A transvaginal sling procedure with bone anchor fixation

TRANSVAGINAL SLING USING ACELLULAR HUMAN DERMAL ALLOGRAFT: SAFETY AND EFFICACY IN 253 PATIENTS

PURPOSE

We evaluated the safety and efficacy of using human dermal allograft material for transvaginal slings to treat female stress urinary incontinence (SUI).

MATERIALS AND METHODS

We present a prospective series of 253 patients with SUI treated with a transvaginal sling using a Repliform cadaveric human dermal allograft (LifeCell Corp., The Woodlands, Texas) and a bone anchor fixation kit. Clinical history, urogynecologic examination and videourodynamics were performed preoperatively. Results were assessed by a third party through validated quality of life questionnaires (Incontinence Impact Questionnaire and Urogenital Distress Inventory), overall impression and percent of improvement as perceived by the patients, and pad use. Scheduled followup examination were performed to rule out erosion, infection, obstruction, pain or recurrent incontinence.

RESULTS

Complete followup was available on 234 of 253 patients. Average followup was 18 months. Of the patients 78% were cured or improved according to the questionnaires. The average improvement was 80%. At 18 months of followup incontinence average distress and scores decreased 10 and 7 points, respectively. Complications were de novo urgency in 5% of cases, recurrent SUI in 15% with no cases of persistent SUI, retention in 2% and slow vaginal wall healing in 1.7%. Of 156 patients 51 (22%) had persistent urgency. There were no cases of vaginal or urethral erosion, osteitis pubis or osteomyelitis.

CONCLUSIONS

Our data indicate that use of human dermal allograft for transvaginal slings is associated with low complication rates and favorable outcomes at an average of 18 months of followup.

Incidence of pubic osteomyelitis after bladder neck suspension using bone anchors

OBJECTIVES

To determine the incidence of pubic osteomyelitis after bladder neck suspension using suprapubic bone anchors.

METHODS

The target population consisted of 290 consecutive women who underwent bladder neck suspension using suprapubic bone anchors between June 1994 and November 1999 at two referral centers. A structured telephone questionnaire was designed to elicit any history of clinical symptoms suspicious for pubic osteomyelitis. Positive responses were followed up by a detailed review of the medical records. Nonresponders were evaluated by chart review, with negative cases included only if the documented follow-up reached 1 year.

RESULTS

The sample consisted of 225 women, representing 77.6% of the study population, with a mean age of 69.7 years (range 40 to 88) and a mean follow-up of 31.8 months (range 13.4 to 42.2). Of the 225 women, 179 (80%) completed the telephone survey; 46 patients (20%) were evaluated by long-term chart review. Three patients (1.3%) reported positive responses to the screening questionnaire and were confirmed to have developed pubic osteomyelitis. Each had undergone exploratory laparotomy, anchor removal, bony debridement, and prolonged parenteral antibiosis. The most common noninfectious complaints were irritative voiding symptoms and pubic or groin pain responding to "conservative" therapy (3.5%), including 1 case of osteitis pubis. One subject underwent repeated operation because of erosion of the sling sutures into the bladder.

CONCLUSIONS

The estimated incidence of osteomyelitis after bone-anchored bladder neck suspension was 1.3%. Although postoperative osteomyelitis is rare, each case incurs substantial morbidity and a complicated postoperative course.

[Urethrocystopexy with bone anchors: technical modification]

OBJECTIVE

To communicate a technical modification of urethrocystopexy which consist in the suspension of the urethropelvic ligaments to the posterior pubic bone with using bone fixations inserted with the In-Fast system.

MATERIAL AND METHODS

Between August 2000 and January 2001, thirteen patients with an mean age of 56.1 years were operated with this technic. Using a transvaginal approach and after great opening of the endopelvic fascia we insert one fixation screw in each side of the symphisis pubic bone, later we give two or three stitches to the urethropelvic ligament with the polypropylene no. 1 suture that each screw have joined to their end.

RESULTS

The mean stay has been 5.1 days. The cystostomy has been remained for a mean of the 10.1 days. We didn't observe any complication neither intra nor postoperatives. With a mean follow-up of 5.3 months all the patients present a disappearance of their stress incontinence.

CONCLUSIONS

Lack of confirm with a larger following and more cases, the suspension of the urethropelvisc ligaments with screw fixations directly situated into the pubic bone per vaginal approach, has been a simple method, safe and highly comfortable for the patients.

Use of bone anchors in female urology

Stress urinary incontinence remains one of the most prevalent conditions encountered by urologists. In many cases, surgical correction of this condition is carried out using a pubovaginal sling procedure. Bone anchors were initially used in transvaginal needle suspension procedures to improve stabilization of the bladder neck. This technology has been extended to sling procedures, allowing completion of these procedures by an entirely transvaginal approach. Early results of these procedures are encouraging, and overall morbidity appears much less when compared with conventional pubovaginal sling procedures. In this article, the application of bone anchors in female urology is reviewed. Techniques of pubovaginal sling and abdominal sacrocolpopexy using bone anchors and potential complications of bone anchor implantation are discussed. Surgeons performing procedures for the treatment of stress incontinence should be aware of the benefits and potential risks of bone anchor implantation.

Metastatic osteomyelitis after pubovaginal sling using bone anchors

We report a case of osteomyelitis with metastasis to the T10 vertebra related to bone anchor use with pubovaginal sling. The morbidity was significant: long-term intravenous antibiotics, multiple surgeries to correct the problem, and subsequent chronic pelvic pain. Given that this complication is unheard of after standard fascia or allograft sling, consideration should be given before bone anchor use in women at risk for wound infection (diabetes, obesity, or reoperation). Minimally, patients should be told of the possibility of this severe complication in the informed consent with bone anchor use.

Comparison of biomechanical properties of periosteal suture fixation and bone anchor fixation to the pubic bone

OBJECTIVES

To compare the relative strength of fixation using bone anchors (BAs) compared with direct suture placement into the periosteum.

METHODS

The anterior bony pelvis was harvested from 21 female cadavers. In each pelvis, BA suture fixation was performed using Cinch anchors on one side of the pubic bone and direct periosteal suture fixation (PSF) on the contralateral side of the same pelvis. We used No. 1 polyproprolene suture for all cases. Using a hydraulic mechanical testing machine, all specimens were loaded in uniaxial tension until failure.

RESULTS

Failure modes for BA-fixed pelves were as follows: 11 BA pull-out, 1 midsuture failure, and 9 suture cut by BA. Failure modes for the PSF pelves were as follows: 6 suture pull-outs through the bone, 14 midsuture failures, and 1 suture cut at the bone. PSF pelves required significantly higher loads to induce failure compared with BA pelves (PSF 92.63 +/- 22.62 N, BA 71.32 +/- 19.76 N, P <0.0002). In many cases, both PSF and BA were adequate points of fixation, and the major mechanism of failure was suture rupture. In pelves with suture failure, the load to induce failure was significantly higher in the PSF group (PSF 105.06 +/- 12.55 N, BA 86.06 +/- 7.78 N, P <0.0025). When the suture failed, PSF was better because BA fixation actually broke some sutures. The load required to induce failure was higher in the PSF groups in 19 (90.5%) of 21 pelves.

CONCLUSIONS

Biomechanical testing using permanent monofilament suture did not demonstrate a superiority of BA suture fixation to PSF fixation. PSF appears superior, since BAs induced suture failure in many cases.