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Sling Failures

Sling Failures

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Sling Failures

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  1. Sling Failures Jerry G. Blaivas, MDClinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

  2. Why Do Operations Fail? • Too tight • Too loose • Wrong position • Detrusor overactivity • De-novo • Persistent • Erosion • Wrong indication

  3. Too Tight • Urethral obstruction • Detrusor overactivity • Erosion • Devascularization > recurrent SUI

  4. Urethral Obstruction • Clinical: • De-novo symptoms • Weak stream • OAB • negative Q-tip angle • Urodynamics: • High detrusor pressure / low flow: pdetmax > 20 cm H20 Qmax < 12 ml/S • Blaivas Groutz nomogram

  5. - 45O

  6. Low flow (0) High pressure (pdetmax = 75) MSCO

  7. Blaivas - Groutz Nomogram Blaivas & Groutz, Neurourol & Urodynam 19:553-564, 2000

  8. Rx of Post op Urinary Retention • Depends on type of sling • Initial Rx intermittent catheterization • Synthetic sling • early intervention days – weeks • Autologous slings • Delayed intervention – months

  9. Rx of Post op Urinary Retention • ? Need for further workup • Q-tip • cystoscopy • urodynamics

  10. Surgical Rx of Sling Obstruction • Sling incision • midline • lateral • Urethrolysis • antero-lateral • circumferential • +/- Martius flap interposition • Technique determined intraop

  11. Sling Incision Results Nitti et al. Early results of pubovaginal sling lysis by midline sling incision. Urology 2002. Amundsen et al. Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure. J Urol. 2000. Goldman et al. Simple sling incision for the treatment of iatrogenic urethral obstruction. Urology 2003

  12. Urethrolysis • Vaginal • Supra-meatal • Retropubic

  13. CircumferentialUrethrolysis

  14. Urethrolysis • Vaginal • Supra-meatal • Retropubic

  15. Urethrolysis • Vaginal • Supra-meatal • Retropubic

  16. Urethrolysis Results

  17. Too Tight • Urethral obstruction • Detrusor overactivity • Erosion • Devascularization > recurrent SUI

  18. Too Tight • Urethral obstruction • Detrusoroveractivity • Erosion • Devascularization > recurrent SUI

  19. Bladder neck Bladder neck Eroded mesh

  20. VLPP

  21. Treatment of Erosions. • remove as much of sling as possible • closure of the urethra • +/ - urethral reconstruction • +/ - biologic sling • +/ - Martius flap

  22. Too Tight • Urethral obstruction • Detrusor overactivity • Erosion • Devascularization > recurrent SUI

  23. Why Do Operations Fail? • Too tight • Too loose • Wrong position • Detrusor overactivity • De-novo • Persistent • Erosion • Wrong indication

  24. Too Loose Urethral hypermobility Intrinsic sphincter deficiency Recurrent sphincteric incontinence

  25. VLPP VLLP = 92 cm H20 Qtip = 0 > 60O AG AG AG

  26. AG

  27. JK VLPP = 42 cm H20 Q tip = 0

  28. Treatment of Recurrent SUI • no compelling data • for hypermobility, surgeon choice • for poorly mobile or pipe - stem urethra, biologic bladder neck sling

  29. Why Do Operations Fail? • Too tight • Too loose • Wrong position • Detrusor overactivity • De-novo • Persistent • Erosion • Wrong indication

  30. Wrong Position • Too far proximal • persistent sphincteric incontinence • urethral obstruction • ureteral injury • Too far distal • persistent sphincteric incontinence • urethral obstruction • urethral hypermobility

  31. Sling proximal to BN VLPP = 35 cm H20 MS

  32. sling

  33. No flow High pdet MSCO

  34. MSCO

  35. MSCO

  36. Why Do Operations Fail? • Too tight • Too loose • Wrong position • Detrusor overactivity • De-novo • Persistent • Erosion • Wrong indication

  37. Wrong Indication • Urinary fistula mistaken for sphincteric incontinence • Overactive bladder mistaken for sphincteric incontinence • Sine-qua-non - Never operate on stress incontinence without actually diagnosing sphincteric incontinence with your own eyes