The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of...

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Cartoon of taking fascia

Transcript of The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of...

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

Cartoon of taking fascia

Page 2: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 3: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Surgical Technique

• Horizontal suprapubic incision (4 cm)

• Excise rectus fascial strip (6 – 8 cm)

• Temporarily leave fascia open

• Horizontal incision over vesical neck

Page 4: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Surgical Technique

• Mobilize vesical neck from

below

• Perforate endopelvic fascia

• Create tunnel & pass slingaround vesical neck

• Cystoscopy

Page 5: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Surgical Technique

• Close vaginal wound

• Bring sutures through fascia

• Close rectus fascia

• Suture ends of sling togetherin midline without tension

• Close abdominal wound

Page 6: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Cartoon of skin incision

Page 7: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 8: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 9: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 10: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 11: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 12: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 13: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 14: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Balloon

Incision

Page 15: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Allis clamps

Page 16: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Traction ofclamp

Push up withindex finger onvaginalwall

Page 17: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Left index finger pushing up on vaginal wall

Shiny white surface superficialto pubo-cervical fascia

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Right wrist flexed downward

Page 19: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Correct (superficial) plane

Incorrect (deep) plane

Page 20: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Correct (superficial) plane

Incorrect (deep) plane

Pubo-cervical fascia

Page 21: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 22: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 23: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 24: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 25: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
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Index fingerbetween clamp& urethra &bladderat all times

Page 27: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 28: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 29: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Ends of sling thru fascia

Sutures through separate stabwounds in rectus fascia

Page 30: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

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)

Page 31: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Push down on cystoscope parallel to thefloor

Take slack out ofsling

Page 32: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

Tie loosely with no tension

Page 33: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 34: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.
Page 35: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

PVS for Simple SUI OUTCOME SCORE

Outcome Total score

Cure 0 67%

Goodresponse

1-2 21%

Fair response 3-4 9%

Poor response 5 3%

Failure 6 0%

100%

0%

Page 36: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

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, 2003Chou et al, J Urol, 2003

Page 37: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 2 4 6 8 10 12

Years Follow Up

Succ

ess

Pro

babi

lity

OverallSUIUI

Page 38: The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University.

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)


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