Pubovaginal Sling Procedure (PVS) & Male Urethral Sling

Definition

Pubo = involving part of the bones of the pelvis

Vaginal = means the surgery is being done (in total or in part) through the vagina

Sling = a material placed around a structure in order to provide it support

The pubovaginal sling procedure (PVS) or male urethral sling is performed in patients with stress-type or total-type urinary incontinence. Only a small percentage of these procedures are performed in males because these types of incontinence are fare more prevalent in female patients. Stress incontinence is when pressure is exerted on top of the urinary bladder (i.e. from coughing, sneezing, laughing, lifting, etc.) and the patient consequently leaks urine. With normal anatomy, the tissue structures that surround the urethra (the tube through which you urinate) would tighten up in response to this increase in pressure to prevent leakage. If the tissue is no longer supportive, the urethra moves up and down (termed urethral hypermobility)resulting in leakage. In total incontinence, the walls of the urethra itself have lost coaptation (the ability of the inner layers to close together) and a patient constantly leaks throughout the day and/or night. A PVS or male sling procedure may help correct either of these problems by simultaneously pushing the walls of the urethra together and/or by preventing the hypermobility(up and down movement) associated with pressure on top of the bladder. Some patients have both problems.

Currently, there are many varieties of sling material available for the surgeon to use. Some are part of your own tissue, some are processed tissue from a cadaver (deceased person) donor, some may be processed tissue from another animal species, and some are completely artificial. The type used will depend on your prior surgeries (if applicable) and anatomy, your surgeon’s preference, and input from you after you understand the pros and cons of each type. In your surgical consultation, we will have discussed the type to be used in your procedure.

Prior to your surgery, we may have already performed a urodynamic test (UDT). This is a minor office procedure used to specifically evaluate problems of urinary incontinence or other problems with urination. Often, other possible conditions causing incontinence need to be excluded prior to recommending a PVS or male sling. Occasionally, the diagnosis (based on your symptoms and physical examination) is straightforward, and UDT is therefore unnecessary.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed with us and/or the anesthesiologist and instructions will have been given to you.

The procedure will not be performed in you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation.

You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

*It is probably to your advantage not to strain to have a bowel movement in the week after the procedure. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas, and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should administer an enema one hour before bed the night before your procedure.

Procedure

To review the basics of what we discussed in the office: The procedure usually takes 1-2hours depending on an individual’s anatomy and whether a previous operation has taken place in this same area. There are some techniques that may only take 30 minutes. Not all patients are suitable candidates for these techniques. A suprapubic tube (small catheter placed through the lower abdomen and into the bladder) may be inserted. This temporary tube would be used in the immediate post-operative period to empty your bladder and possibly measure residual urine volume (the amount of urine left in the bladder after you urinate). Many patients and certain techniques do not require placement of this tube. In some patients, a tube is left in the urethra only for a few days or longer. In some patients, no tubes are left at all.

Female: Depending on your surgeon’s preference, the surgery may be done completely through one or two incisions in the vagina; or through a combination of a vaginal incision and a small lower abdominal incision. The vaginal incision is made for placement of the sling material around the bottom of the urethra. The very low abdominal incision may be for placement of the tiny bone screws into the pubic bone, to anchor the sutures in another fashion, or to obtain some of your own body tissue to use as the sling material. When the procedure is done only through the vagina, the tiny screws may be placed into the underside of the pubic bone instead of the upper margin of the bone. If used, the screws are attached to a very strong suture material that secures the sling in proper position. During the procedure we may perform a cystoscopy (placing a small telescope into the bladder to visualize the inside) to ensure that everything is correctly positioned. Cystoscopy is not always necessary. The incision sites are then closed and your procedure is completed.

Male: For the most part, the procedure is the same. The incision(s) that were vaginal in the female are in the perineum (area between the scrotum and the anal region) in the male. As in the female, the procedure may be done solely through this incision, or can be combined with a small incision on the suprapubic (very low abdomen) area. Again, that will depend on the surgeon’s preference of where to position the bone anchors (if used), or whether to use the patient’s own tissue for a sling material.

Post Procedure

You will be in the recovery room for a short time before being sent to your hospital bed. Although often an ambulatory procedure, some patients usually will stay overnight in the hospital. There may be some discomfort around the incision sites within the vagina (orperineum in the male) and on the lower abdomen. Most patients have some sense of urgency(the feeling of a need to urinate). There will be a dressing over the abdominal incision site which is to remain until your follow-up visit unless otherwise directed.

• Suprapubic Tube (SPT): If used, you may be discharged home with a SPT. It will remain for a week or so until you are urinating well and adequately emptying your bladder. You will be instructed on how to easily open and close the drainage switch. The tube may serve two purposes:
• You will attempt to urinate when you go home. If you are unsuccessful, you can simply open the tube and drain the urine from your bladder. When you are completely empty(no more draining from the tube), you will close the switch and allow your bladder to fill again over the next several hours (time will vary according to how much fluid you are drinking). When you get another sensation to urinate, you will go to the bathroom and attempt to go. Again, if you cannot, you will open the tube, empty the bladder, close the tube, and try again later.
• If you do urinate, you will open the tube when you believe that you are done urinating. The reason for doing so is to determine whether you are emptying your bladder fully. If there is urine remaining in the bladder, you will record how may ounces were left. You will do this each time you urinate so that you and your surgeon know if you are effectively emptying you bladder and thus ready to have the tube removed.
• Urethral Catheter: Sometimes a catheter is left in the urethra and removed a few days or week later to see if you can urinate on your own. If you cannot, it can be replaced, or you can learn self-catheterization.
• Self-Catheterization: You may be instructed on how to catheterize yourself. The indications to do so may be the same. In other words, you would do it if you cannot urinate yet. You may also be asked to catheterize to measure what is left in the bladder after urinating.

