Alan Wein: Hi, it's Dr. Alan Wein from The Desai Sethi Institute at the University of Miami in UroToday. And today we have the great pleasure of having a conversation with Alex Gomelsky, who's now a fellow Floridian, who's Professor and Associate Chair of Clinical Affairs and Chief of Urogynecology and Reconstructive Pelvic Surgery at the University of Florida. And today we're going to talk about stress urinary incontinence procedures. Alex is one of the foremost experts on all types, basically in the country and actually in the world. And today we're going to talk about the history of procedures for stress urinary incontinence and the current utilization of slings, of mid-urethral tapes, mini slings, single incision slings, and other things. So Alex, take it away.
Alex Gomelsky: Well, thank you so much, Alan, for that gracious introduction. It's a real pleasure to be here with everybody. In our next few minutes, I just wanted to really quickly touch on a little bit of the history of slings, a few steps about technique. We'll talk about outcomes in the literature, some adverse events, and also briefly talk about some things that are important about troubleshooting slings going forward. So when we talk about slings, really, we're talking about well over a century of progress for these procedures. And the top picture is what is widely considered to be the first sling done when the pyramidalis muscle is wrapped around the bladder neck. And then we hit another milestone in the 1940s with something called the Aldridge sling, which was really a great predecessor to our autologous slings, where rectus fascia was used for the first time.
And then, really, the seminal events for these types of slings were in the 1980s and 1990s with the work of Jerry Blaivas and Ed McGuire, which is the bladder neck or pubovaginal sling that we really know of today. Everybody will be very familiar with the mid-urethral slings. So these are polypropylene tapes that are tension-free support structures that are placed underneath the mid-urethra. And they came into play initially in the late 1990s, and you could see that it started off with the retropubic approach, and then the transobturator approach, and what's called the mini sling or the single incision sling was FDA approved in 2007. And the mid-urethral sling at this point is the most widely researched procedure in stress incontinence and could be one of the most widely researched procedures worldwide, and definitely in urology. And so this slide kind of summarizes a few very key differences between the slings that we have. So in the column in red are the bladder neck slings, which these days are autologous tissue, which is typically either fascial auto or rectus fascia. And then the mid-urethral slings are in the column on the right. You do need to harvest the tissue, which typically requires a second incision for the bladder neck slings, while there's no harvest incision necessary, but keeping in mind that this is a foreign material or a monofilament polypropylene, a permanent mesh, so to speak.
You do need extra skin incisions for the retropubic and transobturator slings; they're just puncture incisions while the single incision mini sling does not require an exit point through the skin. You need a little bit more vaginal dissection to get it into the space of Retzius with the autologous slings, while that is not required with your mid-urethral slings. And then typically your autologous slings are supported by sutures above the rectus fascia, while the mid-urethral slings do not require any sutures; they're self-anchoring and tension-free. Well, like I said, this is one of the most researched procedures in the world and definitely in urology. So when we look at outcomes, an easy place to start are the Cochrane databases. So when you look at bladder neck slings compared to mid-urethral slings, there were 14 randomized trials, which essentially show that the bladder neck sling is probably no better and maybe slightly less effective than the mid-urethral sling. And you could see the continence rates there up to five years, 67% versus 74%. The mid-urethral sling was definitely associated with fewer perioperative complications, less voiding dysfunction, less de novo urinary storage symptoms, and less rates of sling release. Now, it should be mentioned that these were several different materials, not just autologous slings, that were included in these trials.
When we look at different types of mid-urethral slings compared to one another, you'll see that there are 81 trials and maybe even more at this point comparing retropubic to transobturator slings. And what we're seeing are fairly similar subjective and objective success rates in both short- and medium-term. And there are definitely some long-term studies at this point also echoing this finding, as expected, because the retropubic approach goes through the space of Retzius, there are higher rates of bladder puncture for those procedures, slightly higher rates of voiding dysfunction for the retropubic approach, but there seems to be a higher rate of repeat surgery for stress incontinence after transobturator slings. As far as erosion or exposure of sling material, both rates are quite low. And as it goes along with the method of placement, groin pain is going to be higher with the transobturator approach, while suprapubic discomfort is going to be higher with the retropubic approach. The newest player here are the single incision mini slings, which are placed vaginally and have no skin exit point. And a recent update to the Cochrane database included 62 trials, of which the overwhelming majority compared the single incision slings to the transobturator slings. There are some comparisons with other types of slings there, but the overwhelming data is comparing the transobturator.
