Dr. Nitti started with the indications for a pubovaginal sling:
- Fixed urethra” pure ISD”
- SUI associated with neurogenic bladder when the goal is CIC.
- Complex urethral reconstructive cases.
- SUI requiring sling with prior or current problem with synthetic
- Patient/ surgeon preference for autologous tissue (PVS vs Burch)
- Multiple prior abdominal surgeries.
- Ventral hernia or prior hernia repair
- Mesh on abdominal wall
- Patient preference for thigh incision.
- He usually started with harvesting the rectus fascia before dissecting the vagina.
- 7 cm incision in the suprapubic area with full incision or 5 cm using ring self-retaining retractor.
- Clean the anterior rectus fascia, mark with Bovie 2 cm x 7 cm, using the bovie to harvest the rectus fascia, put 2/0 Proline before continue harvesting the fascia which make it easier. Also, recently he used the small 2/0 PDS single (not loop any more), this will prevent and decrease the risk of the incisional hernia.
- Then start vaginal wall dissection off the periurethral fascia to the pubic bone bilateral (the correct plane is critical).
- Create a small proximally based vaginal wall flap, exposing the underlying proximal urethra and vesical neck.
- Perforate the endopelvic fascia sharply and enter the retropubic space bilateral
- Trick: try to avoid injury to the autonomic nerves which run lateral to the urethra, also try to avoid extensive retropubic dissection unless a urethrolysis is required.
- Placement of the sling: through ½ cm incisions in the lower portion of the rectus fascia a tonsil or ligature carrier through the retropubic space and out the vaginal incision, under direct finger dissection (make sure the bladder empty, be behind the pubic the bone always).
- Grasp a suture one end of the sling and transfer to the suprapubic incision.
- Repeat on the opposite side
- Both arms should be equal and how I know that it brings both sutures ends which should be equal (Dr. Albo’s experience that he marked the fascia in the middle line so he knows that he is the middle.).
- Nitti do secure the fascia in the periurethral fascia with 3/0 vicryl, 2 proximal and 2 distal
- Then closed the vagina.
- At the end, he does the tension of the fascia, suture both ends of the sutures, and air knot with 3 figures breadth.
- Comment on the post-operative obstructive symptoms (TOV in the morning, then CIC or TOV for another 5-7 days. If urinary retention persists for more than 6 weeks need counseling the patient to continue the CIC, and possible ureterolysis in 4-6 months.
- Another question about the concomitant urethral reconstruction (diverticular repair with PVS); Dr. Nitti do first the PVS then the repair; idea about that he doses not like to pass the cystoscopy through the reconstructive part.
Victor William Nitti, MD, New York University
Michael Edward Albo, MD, board-certified urologist, UC San Diego Health
Written by: Bilal Farhan, MD, Clinical Instructor, Female Urology and Voiding Dysfunction, Department of Urology, University of California, Irvine @Bilalfarhan79 at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting, SUFU 2019, February 26 - March 2, 2019, Miami, Florida