FEMALE UROLOGY

Early results of pubovaginal sling lysis by midline sling incision
Nitti VW, Carlson KV, Blaivas JG, Dmochowski RR
Department of Urology, New York University School of Medicine, New York, New York, USA.
Urology. 2002; 59: 47-51

• Objectives: To describe a simplified technique and results of pubovaginal sling lysis by incision of the sling in the midline by way of a transvaginal approach.
• Methods: We reviewed the charts of 19 women who underwent pubovaginal sling lysis for obstruction. Patients presenting with retention, incomplete emptying or storage, or voiding symptoms suggesting obstruction after pubovaginal sling placement were evaluated with videourodynamic studies and cystourethroscopy. The diagnosis of obstruction was made on the basis of a combination of clinical, urodynamic, and endoscopic findings. All patients underwent a midline incision of the sling by way of a transvaginal approach without formal urethrolysis.
• Results: The mean patient age was 57 years. Fifteen women (79%) had an autologous rectus fascial sling, 3 (16%) an allographic fascia lata sling, and 1 (5%) a polypropylene sling. Twelve women (63%) presented with urinary retention and required catheterization to empty. The other 7 women presented with obstructive and/or irritative symptoms without the need to catheterize. The mean time to sling lysis was 10.6 months from the initial surgery. The mean follow-up was 12 months (range 1 to 55). Overall, sling lysis was successful in 84% of the women. Stress incontinence recurred in 17%. No significant perioperative complications occurred.
• Conclusions: Pubovaginal sling lysis without formal urethrolysis appears to be a safe and effective method of relieving obstruction. The success and recurrent stress incontinence rates are comparable to those with formal urethrolysis.
  
  
• Editorial Comment
  The success of urethrolysis, be it formal release of adhesions with placement of an interposition flap or simple sling incision, is judged by the resolution of the symptoms attributed to the iatrogenic obstruction with the continuation or achievement of urinary continence. The importance of this paper is in that it illuminates the possibility of addressing iatrogenic outlet obstruction in minimally invasive fashion with a potentially diminished period of convalescence.
  Most surgeons have traditionally initially opted for vaginal approaches to urethrolysis reserving retropubic urethrolysis for nonfavorable vaginal anatomy and presumed marked retropubic scarring (1). This method mirrors other approaches of transvaginal urethrolysis with the usual focus on identification of an obstructing suture or sling with division of same (2-5). This approach does not depend on access to the retropubic space for reduction of retropubic fibrosis and scarification and thus optimizes the potential for postoperative urinary continence (2,6). Indeed, the postoperative urinary continence rates from simple sling incision (83%) mirror those rates found with other reported urethrolysis series (1-6).
  Another noteworthy point of this report is the length of time between the placement of the obstructing suburethral sling and the time of simple sling incision (mean=10.6 months). Intuitive reasoning would have wagered that by 3 months, fibrosis would be set and a suburethral sling incision would not have yielded the rate of success that was achieved (84%). Perhaps, this paper will allow one to have a deeper appreciation of the subtle difference between the fibrosis of support and that of obstruction (7,8).
  In addition, another value of consideration of this approach is that it does not require the surgeon to contemplate a synchronous resuspension procedure. This differs from a previous report that noted the placement of an interposition graft at the time of sling release (9).
  In summary, this operative approach is very appealing because simple things are easy to do and complex things are not. Though in the past some have argued that to all difficult problems there is a simple solution which usually does not work, this report will embolden all of us to simply incise the sling if we feel it is obstructive and not worry if it greater than one or two months postoperatively.

References
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9. Ghoniem GM, Elgamasy AN: Simplified surgical approach to bladder outlet obstruction following pubovaginal sling. J Urol. 1995, 154:181-3.

Dr. Steven P. Petrou
Department of Urology
Mayo Clinic
Jacksonville, Florida, USA