1. The Gold Standard: Autologous Fascial Pubo-Vaginal Sling
Jerry G. Blaivas Clinical Professor of Urology
Joan & Sanford Weil Medcial School
Cornell University
Adjunct Professor of Urology SUNY Downstate Medical School

2. Cartoon of taking fascia

4. Surgical Technique Horizontal suprapubic incision (4 cm)
Excise rectus fascial strip (6 – 8 cm)
Temporarily leave fascia open
Horizontal incision over vesical neck

5. Surgical Technique Mobilize vesical neck from below
Perforate endopelvic fascia
Create tunnel & pass sling around vesical neck
Cystoscopy

6. Surgical Technique Close vaginal wound Bring sutures through fascia
Close rectus fascia
Suture ends of sling together in midline without tension
Close abdominal wound

7. Cartoon of skin incision

8. Picture of Cartoon of skin incision

18. Balloon
Incision

19. Allis clamps

20. Push up with index finger on vaginal wall
Traction of clamp

21. Left index finger pushing up on vaginal wall
Shiny white surface superficial to pubo-cervical fascia

22. Right wrist flexed downward

23. Incorrect (deep) plane
Correct (superficial) plane

24. Correct plane
Incorrect plane
Vaginal wall
Pubo-cervical fascia

25. Correct (superficial) plane
Pubo-cervical
fascia
Incorrect (deep) plane

31. Index finger between clamp & urethra & bladder at all times

34. Separate Fascial incision
Inferior edge of rectus
Separate Fascial incision
Separate stab wound for sling

35. Ends of sling thru fascia
Sutures through separate stab wounds in rectus fascia
Ends of sling thru fascia

36. How much tension? None (create a backboard)
(Almost) can’t make it too loose
Make sure Q-tip is not negative (elevation of vesical neck)

37. Take slack out of sling
Push down on cystoscope parallel to the floor

38. Tie loosely with no tension

41. URINARY INCONTINENCE OUTCOME SCORE
Groutz & Blaivas, Neurourol & Urodyn 19:127,

42. Urinary Incontinence Outcome Score

43. PVS for Simple & Complex SUI OUTCOME SCORE
93% 7%

44. PVS for Simple SUI OUTCOME SCORE
100% 0%

45. Mixed Incontinence Cure/Improved Rates (UIOS <= 4) :
SUI: 97% (n= 44)
MUI: 93% (n= 47) non-significant difference (p: 0.33), with study powered a priori to detect > 20% difference in outcome score
Chou et al, J Urol, 2003

48. Autologous Sling Outcomes
Cure/Improve rate - 82% at 4 years
Urinary Retention requiring intervention - 8%
De Novo OAB - 9%
(Dmochowski, et al. AUA Guidelines on the Surgical Management of Female Stress Urinary Incontinence, 2010)

49. Conclusions Pubovaginal sling effective for: Urethral hypermobility
Intrinsic sphincter deficiency
Mixed incontinence
Long lasting results
Minimal morbidity

50. Conclusions Recurrent stress incontinence is rare
Major risk factor for recurrent SUI is “pipe stem” urethra
Urge incontinence is the most common cause of failure
Major risk factor for UI is:
increasing # of preop urge episodes
increasing # of preop UI episodes

51. Conclusions Permanent urinary retention is rare
Risk factors for permanent urinary retention are :
preop areflexic neurogenic bladder
grade 3 or 4 cytocele
excessive sling tension > urethral obstruction