There may be small blood staining on the wound dressing. If the dressing becomes soaked, or you see active blood oozing, please contact us immediately. You may shower two days after surgery, but no bathing or swimming (unless otherwise instructed). Some surgeons may ask you to take warm baths a couple of times a day a few days after your surgery. We ask that you refrain from any strenuous activity or heavy lifting until your follow-up office visit.

Every patient has some degree off swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. It is very important that you intermittently apply ice to the abdominal area as soon as you return home for 24 hours as instructed.

We strongly encourage you to take at least one week off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. In the first 48 hours, it is to your advantage to minimize activity and to often rest in a lying down position. Periodic walking is encouraged. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days to weeks. Severe pain is unlikely but possible.

We may provide you with a prescription for pain medication to alleviate most of the discomfort. Take this medication as prescribed and as needed. An antibiotic prescription may also be given and should be taken until completion. If any side effects occur, contact our office immediately.

*You must refrain from any strenuous activity or heavy lifting until we tell you otherwise. Sexual activity of any sort is absolutely prohibited (usually 4-6 weeks) until we tell you that you may resume.

Expectations of Outcome

Sling placement is a very effective modality for curing stress or total urinary incontinence.”Normal voiding” may be delayed for many weeks due to swelling and operative manipulations. Improvement is usually gradual and not immediate. *There is an entity termed “bladder instability” that should be understood. It is actually not a complication of the surgery because we expect some degree of its presentation in anywhere from 30-40% of patients following repair of urethral hypermobility. Because the bladder neck support has been restored, you may develop urinary frequency and/or urgency (a sensation to urinate urgently). When severe, this rarely can be associated with urge-type incontinence (strong urge to void with an uncontrolled loss of some urine). The symptoms are usually mild and resolve with time. In few patients, medications could be necessary to relax the bladder. Very rarely are other treatments necessary.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Urinary Tract Infection or Sepsis: Although we may give you antibiotics prior to and after the operation, it is possible for you to get an infection. The most common type is a simple bladder infection (after the catheter is removed) that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system.
• Wound Infection: The incision sites can become infected. While it typically resolves with antibiotics and local wound care, occasionally, part of all of the incision may be open and require revision and/or catheter replacement. *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Treatment Failure: Although usually associated with a high success rate, the procedure can fail immediately, or months to years later. In this regard, stress-type or total incontinence may persist or resume.
• Urinary Retention: Retention is the inability to urinate and occurs in fewer than 5%of cases. Usually, a patient is able to urinate normally within 2-3 weeks following the procedure. However, if retention is prolonged, a catheter may be necessary. If you had a SPT placed, it may remain in for a while longer. Otherwise, you could learn to self-catheterize or simply have a urethral catheter placed back in for a few days at a time. It would periodically be removed to test whether you are able to urinate. We always encourage patients to be patient, because urinary retention usually resolves with time and observation. In rare instances of prolonged retention, a corrective procedure may be required. Factors which may delay the rapid return of voiding include: excessive sling tension, poor bladder function before the surgery, and multiple repaired organs (i.e. a dropped bladder, a dropped uterus, or a prolapsed rectum) during the same surgery. Urodynamic testing may need to be performed for further assessment.
• Blood Loss/Transfusion: The vaginal region is quite vascular. Usually blood loss in this procedure is minimal to moderate. In 1-2% of cases, blood loss can be significant enough to necessitate transfusion.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
• Sling Erosion: It is possible for the sling material to erode through the tissue that surrounds it. In the female, if the vaginal tissue breaks down, the sling can often be removed with a minimal procedure. Often, the patient is still continent because scar tissue from the surgery will continue to support the urethra. On the contrary, if the back of the sling erodes into the urethra in either females or males, the surgical removal is more involved, and the rates of incontinence afterward are higher.
• Bleeding/Hematoma: When a small blood vessel continues to ooze or bleed after the procedure is over, the area of collected blood is referred to as a hematoma. The body normally re-absorbs this collection over a short period of time, and surgical drainage is rarely necessary.
• Lower Extremity Weakness/Numbness: This, too, is a rare event which may arise due to your position on the operating table. It is possible in procedures in which you are in the lithotomy (legs up in the air) for a long period. The problem is usually self-limited with a return to baseline expected.
• Injury from Suprapubic Tube: If a suprapubic tube is being placed, it can rarely puncture a structure adjacent to the bladder. Although rare in any instance, the small intestine is the most commonly involved organ. When recognized, a general surgeon may be consulted to repair the intestine or other organ.
• Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery. Typically, the pain disappears over time, although some feeling of numbness may persist. If persistent, further evaluation may be necessary.
• Transferred Viral Infection: With the use of human cadaveric material, transferred virus is theoretically possible. The processing of this material is quite extensive. With use in tens of thousands of patients, we are not aware of a single published case of transferred viral infection.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.