PUBOVAGINAL SLING OPERATION
What is it?
A Pubo-Vaginal Sling is an operation for the treatment of stress incontinence.
What is Stress Incontinence?
Stress incontinence refers to leakage of urine associated with activities like coughing, sneezing, laughing, lifting or even walking or standing. Stress incontinence results from either weakness of the supports of the urethra (urethral hypermobility – Type II Stress Incontinence) or an actual weakness of the sphincter muscle in the wall of the urethra (Intrinsic Sphincter Deficiency – Type III Stress Incontinence). Which type you have is determined by your history, examination finding and the results of Fluoroscopic Urodynamic Studies. A pubo-vaginal sling is an effective treatment for both Type II and Type III Urinary but more likely to be the preferred option for Type III stress incontinence.
Stress Incontinence
Stress incontinence is different to incontinence due to urgency (Urge Incontinence). Urinary urgency is a strong desire to pass urine that is difficult to postpone. You may have a combination of different types of incontinence.
What is done?
The procedure involves both an abdominal and a vaginal incision (or cut).
Through the abdominal incision a strip (about 9 x 1cm) of your Rectus Fascia is removed to make the sling. The Rectus Fascia is the tough covering over your abdominal muscle, Rectus Abdominus. (The fascial defect created is later sutured closed).
The urethra is the tube from the bladder through which urine passes out of. The sling is placed via the vaginal incision around the first part of the urethra (the bladder neck). The sling is suspended on strong sutures that are passed up internally through the pelvis (behind the pubic bone), and then tied together over the Rectus Fascia.
It works by allowing the urethra to be closed/supported both at rest, and also with straining. With straining or any rise in abdominal pressure the sling pulls the urethra up and forward as the bladder is pushed down and back, preventing leakage of urine.
What are the alternatives?
There are non-operative treatments for stress incontinence such as bladder training and pelvic floor exercises. There are minor operations such as ‘injectables’. There are also other types of surgery for stress incontinence. The pubovaginal sling is considered by many as the operation of choice for women with Type III stress incontinence. It is also, as other operations (e.g. Burch colposuspension or TVT tape), available for the treatment of Type II stress incontinence.
Will it work and for how long?
Following this operation most patients with stress incontinence will be dry or significantly improved. The operation has a 92-95% success rate at 5-10 years[1, 2]
What is the post-operative course?
The average hospital stay is 3 days.
It is usual following surgery to have some spotting, bleeding or discharge from the vagina. This usually stops by about 3 weeks. When this has stopped and the vaginal wound has healed you can have sexual intercourse, as comfortable (usually by 3 weeks). Also avoid using tampons until after this time.
It is usual to have some wound pain post-operatively but this mainly resolves by 6 weeks. Usually this is controlled with paracetamol. You can take up to 2 paracetamol every 4 hours to 6 hours (maximum 8 per day). Some patients describe occasional discomfort from their abdominal wounds for up to 12 months following surgery. Up to a third of patients have some difficulty completely emptying their bladder initially. This is managed by learning to pass a small catheter via the urethra to empty the bladder, (Intermittent Self Catheterisation). You will be taught how to do this, usually before your operation. How often, and how long, this is required varies between patients. Most patients do not need to do this for more than 4 weeks but can be required for 12 weeks or longer. It is important to do this and therefore prevent the bladder from becoming over-distended as this may delay the return of voiding to completion even more. Intermittent self-catheterisation is usually performed until the postvoid residual is < 100ml.
About 2% of patients can have permanent or prolonged post-operative retention of urine.[3] These patients may then require another minor operation to loosen or divide the sling and its sutures to be able to void again without passing a catheter. This does not usually result in the return of stress incontinence. The risk of permanent retention that cannot be reversed with further surgery requiring permanent catheterisation is very rare.
