Autologous fascia advised for incontinence slings

OB/GYN News, Nov 15, 2001 by Kathryn DeMott

ST. LOUIS -- Not all materials for constructing urinary incontinence slings are created equal, Dr. Fred E. Govier said at the 11th International Pelvic Reconstructive and Vaginal Surgery Conference.

The hands down best material for a sling is some form of autologous fascia. "I don't care if it's rectus or fascia lata." Within 2 weeks, that fascia is fixed and by 4 weeks "it is cement. You can't move it, and if you get a good result initially, late failures are extremely rare." Unfortunately, one has to accept the morbidity of harvesting this tissue if it is used, said Dr. Govier, head of urology and renal transplantation at Virginia Mason Medical Center, Seattle.

By contrast, cadaveric slings in some cases are still movable 4-5 weeks after surgery. And late failures are not uncommon, depending on the method by which the cadaveric tissue has been processed.

Case in point: In a study involving 35 patients who received slings made out of freeze-dried, irradiated fascia lara grafts, 8 required reoperations for persistent or recurrent stress incontinence. The sling failed in seven of the eight patients: The allograft was present but grossly degenerated in two and completely absent in five (Br. J. Urol. 84[7]:785-88, 1999).

Echoing those findings was another more recent study in which a single surgeon placed a bone-anchored, cadaveric fascia sling in 154 patients. After an average follow-up of only 11 months, 17% of patients required reoperations for moderate to severe recurrent incontinence. The anchors were in position and the sutures intact, but across the board the sling materials were fragmented, attenuated, or absent altogether (J. Urol. 165[5]:1605-11, 2001).

Fresh-frozen cadaveric tissue may not be much better than the freeze-dried kind. In his own case series he has now identified 11 intermediate failures in 131 patients. All patients were completely cured at 3 months, but failed in a 4- to 23-month period.

"My surgical technique was good, the tension was right, everything looked good, and now these people have failed.... That really makes me nervous," Dr. Govier said at the conference, jointly sponsored by the Society of Pelvic Reconstructive Surgeons and the American College of Obstetricians and Gynecologists. By contrast, he has never experienced an intermediate or late failure after an autologous graft that was functioning well at 3 months. Cadaveric tissue is broken down by the patient and rebuilt over time. This tissue acts as a framework that the body revascularizes and repopulates with fibroblasts and collages.

With autologous tissues, the body revascularizes them without first breaking them down. In histologic and MRI studies of patients who have had autologous grafts placed several months earlier, the architecture remains completely unchanged.

The choice of material should be the patient's decision. If the patient doesn't want to accept the morbidity of harvesting autologous fascia or the risks of a permanent mesh sling, he prefers solvent dehydrated proprietary cadaveric material. For a straight sling he prefers dermis and for a sling and cystocele repair he uses fascia lata. But for the most part, he reserves use of such materials for healthier women who have the best shot at remodeling the material.

In young active women, the second best choice after an autologous sling may turn out to be some form of permanent mesh sling. Dr. Govier said that he has been encouraged by data from Europe showing 5-year success with minimal morbidity, but stressed that until more data are available it will be necessary to be very concerned about late erosisons and infections.

For the complex patient, whose procedure is anatomically difficult because of a fixed ureter without much mobility or the failed cadaveric material, he insists on the superiority of the autologous sling.