We were very interested to read the recent study by Welk and Herschorn, and the related commentary by Steele, regarding the role of autologous rectus fascial slings for complex recurrent female stress urinary incontinence (SUI).1,2 The authors report that, on medium-term follow-up of 33 women with previous failed continence surgery, pubovaginal sling was associated with a significant reduction in pad usage and good patient satisfaction rates.1
In 2010, we reviewed the published literature on therapeutic options for managing women with recurrent SUI after failed synthetic mid-urethral sling (MUS).3 At that time, no studies reporting outcomes after PVS for a previous failed MUS had been reported and thus, the data reported by Welk and Herschorn are particularly welcome. We also recently collected data on women undergoing rectus fascial PVS for complex recurrent SUI in our tertiary urogynecology unit. Preoperative video-urodynamics was performed in all women considering PVS. The surgical technique used was very similar to that by Welk and Herschorn,1 with a 13 × 2-cm strip of rectus fascia harvested. All cases were seen in the clinic at 6 weeks and 12 months postoperatively and at variable follow-up periods thereafter. At follow-up visits, uroflowmetry and post-void residual volume were performed and subjective cure of SUI was assessed.
We identified 7 women who underwent PVS after a previously failed MUS, who were contacted by telephone to complete the ICIQ-SF questionnaire4 and to ascertain cure (Table 1). Women had a median age of 61 (range: 41–73) years and were a complex group, with a median of 2 (range: 1–4) prior continence surgeries. All women completed the telephone survey and the median interval since the PVS was 5 years (range: 0.5–9 years). The long-term failure rate following PVS for recurrent SUI in our population was 14% (1/7). This patient had preoperative voiding dysfunction and was still requiring self-catheterizing 4.5 years after the PVS. A second patient required self-catheterization for de novo voiding dysfunction but was dry.
Table 1.
| Case | MUS | Interval (years) | Other SUI treatment | BMI | Preoperative videourodynamics | Postoperative complications | Telephone follow-up | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||||
| DO | PVR (mL) | MUCP (cmH2O) | Time (years) | ICIQ | OAB | SUI | ||||||
| 1 | IVS | 1 | Bulking | 29 | N | 0 | 18 | - | 9 | 3/21 | N | V. mild |
| 2 | IVS | 4 | None | 21 | N | 0 | 52 | - | 7.5 | 8/21 | Y | N |
| 3 | IVS | 6 | Incontinence pessary | 32 | N | 0 | 25 | Pulmonary embolus | 6 | 3/21 | Y | N |
| 4 | IVS | 2 | Repeat IVS | 33 | Y | 200 | N/A | Pre-existing voiding dysfunction (CISC) | 4.5 | 19/21 | Y | Y |
| 5 | TVT-O | 2 | Colposuspension & bulking (x2) | 27 | N | 40 | 11 | UTI, fever | 3 | 7/21 | Y | N |
| 6 | TVT | 4 | Pessary & bulking | 27 | Y | 30 | 25 | - | 2 | 0/21 | N | N |
| 7 | TVT | 5 | Colposuspension & pessary | 28 | N | 0 | 29 | De novo voiding dysfunction (CISC) | 0.5 | 19/21 | Y | N |
MUS: midurethral sling; SUI: stress urinary incontinence; BMI: body mass index; DO: detrusor overactivity; PVR: post-void residual volume; MUCP: Maximum urethral closure pressure; ICIQ: International Consultation on Incontinence (short form); OAB: overactive bladder; IVS: intravaginal sling; TVT-O: trans-vaginal tape-obturator; UTI: urinary tract infection; CISC: clean intermittent self-catheterization; PVS: pubovaginal sling.
Overall, 71% (5/7) of women were completely cured and 86% (6/7) were satisfied. The rate of de novo OAB in women with a stable bladder preoperatively was 80% (4/5). One woman, with a history of known thrombophilia, suffered a large pulmonary embolus on postoperative day 12 but recovered fully.
We agree with the comments of Steele that autologous PVS still has a role as a salvage procedure in complex recurrent female SUI. We found that PVS was associated with a low failure rate, but a high rate of de novo OAB at 5 years in a small population of women with previous failed synthetic MUS. Although the case of pulmonary embolus in our population raises some concern, previous work from the Urinary Incontinence Treatment Network reported a low rate (0.3%) of venous thromboembolism after PVS, which is reassuring.5
References
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