Some patients with stress incontinence also have an urgency to pass urine. After stress incontinence surgery this urgency will get better in most patients, (75%).[3]
Urinary urgency can occur as a new symptom in some patients after stress incontinence surgery, (3-10%), and can be severe enough to even result in urge incontinence, (an urgent desire to pass urine followed by leakage of urine). Although some studies have reported that new post-operative urgency is more common with a sling operation than with other stress incontinence procedures, this has not been supported by other studies findings. We can not accurately predict which patients will get resolution of urgency post sling operation. The risk of making your incontinence worse after surgery is very rare.
Other instructions for when you go home.
It takes about 4-6 weeks to return to normal activity.
It is important during to avoid any straining, heavy lifting or strenuous activity for up to 12 weeks as this could break the sling or wound sutures. If the sling breaks stress incontinence may recur.
Pelvic Floor Exercises.
You should learn pelvic floor exercise and optimise your pelvic floor muscle strength prior to surgery. Pelvic floor exercises can cure stress incontinence in some women and avoid the need for surgery. Learning to contract you pelvic floor during activities will help protect your pelvic floor for life. You can recommence these about 6 weeks after surgery when comfortable and healing has occured. Physiotherapists or continence nurses can assist with pelvic floor education and an exercise program.
What are the other risks and complications?
There are general medical risks of abdominal, cardiovascular (heart), and pulmonary (lung) illnesses; 2-5%. These include Deep Vein Thrombosis (blood clots in deep leg veins),
Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke).
There is a small risk of death; 5 in 10,000.
There is a small risk of bleeding requiring a blood transfusion; 3-5%.
Injury to the bladder, urethra or ureter is uncommon; 1-6%. If the bladder is perforated the sling is repositioned and the catheter needs to remain in for 5-7 days
Bowel, nerve or vascular injuries are rare.
There is a small risk of urine infection, wound infection, wound breakdown, haematoma (collection of blood) or seroma (collection of fluid) post-operatively; 5-10%.
Other rare complications include a significant pelvic haematoma (collection of blood), infection or abscess, a urinary fistula (leak). Sling erosion into the urethra or vagina is very rare as this is a natural, not a synthetic sling.
Overall, the risk of complications requiring further surgery is 2-5%.
There is a risk of pain related to the sling or the sling sutures. It is quite common to feel a pulling sensation in either groin for 1-5 weeks after the procedure. This is usually temporary and rarely persists. [4]
Also 2-13% of patients have reported bladder or pelvic pain, sexual dysfunction or pain on intercourse after this procedure.
Many patients notice passing urine is different after a sling operation. The flow of urine may be slower and take a longer time to empty. Some patients bend forwards or even stand to pass urine. This may mean the sling needs loosening.
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
How long does the operation take?
About one and a half hours.
Post-operative follow-up.
You will be given a follow up appointment.
If you experience any of the following problems after discharge you should seek medical attention;
- Severe pain not controlled with pain killers
- Bleeding
- Wound problems – infection or breakdown
- Inability to pass a catheter if required
- Or any other significant trouble.
If at any stage your incontinence returns you should arrange a review visit.
Note - After a sling operation both normal vaginal and caesarean section are feasible without damage to the sling but if anticipated it should be discussed with your surgeon prior to sling surgery to allow planning of the time of your surgery to get optimal results.
References
1. Gormley, E.A., et al., Pubovaginal slings for the management of urinary incontinence in female adolescents. J Urol, 1994. 152(2 Pt 2): p. 822-5; discussion 826-7.
2. McGuire, E.J., et al., Experience with pubovaginal slings for urinary incontinence at the University of Michigan. J Urol, 1987. 138(3): p. 525-6.
3. Morgan, T.O., Jr., O.L. Westney, and E.J. McGuire, Pubovaginal sling: 4-YEAR outcome analysis and quality of life assessment. J Urol, 2000. 163(6): p. 1845-8.
4. O'Donnell, P.D., URINARY INCONTINENCE. 1ST ed, ed. S. BAXTER. 1997: PATTERSON, A. S. 474.
Version: V4, July 2017
