controlled trials are needed to confirm these findings.

Effective Treatment for Mixed Urinary Incontinence with a Pubovaginal Sling

We assessed the results of autologous fascia pubovaginal sling (PVS) in women with mixed incontinence using a validated outcome score and identified risk factors for failure. A total of 131 women who received a PVS for sphincteric incontinence (SUI) confirmed by history, physical examination and/or videourodynamic study (VUDS) were identified from a database during the accrual dates 1995 to 2001. Patients with a urethral diverticulum, neoplasm or urinary fistula were excluded. Patients with SUI who also complained of urinary urge incontinence (UUI) and/or had detrusor instability that reproduced incontinence symptoms during VUDS were diagnosed with mixed incontinence (MUI). Patients completed a urological questionnaire, 24-hour voiding diary, pad test, VUDS and cystoscopy preoperatively. The diagnosis of SUI and UUI was further confirmed by physician interview. In patients with MUI detrusor overactivity was classified according to urodynamic criteria. At least 1 year postoperatively the validated Urinary Incontinence Outcome Score (UIOS) was calculated from a 24-hour diary, pad test and questionnaire, and outcomes in patients with SUI and those with MUI were compared. The study was powered a priori to detect a 20% difference in outcome score. Cured patients (UIOS 0) were compared with those who were not cured (UIOS 1 or greater) and univariate analysis was applied to identify the correlates of failed PVS. Of the 131 patients evaluated 33 with a diverticulum or fistula were excluded and 98 underwent PVS. Patient age was 45 to 84 years (median 66). Followup was 1 to 7 years (median 3). A total of 46 patients (48.5%) had simple SUI and 52 (51.5%) had MUI. Two patients were lost to followup (2%) and the procedure was presumed to have failed. There were no differences in age, hormone status, previous surgery or pelvic organ prolapse between patients with SUI and MUI. The cure/improved rate was 97% in 44 SUI cases and 93% in 47 MUI cases, which was a nonsignificant difference (p = 0.33). Analysis of the MUI group showed that patients who were cured and not cured had similar age, parity, urethral angle, bladder capacity, leak point pressure and pad tests. Patients with MUI who were cured had a higher number of voids in 24 hours on preoperative voiding diary (12 vs 8, p = 0.01), while those who were improved or in whom treatment failed had a greater number of urgency (5.6 vs 4.1, p <0.05) and UUI (5.1 vs 3.0, p <0.01) episodes. Univariate analysis of MUI cases showed that an increasing number of preoperative urgency and urge incontinence episodes correlated directly with PVS failure (r = 0.33, p = 0.038 and r = 0.35, p = 0.048, respectively). In contrast, an increasing number of voids correlated with successful PVS (r = 0.4, p = 0.01). Women with SUI and concurrent urge incontinence or detrusor instability have a successful PVS outcome at a rate comparable to that in women with simple SUI, in contrast to our previous findings. Increasing episodes of urgency and urge incontinence on the preoperative voiding diary correlated directly with surgical failure, while voiding frequently was associated with cure.