Flawed methodology in the few randomized, controlled trials that have compared the pubovaginal sling with the tension-free vaginal tape (TVT) has cast doubt on their findings.
When placing an autologous pubovaginal sling in the setting of urethral reconstruction or as tissue interposition, harvest the fascia and prepare and deploy the sling (with passage of the retropubic sutures) before reconstructing the urethra--but refrain from tensioning until after the reconstruction is completed.
When considering which sling type to use for which incontinent woman, the published data demonstrates excellent results for both synthetic mesh (retropubic or transobturator routes) and fascial pubovaginal slings for most patients.
In the past, retropubic colposuspensions and pubovaginal slings (PVS) with autologous fascia were the primary surgical modalities used to treat SUI; however, over the last 20 years, far fewer of both procedures have been performed, as the therapeutic technology for treating SUI has advanced to include synthetic material.
If a patient fails a first pubovaginal sling
for incontinence "please don't be hesitant to include [a repeat sling] in your options.
MUS: midurethral sling; SUI: stress urinary incontinence; BMI: body mass index; DO: detrusor overactivity; PVR: post-void residual volume; MUCP: Maximum urethral closure pressure; ICIQ: International Consultation on Incontinence (short form); OAB: overactive bladder; IVS: intravaginal sling; TVT-O: trans-vaginal tape-obturator; UTI: urinary tract infection; CISC: clean intermittent self-catheterization; PVS: pubovaginal sling
A Cochrane review concluded that MUS have similar efficacy to traditional pubovaginal slings
, but with the advantages of shorter operating time, less postoperative voiding dysfunction, and fewer de novo urgency symptoms.
Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings
, and midurethral tapes in the surgical treatment of female stress urinary incontinence.
The 14 chapters describe the etiology and epidemiology of urinary incontinence; selecting interventions for the diagnosed type; anatomy; standard retropubic operations, including the Burch and paravaginal repairs; bladder neck biologic pubovaginal slings
and aspects of tissue harvest and selection; synthetic midurethral slings; voiding dysfunction and retention after procedures; the current status of bulking agents, especially techniques for implantation; surgical interventions for detrusor compliance abnormalities, especially sacral nerve stimulation, botulinum toxin therapy, and bladder augmentation; and the management of mixed incontinence and that associated with pelvic organ prolapse and how to avoid and manage complications related to procedures for stress incontinence.
Compared with pubovaginal slings
, which are fixed at the bladder neck, midurethral slings are associated with less postoperative voiding dysfunction and fewer de novo urgency symptoms.
In the early days of midurethral pubovaginal slings
using polypropylene, the adage was "looser is better than tighter.
These types of pubovaginal slings
are no longer used for urinary SUI due to the above-mentioned complications and are no longer commercially available.