SLING SURGERY WITH CONCOMITANTANTERIOR REPAIR PERFORMED THROUGH THE SAME INCISION: IS THERE ANIMPACT ON SLING LOCATION?
A. HEGDE1, N.CHANDRASEKARAN 2, V. AGUILAR 3, G. DAVILA 2;
1CENTER FOR UROGYNECOLOGY AND PELVIC HEALTH, NEWDELHI, India, 2Cleveland Clinic Florida, Weston, FL, 3UTSWat Austin, Austin, TX.
Introduction: In transobturatorsling surgery, proximal sling location has been found to beassociated with poor outcomes (1). Patients with POP and SUIfrequently undergo sling placement with concomitant anterior repair.Previously we have shown that patients who undergo transobturatorsling surgery, with concomitant anterior repair performed through thesame incision, are more likely to have the sling located moreproximally when compared with patients who undergo sling surgeryalone (2).
Objective: To compare the location of thetransobturator sling, retropubic midurethral sling and pubovaginalsling at rest, as seen on 3 dimensional endovaginal ultrasound (3DEVUS) one year following sling surgery, in patients who underwentconcomitant anterior repair through a single incision.
Methods:This is a retrospective cohort study of 109 patients who underwentsling surgery for SUI and concomitant anterior repair through thesame incision at our center in 2010 - 2013. Group A consisted of 50patients who underwent transobturator sling surgery (MonarcTM,American Medical Systems, Minnetonka MN), group B consisted of 29patients who underwent retropubic midurethral sling surgery (TVT,Ethicon, Bridgewater, NJ) and group C included 30 patients whounderwent pubovaginal sling procedure during which the tape wassuture-fixated to the proximal urethra (I-STOP, CL Medical, Lyon,France). In groups A and B, the sling was not suture- secured to themidurethra. 3D EVUS of the anterior pelvic compartment was performedwith the 8848 transducer (BK Medical Profocus Ultraview, Peabody, MA)at the one year follow-up visit by a fellow who was blinded to thetype of sling surgery done. The 3D volumes obtained were analyzed todetermine the location of the sling along the urethral length in themidsagittal view (figure 1). The urethra was divided into three equalparts: proximal, mid and distal urethra and the position of the slingsuburethrally was determined (proximal, proximal-mid, mid, mid-distaland distal). The tape percentile (distance of the midpoint of thesling from the urethrovesical junction divided by the urethrallength) was calculated. The number of patients that had the sling inthe desired position was compared between the three groups.
Results:The three groups matched with respect to their demographic data ofage, BMI, parity, smoking history and menopausal status (p >0.05). The median weeks of follow-up were also similar between thetwo groups (p > 0.05). The tape location in the three groups wasas seen in table 1. When group A was compared with group B, theoverall sling location was similar (p = 0.881). The tape location ingroup A was more proximal than that in group B when the tapepercentile was considered, however it was not statisticallysignificant (p = 0.2441). The odds for the three slings to be foundin the desired location are as given in table 2.
Conclusions:The odds of finding the midurethral retropubic sling in the desiredlocation, when concomitant anterior repair is performed through thesame incision, are significant and higher than that with thetransobturator sling. The pubovaginal sling has the highest odds ofbeing in the desired location, possibly because of the suturefixation of the sling and easier definition of the correct locationusing the bulb of the indwelling Foley’s catheter.
References:1. Int Urogynecol J Dec 2016 [Epub ahead of print]2. Int Urogynecol J2014 suppl (1): s152 - s153.
Table1: Location of the sling relative to the urethra in the threegroups
GroupA (n = 50) n (%)
GroupB (n = 29) n (%)
GroupC (n = 30) n (%)
Locationrelative to the urethra
Proximalto urethrovesical junction
Tapepercentile Median (interquartile range)
*FisherExact test; ^Mann Whitney U test
Table2: Odds Ratio for the sling to be in the desired location
GroupA (n = 50)
GroupB (n = 29)
GroupC (n = 30)