Overview of Pubovaginal Sling
Stress urinary incontinence, also known as SUI, is a condition where you might accidentally release urine when your abdomen is under pressure. Think of it as having slight leaks when you laugh, cough, or lift something heavy. It’s a condition that many individuals experience, especially women. Up to half of the women across the world have experienced this condition.
There are a host of options for treating this issue, close to 200 different methods according to medical research. But, the most accepted and standard way of treatment is a procedure called a pubovaginal sling, or PVS in short. This is a surgery that helps to support the urethra and stop urine from leaking out unexpectedly.
Anatomy and Physiology of Pubovaginal Sling
The female urethra, which is the tube that allows urine to pass out of the body, is made up of four different layers. These layers combine to keep the urethra closed when it needs to be. The important middle and outer layers are muscular, while the innermost part includes what we call an internal sphincter, located where the urethra connects with the urinary bladder.
The external sphincter, another important muscle, helps control when we voluntarily hold in urine and also reacts automatically to prevent leakage when the bladder is filling. The pelvic diaphragm, a group of muscles at the bottom of the pelvis, play a crucial role in controlling urine flow and heavily depend on the levator ani muscles.
Extra support for the urethra comes from the pubocervical fascia and ureteropelvic ligament. Damage or injury to any of these supporting elements could lead to a condition called Stress Urinary Incontinence (SUI), which could cause unintentional leakage of urine.
In females, SUI is commonly linked to two conditions: intrinsic sphincter deficiency (ISD) and urethral hypermobility. ISD can cause incontinence because resting urethral closure pressure drops due to defects in the urethra and a lack of coordination in the function of the sphincters. On the other hand, urethral hypermobility means the urethra can move around more than it should; if the pressure inside the abdomen increases, this can cause the front and back walls of the urethra to slide apart, making urine leak out.
The PVS (a medical device) is placed at the area where the bladder connects to the urethra and incorporates into the endopelvic fascia through fibrosis, a process that involves the formation of extra connective tissue. This can help the urethra to close properly even when the intra-abdominal pressure increases.
Why do People Need Pubovaginal Sling
When a woman experiences urinary leakage (stress urinary incontinence – SUI) due to her urethra (the tube that passes urine out of the body) moving too easily (urethral hypermobility), or if it’s poorly functioning (intrinsic sphincter deficiency – ISD), a procedure called pubovaginal sling placement is often the main treatment. This operation is also used as a secondary treatment if a different procedure, such as a mid-urethral sling or colposuspension, failed to solve the problem.
When a Person Should Avoid Pubovaginal Sling
The placement of a Pelvic Organ Prolapse Surgery (PVS) is something that can be planned and scheduled according to a person’s needs. However, there are certain situations or health conditions that could make this surgery riskier. The factors that may prevent a person from having this surgery include an ongoing vaginal or urinary tract infection, being pregnant, having uncontrolled diabetes, having untreated bleeding disorders, or being at a high risk for complications from anesthesia because of poor functioning of certain organs.
On a separate note, there is a specific type of this surgery where a synthetic mesh sling is used. However, this is not recommended for patients who at the same time are having surgery for stress urinary incontinence, repairing a fistula (an abnormal connection) between the urethra (the tube that carries urine out of the body) and the vagina, having surgery to remove a sac or pouch in the wall of the urethra (known as urethral diverticulectomy), or if they need to have mesh that has moved inappropriately taken out.
Equipment used for Pubovaginal Sling
There are several different options currently available for pubovaginal sling (PVS) surgery. These include materials that are synthetic, autologous (from the patient’s own body), xenograft (from an animal), and allograft (from another human). The best material for the sling is one that can mesh with the patient’s own tissue and provide long-lasting support underneath the urethra. The choice depends on both the patient’s specific situation and the surgeon’s experience.
Synthetic materials and other biomaterials have gained popularity because they reduce the length of the surgery and the recovery time needed after the operation. However, materials from the patient’s own body have been considered the best option for PVS surgeries. This is because they cause fewer reactions related to inflammation and foreign bodies.
Some of the most common materials that can be used include the fascia (a band of connective tissue) from the rectus abdominis (abdominal muscle) and the fascia lata (a band of tissue on the outer thigh).
Before surgery, a decision needs to be made about which type of pubovaginal sling will be put into position. The surgeon needs to ensure that the hospital or surgical center has the chosen product available if a synthetic, animal, or human cadaveric sling will be used.
Who is needed to perform Pubovaginal Sling?
The procedure to place a pubovaginal sling, which is a treatment for urinary incontinence, can be done by either a urologist (a doctor specializing in the urinary system) or a gynecologist (a doctor specializing in the female reproductive system). Most often, these doctors will also work alongside experienced medical assistants to best ensure a successful operation. Medical device sales representatives, who are specialists in the specific tools used during surgery, are often present in the operating room as well. They provide expertise and guidance to the medical team, especially if any issues arise with the devices being used.
