Does the vaginal wall sling still has a role?

Costantini E1, Natale F2, Trama F1, Marchesi A1, Illiano E1

Research Type

Clinical

Abstract Category

Female Stress Urinary Incontinence (SUI)

Abstract 176
ePoster 3
Scientific Open Discussion Session 12
On-Demand
Incontinence Stress Urinary Incontinence Surgery
1. Andrology and Urogynecological Cinic,Santa Maria Terni Hospital,University of Perugia, 2. Uorgynecological Clinic,San carlo Nancy,Rome
Presenter
E

Ester Illiano

Links

Abstract

Hypothesis / aims of study
The vaginal wall sling involves construction of a sling from the anterior vaginal wall to provide compression and support for the mid-urethra and bladder neck. It for years, untill the introduction of synthetic slings on the market, it has been considered an excellent surgical approach to stress urinary incontinence (SUI). After the warnings issued by the FDA in 2008 and 2011 in some countries it has returned to use the vaginal wall sling. The primary aim of this study was to evaluate the long term functional outcomes of vaginal wall sling. The secondary aim was to evaluate the patient’s satisfaction.
Study design, materials and methods
This was a prospective single centre study, on patients with SUI underwent in situ vaginal sling surgery. Pre operative evaluation included: history, clinical examination, urodynamic test, UDI-6 questionnaire. All patients underwent check-ups at 1, 3, 6 and 12 months post-operatively and then annually, with the preoperative protocol except for urodynamic test. They performed uroflowmentry and at last visit they completed the PGI-I questionnaire. The sling was fashioned by making two horizontal and two vertical incisions, placed to form a rectangle, on the anterior vaginal wall. The proximal horizontal incision was at the level of the bladder neck and the distal was about 1 cm posterior to the urethral meatus. The vertical incisions completed the rectangular vaginal segment (15–20*25 mm). After preparing the sling, the proximal anterior vaginal wall edge was undermined beneath the bladder neck and the posterior bladder wall to prepare it to cover the vaginal island. After this first step, dissection was continued along the lateral edges of the sling toward the inferior pubic ramus and the endopelvic fascia was opened. Helicoidal sutures in 0-non-reabsorbable monofilament and roll of Marlex mesh were positioned on each side of the sling to ensure reinforcement. The two suprapubic sutures were tied above the rectus fascia. Statistical analysis: McNemar chi-square test.
Results
From May 1996 to May 2002, 40 consecutive women underwent to vaginal sling surgery for SUI. Six patients were lost to follow-up and 12 had passed away: the remaining 20 patients (mean age 56 ± 8.6) were re-evaluated between January 2019 and February 2019, and are included in this report. Median follow-up was 243.4 months (range 203.4–275.1 months). Table 1 showed an postoperative increase of storage and voiding symptoms. After an initial improvement (1 year after surgery) at last visit there were the worsening of urinary symptoms. (Graph 1)  After 1 postoperative year, the objective success rate was 55% and at last visit was 40%. Of the 12 failed patients 10 underwent further SUI surgery with synthetic sling (within 5 years from previous surgery), and 2 underwent pelvic rehabilitation. De novo urgency and voiding symptoms occurred in 40%and 4% of cases respectively. These results were confirmed also low PGI-I score
Interpretation of results
In an era in which synthetic sling are less used, and sometimes in some countries removed from the market, the use of autologous sling is increasing more and more. However, the long-term results of autologous sling are not promising, probably for technical reasons. The high rate of long-term voiding symptoms, as well as the low cure rate of SUI compared to synthetic sling should make you think (TOT:at follow-up mean 145 months the objective cure rates was 78.9% subjective cure rate was 62.6%;TVT: at follow-up mean 139 months the objective cure rates was 80.2% subjective cure rate was 73.4% ); on the other hand, the complications of synthetic sling in expert hands are few (4% mesh exposure)
Concluding message
These results should justify the use of synthetic slings which in expert hands can give better long-term functional outcomes. 
The return to old surgical techniques, abandoned over time due to the low results and the important complications, may not be justified
Figure 1
Figure 2
Disclosures
Funding None Clinical Trial No Subjects Human Ethics Committee CEAS Umbria Helsinki Yes Informed Consent Yes
22/07/2024 10:36:50