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Biologic Slings Indications & Techniques in 2012

Biologic Slings Indications & Techniques in 2012. Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University Adjunct Professor of Urology SUNY Downstate Medical School. Or,. Do you really still do biologic slings? If so, why? When? With what ?

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Biologic Slings Indications & Techniques in 2012

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  1. Biologic SlingsIndications & Techniques in 2012 Jerry G. BlaivasClinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University Adjunct Professor of UrologySUNY Downstate Medical School

  2. Or, Do you really still do biologic slings?If so, why? When? With what ? And how?

  3. Zenograft • porcine SIS • porcine dermis • bovine pericardium • Autograft • rectus fascia • fascia lata • Allograft • Fascia lata • Dermis • Dura mater

  4. Cartoon of taking fascia

  5. Balloon Incision

  6. Push up withindex finger onvaginalwall Traction ofclamp

  7. Left index finger pushing up on vaginal wall Shiny white surface superficialto pubo-cervical fascia

  8. Right wrist flexed downward

  9. Incorrect (deep) plane Correct (superficial) plane

  10. Correct (superficial) plane Pubo-cervical fascia Incorrect (deep) plane

  11. Index fingerbetween clamp& urethra &bladderat all times

  12. Inferior edge of rectus Separate Fascial incision Separate stabwound for sling

  13. Sutures through separate stabwounds in rectus fascia Ends of sling thru fascia

  14. How much tension? • None (create a backboard) • (Almost) can’t make it too loose • Make sure Q-tip is not negative(elevation of vesical neck)

  15. Take slack out ofsling Push down on cystoscope parallel to thefloor

  16. Tie loosely with no tension

  17. URINARY INCONTINENCE OUTCOME SCORE • Groutz & Blaivas, Neurourol & Urodyn 19:127, 2000

  18. Urinary Incontinence Outcome Score

  19. PVS for Simple & Complex SUI OUTCOME SCORE 93% 7%

  20. PVS for Simple SUI OUTCOME SCORE 100% 0%

  21. Mixed Incontinence • Cure/Improved Rates (UIOS <= 4) : • SUI: 97% (n= 44) • MUI: 93% (n= 47)non-significant difference (p: 0.33), with study powered a priori to detect > 20% difference in outcome score Chou et al, J Urol, 2003

  22. Autologous Sling Outcomes • Cure/Improve rate - 82% at 4 years • Urinary Retention requiring intervention - 8% • De Novo OAB - 9% Dmochowski, AUA Guidelines on the Surgical Management of SUI, 2010

  23. Insert leach data • Complications from zenografts

  24. Conclusions • Pubovaginal sling effective for: • Urethral hypermobility • Intrinsic sphincter deficiency • Mixed incontinence • Long lasting results • Minimal morbidity

  25. Autologous Fascia vs Synthetics: • Pros: • well documented long term success • no erosions • rare adjacent organ injury, serious complications, refractory pain • Cons • Greater short term morbidity: urethral obstruction, wound inf, hernia, etc • Longer learning curve for surgeon

  26. The Gold Standard: AFPVS • AFPVS has (almost) no life-style altering complications: • intractable pain • erosions • vaginal extrusions • There are 2 absolute indications: • recurrent sphincteric incontinence after urethral erosion of synthetic sling • concomitant sling & urethral diverticulectomy

  27. The Gold Standard: AFPVS • Strong indication – whenever bladder neck sling is needed • “pipe-stem urethra” • no urethral mobility • So, AFPVS or mid-urethral synthetic sling? • You decide!

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