Tradition is yielding to new technology’s advantages, time-tested though they are not—yet
Adjustable suburethral sling
One of the challenges in placing a suburethral sling is adjustment for efficacy without overcorrection and resultant bladder neck obstruction, urinary retention, or persistent and refractory overactive bladder symptoms. An adjustable transvaginal midurethral synthetic sling procedure was recently introduced in the United States: the Remeex Tensionfree Readjustable Tape, (Neomedic International, Spain). A retropubic minimally invasive midurethral sling is attached to sutures that are taken through a tensioning device placed above the fascia in the suprapubic region. The tensioning device has a small adjustment kit similar to a screwdriver, which is left in place at the time of surgery. The sling is intentionally left loose for postoperative adjustment. Following surgery, a filling cystometrogram confirms stress incontinence. The sling is then progressively tightened until the leaking ceases. This technology is designed to prevent or correct overtightening, and avert bladder outlet obstruction. The sling can be adjusted via a small suprapubic incision, even years later; adjustment has been reported up to 7 years later.
In a recent study of 62 patients with stress urinary incontinence, 58 patients (94%) were completely dry and cured, and 4 patients (6%) reported occasional slight urine leakage. Operative time was 20 to 40 minutes (only stress urinary incontinence and cystocele). Six patients required long-term readjustment (5 to increase tension and 1 to reduce tension). No major intra-operative complications occurred. Late complications included suprapubic wound pain (12 transitional and relieved with analgesics), 3 urinary tract infections, 2 wound seromas, 1 case requiring prosthesis removal due to infection, and 3 cases of hyperactivity de novo, which required anticholinergic treatment.9
Although postoperative urinary retention or postoperative failure is relatively uncommon in transvaginal or transobturator suburethral sling procedures performed by experienced surgeons, the adjustable sling may be especially useful in patients with increased risk of postoperative voiding dysfunction, as well as limited urethral hypermobility/fixed urethra, because the sling can be adjusted long after the operation. Risks include infection due to foreign body (indwelling placement of the tensioning device) as well as palpation and incisional discomfort in very thin patients. Further clinical experience is needed, but the concept of a sling that can be adjusted immediately or even years later is appealing.
Graft/mesh augmentation for prolapse repair
Augmentation of pelvic prolapse repair using mesh and graft materials is used increasingly in an effort to improve long-term outcomes, although we lack randomized prospective data and long-term outcome studies. Synthetic materials offer ready availability, consistent tissue properties, cost effectiveness, and permanent placement, although there are risks: infection, dyspareunia, and erosion or exposure. Success and complications may depend on surgical technique, choice of material, patient selection, postoperative management, or other factors.
The overall success rate was 94% at a mean of 17 months after operation, in a study of 63 women in whom polypropylene mesh was used for augmentation of cystocele and rectocele. However, the authors recommended abandonment of the procedure due to an unacceptably high rate of complications.10 In the 32 women undergoing anterior repair, sexual activity rate did not alter, but dyspareunia increased in 20%. Urge and stress incontinence did not change, but urgency improved in 10%; 13% had vaginal erosion of the mesh. Of the 31 patients undergoing posterior repair, sexual activity decreased by 12% and dyspareunia increased in 63%. Constipation improved in 15% and anal incontinence in 4%; 6.5% had vaginal erosion of mesh and 1 required mesh removal for abscess.
In another study, results were improved and complications were fewer. After 2 years, 24 of 26 women who had posterior repair with polypropylene mesh were cured (92.3%) and 1 had asymptomatic stage 2 rectocele. All but 1 reported improved symptoms and quality of life. No postop infection or rectovaginal fistula was reported; there were 3 vaginal erosions (12%), and 2 patients had de novo dyspareunia (7.7%).11
To make graft/mesh augmentation easier and faster, needle-suspension techniques were recently introduced. Needles are inserted either through the transobturator space (anterior mesh placement) or ischiorectal fascia (posterior placement) and exit through the pelvic sidewall in proximity to the ischial spine. A multi-arm mesh is then attached to the needles, which are withdrawn. Tension secures the mesh and provides “tension-free” anterior or posterior wall support. Colporrhaphy can be performed prior to mesh placement at the surgeon’s discretion.
Because we have few data on patient selection or long-term safety and efficacy (most of it presented at recent meetings12,13 ), these techniques call for caution. Blind needle passage can be associated with complications such as rectal injury and rectovaginal fistula.14 But complication rates may reflect early evolution and may improve with time and experience.
