Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center...

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

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Page 1: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Sling Failures

Jerry G. Blaivas, MDClinical Professor of Urology Weil-Cornell Medical Center

Adjunct Professor of UrologySUNY Downstate Medical Center

Page 2: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 3: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 4: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

• Clinical:– De-novo symptoms

• Weak stream• OAB• negative Q-tip angle

• Urodynamics:– High detrusor pressure / low flow:

pdetmax > 20 cm H20Qmax < 12 ml/S

– Blaivas Groutz nomogram

Urethral Obstruction

Page 5: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

- 45O

Page 6: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

MSCO

MSCO

High pressure (pdetmax = 75)

Low flow (0)

Page 7: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Blaivas - Groutz Nomogram

0

20

40

60

80

100

120

140

160

0 10 20 30 40 50Free Qmax (ml/ sec)

pdet

.max

(cm

H2O

)

Moderate obstruction (2)

Severe obstruction (3)

Mild obstruction (1)

Unobstructed (0)

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

Page 8: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

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

Page 9: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Rx of Post op Urinary Retention

• ? Need for further workup

• Q-tip

• cystoscopy

• urodynamics

Page 10: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Surgical Rx of Sling Obstruction

• Sling incision• midline• lateral

• Urethrolysis• antero-lateral• circumferential • +/- Martius flap

interposition• Technique determined intraop

Page 11: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 12: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 13: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 14: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

N Type Success % SUI %

Nitti, et al 19 Midline Incision 84% 17%

Amundsen, et al

32 Various 94% 9%

Goldman,et al

14 Midline Incision 93% 21%

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

Page 15: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Urethrolysis

• Vaginal

• Supra-meatal

• Retropubic

Page 16: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 17: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 18: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 19: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 20: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Circumferential Urethrolysis

Page 21: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Urethrolysis

• Vaginal

• Supra-meatal

• Retropubic

Page 22: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 23: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 24: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 25: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 26: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Urethrolysis

• Vaginal

• Supra-meatal

• Retropubic

Page 27: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Urethrolysis Results

N Type Success % SUI (%)

Foster & McGuire48 Transvaginal 65% 0%

Nitti & Raz 42 Transvaginal 71% 0%

Cross, et al 39 Transvaginal 72% 3%

Goldman, et al 32 Transvaginal 84% 19%

Petrou, et al 32 Suprameatal 67% 3%

Petrou & Young 12 Retropubic 83% 18%

Carr & Webster 54 Mixed 78% 14%

Page 28: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 29: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 30: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Bladder neck

Bladder neck

Eroded mesh

Page 31: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

VLPP

Page 32: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 33: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Treatment of Erosions.

• remove as much of sling as possible

• closure of the urethra

• +/ - urethral reconstruction

• +/ - biologic sling

• +/ - Martius flap

Page 34: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 35: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 36: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Too Loose

Intrinsic sphincter deficiency

Urethral hypermobility

Recurrent sphincteric incontinence

Page 37: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

VLPP

AGAGAG

VLLP = 92 cm H20Qtip = 0 > 60O

Page 38: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

AG

Page 39: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

JK

VLPP = 42 cm H20Q tip = 0

Page 40: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.
Page 41: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Treatment of Recurrent SUI

• no compelling data

• for hypermobility, surgeon choice

• for poorly mobile or pipe - stem urethra, biologic bladder neck sling

Page 42: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 43: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Wrong Position

• Too far proximal – persistent sphincteric incontinence

– urethral obstruction– ureteral injury

• Too far distal – persistent sphincteric incontinence

– urethral obstruction

– urethral hypermobility

Page 44: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

MS

VLPP = 35 cm H20

Sling proximal to BN

Page 45: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

sling

Page 46: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

MSCO

High pdet

No flow

Page 47: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

MSCO

Page 48: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

MSCO

Page 49: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 50: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

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

Page 51: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center.

Conclusion• Complications & failures after

incontinence surgery are not uncommon

• Early evaluation to rule out remediable causes should be undertaken– UTI– Urethral obstruction – sling erosion– foreign body

• A successful outcome is likely in the majority of patients


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