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The Midurethral Fascial "Sling on a String": An Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications.
Eur Urol. 2018 08; 74(2):191-196.EU

Abstract

BACKGROUND

Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms.

OBJECTIVE

The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of data on patients undergoing AFS at a tertiary referral unit.

SURGICAL PROCEDURE

AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD.

MEASUREMENTS

Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC).

RESULTS AND LIMITATIONS

A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24-83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery.

CONCLUSIONS

A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate.

PATIENT SUMMARY

A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material.

Authors+Show Affiliations

Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK.Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK.Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK.Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK; University of Dammam, Kingdom of Saudi Arabia.Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK.Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK. Electronic address: c.r.chapple@sheffield.ac.uk.

Pub Type(s)

Journal Article
Video-Audio Media

Language

eng

PubMed ID

29803585

Citation

Osman, Nadir I., et al. "The Midurethral Fascial "Sling On a String": an Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications." European Urology, vol. 74, no. 2, 2018, pp. 191-196.
Osman NI, Hillary CJ, Mangera A, et al. The Midurethral Fascial "Sling on a String": An Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications. Eur Urol. 2018;74(2):191-196.
Osman, N. I., Hillary, C. J., Mangera, A., Aldamanhoori, R., Inman, R. D., & Chapple, C. R. (2018). The Midurethral Fascial "Sling on a String": An Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications. European Urology, 74(2), 191-196. https://doi.org/10.1016/j.eururo.2018.04.031
Osman NI, et al. The Midurethral Fascial "Sling On a String": an Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications. Eur Urol. 2018;74(2):191-196. PubMed PMID: 29803585.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The Midurethral Fascial "Sling on a String": An Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications. AU - Osman,Nadir I, AU - Hillary,Christopher J, AU - Mangera,Altaf, AU - Aldamanhoori,Reem, AU - Inman,Richard D, AU - Chapple,Christopher R, Y1 - 2018/05/24/ PY - 2017/11/26/received PY - 2018/04/30/accepted PY - 2018/5/29/pubmed PY - 2019/5/29/medline PY - 2018/5/28/entrez KW - Autologous fascial sling KW - Midurethral tape KW - Stress urinary incontinence SP - 191 EP - 196 JF - European urology JO - Eur Urol VL - 74 IS - 2 N2 - BACKGROUND: Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms. OBJECTIVE: The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of data on patients undergoing AFS at a tertiary referral unit. SURGICAL PROCEDURE: AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD. MEASUREMENTS: Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC). RESULTS AND LIMITATIONS: A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24-83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery. CONCLUSIONS: A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate. PATIENT SUMMARY: A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material. SN - 1873-7560 UR - https://www.unboundmedicine.com/medline/citation/29803585/The_Midurethral_Fascial_"Sling_on_a_String":_An_Alternative_to_Midurethral_Synthetic_Tapes_in_the_Era_of_Mesh_Complications_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0302-2838(18)30337-3 DB - PRIME DP - Unbound Medicine ER -