low urethral resistance with decreased bladder compliance.
urethral incompetence and large urethral diverticulum.
urethral incompetence in a T12 spinal cord injury.
proximal urethral loss secondary to long-standing indwelling Foley catheter.
refractory stress urinary incontinence (SUI) after failed midurethral sling and bulking agents.
The female urethra is composed of four separate tissue layers, and the middle seromuscular layer is most important in enhancing the urethral sphincter mechanism during voiding.
The Valsalva pressure of the bladder exceeds the resting closing pressure of the internal sphincter.
The levator ani, urethropelvic ligament, and round ligament provide needed support to the bladder neck and undersurface of the bladder.
The PVS is placed at the bladder neck to provide adequate urethral coaptation at rest and to decrease urethral responsiveness to abdominal pressure.
The fast-twitch fibers of the external sphincter are responsible for sudden voluntary guarding reflex, and slow-twitch fibers provide passive control through the involuntary guarding reflex.
Porcine small intestinal submucosa has less tensile strength than cadaveric fascia lata.
The ideal material has minimal tissue reaction and complete biocompatibility.
The estimated risk of human immunodeficiency virus (HIV) transmission by an allograft sling is about 1 in 1,660,000.
Stiffness and maximal load failure are the same between freeze-dried fascia lata and solvent dehydrated and dermal grafts.
Synthetic materials are associated with high erosion rates during use for bladder neck PVS.
(c) Bladder neck PVS slings should be utilized for refractory or recurrent SUI but are associated with worse outcomes.
(d) In the SiSTER trial, cure rates and voiding symptoms were greater for the pubovaginal sling than for the Burch colposuspension.
a and d
(b) Preoperative Valsalva leak point pressure is a reliable predictor of outcomes after sling surgery.
(a) Reported cure rates after an autologous PVS procedure are 50% to 97%.
There are only four cases of urethral erosion of an autologous PVS in the literature, and in most cases this may have been avoided by thorough cystoscopy.
Synthetic slings erode into the urethra 15 times more often than autologous, allograft, or xenograft slings.
Urethral erosions are often associated with urinary retention and mixed urinary incontinence.
The incidence of recurrent SUI in urethral erosions after use of a synthetic PVS is 74% to 100%.
Erosion from synthetic slings requires removal of all visible and palpable sling material.
There is up to a 20% recurrent SUI rate after urethrolysis.
Urodynamic study is valuable in assessment and planning management.
Persistent urgency is more common than urinary retention in bladder outlet obstruction after a PVS procedure.
Obstruction, detrusor overactivity, or impaired detrusor contractility are all manifestations of voiding dysfunction for iatrogenic PVS obstruction.
Fifty percent of affected patients have symptoms of overactive bladder, which can be avoided if sling lysis is performed within 2 weeks of PVS placement.
ISD is the primary underlying cause of SUI for women, with hypermobility being a secondary finding.
hypermobility is the main underlying cause of SUI.
the extrinsic urethral skeletal sphincter is the primary mechanism for urinary continence.
the levator floor provides active compression to the proximal urethra.
intrinsic sphincter deficiency (ISD) is rarely the primary cause of SUI.
the midurethral mechanism is intrinsically involved with bladder neck support.
the pubourethral ligaments and pubococcygeal muscles provide a central support point that, during stress events, function to kink or functionally hinge the urethra, rendering continence.
aging and childbirth have no effect on the midurethral support structures.
the midurethral continence mechanism is active both passively and during stress events.
the pubourethral ligaments are a secondary component of the complex.
cystoscopy is a crucial component of the procedure.
the sling is sutured to the underlying tissues for fixation purposes.
insertion trocars are used to transpose the implanted material into position.
loose tension is placed on the sling material.
the synthetic material used is a wide porosity mesh.
Postoperative voiding dysfunction is more common with midurethra procedures than with other types of suspension procedures.
Midurethral slings are less effective than open colposuspension procedures.
Five-year results demonstrate durability similar to 1-year results.
Midurethral slings produce inferior results compared with laparoscopic colposuspensions.
Mixed incontinence results are superior to those of pure SUI.
result in postoperative urinary retention occurring more frequently.
are less effective than in younger patients.
have rates of postoperative urgency higher than those in young patients.
have satisfaction rates lower than those in young patients.
have mixed incontinence resolution rates higher than those in young patients.
concomitant hysterectomy has an adverse effect on incontinence outcome.
occult incontinence is not adequately addressed.
rates of retention are slightly higher than in those undergoing a sling procedure only.
risks of erosion and infection are higher than in cases in which only a sling is performed.
rates of urethrolysis for postoperative retention are higher.
failure rates are unaffected by urethral hypermobility.
bladder perforation is less than in primary cases.
overall efficacy is similar to that of primary implantation.
the technique needs to be altered when done as a primary procedure.
complication rates are higher than when midurethral slings are done primarily.
de novo urgency occurs in up to 12% of patients.
bladder perforation injury rates range up to 5%.
all of the above.
voiding dysfunction ranges from 4% to 20%.
wound healing is delayed in approximately 1%.
decreased by the macroporous nature of the sling material.
associated with bladder erosion rates of 20%.
associated with vaginal erosions approximately 20% of the time.
do not affect outcomes or satisfaction.
unaffected by tension placed on the slings.
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