Preparing for Pubovaginal Sling
According to the latest guidelines from the American Urological Association (AUA) in 2017, if a woman is considering surgery to correct Stress Urinary Incontinence (SUI) – an issue that causes unintentional urine leakage – she should first undergo a thorough health checkup. This includes giving information about her symptoms, having a physical checkup, including an intensive pelvic exam, a urine test, and an assessment to examine how much urine is left in the bladder after she urinates. The doctor will get to know how much the issue is bothering her by using specific questionnaires. The pelvic examination will include tests such as the Valsalva stress test or a cough test to confirm the presence of SUI, and these tests will be conducted when the patient’s bladder is comfortably full.
When explaining the upcoming surgery, doctors need to educate patients about the common risks involved in any surgery and the particular complications that may arise from placing a sling—a medical device used to support the bladder. The awareness regarding the possible issues of using a synthetic mesh—a material used in surgeries—has grown due to the attention it has received from the media. Therefore, it’s crucial to tell women patients about the serious complications and the permanent nature of synthetic mesh. After the sling placement, doctors must inform the patients about the possible changes in urination such as new-onset urgency, frequent urination, and difficulty in emptying the bladder entirely (urinary retention).
The AUA, in its 2019 recommendations, mentioned that all patients undergoing urethral sling procedures should receive a single pre-surgery dose of either 1st or 2nd generation cephalosporins—types of antibiotics. Additionally, the decision to give medicine to prevent deep vein thrombosis or blood clots in patients who are undergoing incontinence surgery needs to be determined based on individual patient risk and the specific surgical procedure.
How is Pubovaginal Sling performed
Before surgery begins, you will be given antibiotics. This is done to prevent infections. Depending on the type of surgery, you might be put to sleep using general anesthesia or you will feel no sensation from your waist down via spinal anesthesia. Once you’re properly anesthetized, you will be placed in a position that helps to prevent any nerve injuries in your lower extremities (legs).
If natural tissues from your thigh (called autologous fascia lata) will be used in the procedure, your knee on this side will be lifted, turned inward at the hip, and secured. The key anatomical marks around your thigh will be clearly marked for precision.
Usually, a standard-sized tube (Foley catheter) is inserted into your bladder to help it drain. To help the surgeon see better, you might be placed in a position with your feet raised higher than your head (moderate Trendelenburg position). Afterward, a specially designed instrument (weighted speculum) is placed into your vagina and a ring-shaped retractor used to hold back your labia majora.
The surgeons would then move to get the needed tissue (fascia). They could get this from either just above your pubic bone, being careful not to harm your ilioinguinal and iliohypogastric nerves, or from your thigh. Once the needed tissue is obtained, the incisions made would be closed.
Saline solution (sterile water) is then used to prepare the vaginal wall before creating a surgical flap. By injecting it into the middle of your urethra and bladder neck, the surrounding tissue swells up, making it easier to operate on. After securing the surgical site, their first cut is usually made about an inch below where you urinate from (urethral meatus). This cut would run upwards towards your bladder neck.
Using special surgical scissors, they would then create thick vaginal flaps. After this, another special surgical instrument is inserted into the site and the surgeon uses their fingers to feel their way around the area, carefully creating space for the surgery.
A needle is then used to pass the sutures (a type of surgical thread) from your abdomen to your vagina. The surgeon will use a special camera (cystourethroscope) to make sure the needles are in the right place and have not accidentally pierced your bladder. If your bladder has been pierced, the needle can be repositioned with the help of real-time images from the camera.
Sutures are then used to pass the sling from the abdominal incision. The sling is then attached to the tissue near your urethra. The incision made is closed, and the sling attached to the abdominal wall, while leaving enough space for movement. Finally, the surgeon would then close the first incision made on your abdomen. Every stitch made is usually in the surgeon’s preferred style.
Possible Complications of Pubovaginal Sling
Advances in technology have helped reduce problems related to PVS (Pelvic Organ Prolapse) surgery. According to research by Chan and colleagues, about 19% of patients experienced minor complications in the short term after PVS surgery. This includes problems such as difficulty urinating, infections at the cut site, and accidental cuts to the bladder during surgery.
Some other potential issues from PVS surgery might include accidental damage to the urinary tract or bowels, heavy bleeding, mesh exposure (the mesh is a supportive device used in the surgery), infections of the surgical implants, changes in urination, inability to urinate, and urinary tract infections (UTIs).
While most of these complications can be solved easily and are temporary, a few can be more challenging to deal with. For example, erosion and accidental damage to organs might require more surgeries and can pose an increased health risk to patients.
What Else Should I Know About Pubovaginal Sling?
PVS, or Pubovaginal Sling, operation is crucial to prevent incontinence – a medical term for loss of bladder control. It does this by increasing support to the tube that carries urine out of the body during strain. Furthermore, this operation helps to bring back normal urination by establishing a sort of “seal” in the urethra. This seal plays a key role in the natural process of passing urine.
