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.
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.
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.
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.
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.
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.
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:
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.