Autologous (fascial) sling
An autologous sling is a retropubic sling made from the patient’s own fascia; it is harvested from either the fascia lata of the lateral thigh or the rectus fascia of the abdomen. The sling is placed beneath the urethra in the bladder neck region, and sutures affixed to the sling edges pass behind the pubic symphysis and through the abdominal fascia to anchor it in place.
Choose a sling based on the clinical situation and patient goals
Consider the unique features of each sling when selecting the proper sling; this should be a shared decision with the patient after thorough counseling. Below, we present 4 clinical cases to exemplify scenarios in which different slings are appropriate, and we review the rationale for each selection.
CASE 1 SUI that interferes with exercise routine
Ms. P. is a 46-year-old (G3P3) active mother. She loves to exercise, but she has been working out less frequently because of embarrassing urinary leakage that occurs with activity. She has tried pelvic floor exercises and changing her fluid intake habits, but improvements have been minimal with these interventions. On evaluation, she has a positive cough stress test with a recently emptied bladder and a normal postvoid residual volume.
What type of sling would be best?
Because this patient is young, active, and has significant leakage with an empty bladder, a sling with good long-term treatment success is likely to provide her with the best results (Figure 1). We therefore offered her a retropubic midurethral sling. The retropubic approach is preferred here as it is less likely than the transobturator sling to cause groin/thigh pain, which is an important consideration in this young, active patient.
Further testing is not needed
For women with uncomplicated SUI who demonstrate leakage with stress (coughing, Valsalva stress test) and who have a normal postvoid residual volume, additional testing, such as urodynamic evaluation, is not necessary.12 These patients can be counseled on the range of conservative management options and as well as surgical inventions.
CASE 2 Return of SUI symptoms after transobturator sling placement
Ms. E. is a 70-year-old woman who had a transobturator sling placed 5 years ago. Initially, her SUI symptoms improved after surgery. Recently, however, she noticed a return of her SUI, which she finds bothersome and limiting to her quality of life.
How would you manage this patient?
While midurethral slings are highly effective, there are instances in which patients will have symptom recurrence. For women who already have a midurethral sling, consider the following important questions.
Is this truly recurrent SUI, or is it a new process?
Like any reconstructive procedure, midurethral sling success rates decline over time and recurrent SUI can develop.7 However, it also is possible for urge urinary incontinence to develop as a new process, and it is important to distinguish which type of urinary incontinence your patient has prior to counseling about treatment options.
To further evaluate patients with recurrent incontinence and a prior sling, we recommend urodynamic studies with cystoscopy (in addition to a detailed history and physical exam). This not only helps rule out other forms of incontinence, such as overactive bladder, but also evaluates for possible mesh erosion into the urethra or bladder, which can cause irritative voiding symptoms and incontinence.
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