Pubovaginal Sling

In 1907, Von Girodano introduced the sling concept for treatment of urinary incontinence when he wrapped a gra-cilis graft around the urethra. However, credit for the first pubovaginal sling went to Goebell in 1910 when he rotated the pyramidalis muscles beneath the urethra and joined them in the midline. In 1914, Frangenheim used rectus abdominis muscle and fascia for slings. Stoeckel argued that the material used for the slings was not important in the outcome, and the success depends on a high urethral position and attachment of the sling to the abdominal muscles. Price described the first fascial sling in 1933. Millin used strips of rectus fascia, looped them under the urethra, and tied them over the top of the urethra. In 1942, Aldridge used fascial slings in conjunction with vaginal plastic operations. He mobilized strips of abdominal fascia, leaving the edges attached to the recti muscles medially, and tunneled the strips through the recti 4 cm above the pubis. The two ends were sutured together through a vertical vaginal wall incision. The Aldridge procedure dominated sling surgery for many decades. Green and Robertson in 1962 and 1970, respectively, described incontinence cases that were well supported but leaked with increases in abdominal pressure. McGuire also reported a high failure rate for anterior colporrhaphy and retropubic suspension in women who had type III SUI. When these patients were treated with a pubovaginal sling, they had a 91% cure rate at a mean of 2.3 years.2 The sling was rein-troduced to urologists and, since then, sling material, size, suture, and point of fixation have undergone numerous revisions. The sling may be placed abdominally or trans-vaginally. The common goal is to restore sufficient urethral outlet resistance while avoiding urethral obstruction and allowing spontaneous micturition. The mechanism by which the sling accomplishes these goals remains controversial. Ghoniem and Shaaban3 performed videourody-namics on 35 women undergoing a pubovaginal sling for intrinsic sphincter deficiency. Fluoroscopic monitoring during straining showed upward and outward movement of the sling, and downward and inward movement of the bladder base. The opposing forces closed the bladder neck, preventing leakage of contrast material and restoring outlet resistance. The sling restores anatomic position of the urethra. Thus, it is effective for treating intrinsic sphincter deficiency and urethral hypermobility. A variety of materials have been used successfully as suburethral slings. Slings can be made from autologous materials, allo-grafts, or synthetic materials.

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