Renaissance of the autologous pubovaginal sling

Excerpt

Autologous tissue has been used to treat female stress urinary incontinence (SUI) for almost a century, with many operative modifications introduced throughout the years of the standard procedure known as pubovaginal sling (PVS) [1]. Currently, either rectus fascia or fascia lata are used to create a hammock on which the bladder neck and urethra can rest. The use of other biological tissues, however, failed the test of time, albeit the earlier good results. During the past decade, the US Food and Drug Administration (FDA) public communications caused a dramatic increase in litigation and malpractice claims related to synthetic mesh use for midurethral slings (MUS). As a direct result, the use of these slings significantly decreased, partly because their production was abandoned by many manufactures, and partly due to the growing concern among women about having this type of surgery [2]. This factor was responsible for the resurgence of interest in recent years to adopt the autologous PVS or fascial sling as an alternative surgical option for treatment of SUI when there is concern about tissue quality, possible litigation, and when patients refuse synthetic slings. The low rate of adverse events with PVS, such as vaginal erosion, infection, and urethral damage attributable to synthetic mesh, also supported this decision. The PVS can thus be used in patients when placement of a synthetic mesh sling is contraindicated, such as with concomitant urethral diverticulectomy, repair of urethrovaginal fistulae, prior pelvic radiation, or history of prior or concurrent urethral mesh erosion [2]. Traditionally, the PVS was reserved for recurrent SUI due to intrinsic sphincteric deficiency because of the technical difficulty involved and the special surgical skills required for performing the procedure. More recently, the operation has been successfully used for primary SUI, as continence rates were better with greater patient satisfaction despite the higher incidence of postoperative voiding dysfunction compared with Burch colposuspension [3]. This finding is supported by results of a recent meta-analysis of 15,855 patients showing that both synthetic and PVS had similar objective cure rates that were superior to Burch colposuspension [4]. …