At this point, there is no difference in subjective cure improvement at 12 months, which is encouraging. The number of mesh exposures are similar, and it's not currently clear if there's a difference in dyspareunia or reoperation for urinary incontinence. So the majority of those outcomes are short-term, so the long-term data is still largely absent for these procedures, but encouraging in the short-term. On the bottom, you'll see the most recent version of the AUA stress incontinence guidelines that were done in conjunction with SUFU, and they were amended in 2023. You'll notice that both mid-urethral slings of all types and autologous fascia pubovaginal sling are considered an option for surgical treatment of stress urinary incontinence, keeping in mind that each has its own risks and benefits that should be discussed with the patient, and especially the use of permanent synthetic mesh in the patients. The last part of this presentation is just a brief overview of troubleshooting. We'll see that persistent voiding symptoms are possible after any type of sling procedure with the mid-urethral slings. If those symptoms don't resolve, especially urinary retention, an early sling incision may be indicated. The role of urodynamics in these patients can be questioned. With rectus fascia slings, we might want to wait a little bit longer before we do a sling incision since these can loosen up with time.
De novo or worsened urinary storage symptoms are a little bit tougher to diagnose or to decide on treatment because bladder outlet obstruction could be responsible. So there may be some consideration given to sling release or proceeding down the overactive bladder pathway and treating it as you would an overactive bladder. Sling exposure in the vagina can be observed if it's small, or it can be excised. If there's mesh in the urethra, that should be excised, and the urethra should be repaired. And if it's in the bladder, there are some reports of laser treatment of exposed mesh, but many will also require excision. And then the last part is persistent urinary incontinence or recurrent urinary incontinence afterwards. And this is kind of a tough area because the obvious question is, what failed? Was it the choice of procedure or technique? Was it patient demographics or patient factors that led to suboptimal results, or was it expectations that were not met? Conservative management is always an option for these patients, and optimizing patient factors before proceeding with additional surgery. And then cystoscopy and urodynamics do have a role in these patients that can help us determine what the next step might be. And so, take-home messages, obviously, we have a lot of data at this point about slings. We know that it's a very studied procedure. The outcomes are durable with established adverse event profiles. The single incision sling is promising, but it's still early, and troubleshooting may be necessary. And I tell all my trainees to maintain an open mind, especially even if you were the one that did the sling. And thank you very much, and I'll turn it back over to Alan.
Alan Wein: Thank you so much. That was an amazing collection of facts and data. So at the beginning, when the mid-urethral sling first came into focus, there was a pretty clear distinction, at least in the literature, about who you used a bladder neck sling on and who you used a mid-urethral sling on, because the point of continence in the female urethra is mid-urethral. So it looks as though, correct me if I'm wrong, that over the years that that distinction has pretty much given away to the view that mid-urethral sling can pretty much fix anything that a bladder neck sling can fix. Is that not correct now?
Alex Gomelsky: It's a great point. The thinking has definitely changed. A lot more face value was given to leak point pressures and what we would typically refer to intrinsic sphincter deficiencies when we felt that there was, again, that women would leak at lower increases in abdominal pressure, that potentially mid-urethral slings would not be as effective in those patients, and we would do more bladder neck slings in them. And at this point, I think the thinking is more about the urethral mobility. If there's still retention of urethral mobility, then a mid-urethral sling may be effective in that population as well. Now granted, if there's a fixed urethra that doesn't move, I think you can make an argument that mid-urethral slings may not be as effective.
Alan Wein: So that would be the prime indication in your practice for a bladder neck sling, now would be someone that we used to call having intrinsic sphincter deficiency, or basically a non-mobile urethra that leaks all the time.
Alex Gomelsky: I think that is the primary role in my practice at this point. I do find that those patients have typically undergone several procedures already or maybe have very poor quality tissue, and I feel more comfortable placing an autologous sling in them as far as the healing aspect of it, but it's at the risk of more urinary retention and more voiding symptoms afterwards.
Alan Wein: So the single incision sling, I mean, it looks as though the short-term results are what we would call short-term results because the results for the other types are really so much more lengthy, but it looks like the short-term results are pretty equivalent. If the long-term results are, let's say, equivalent, then do you see the TOT, the transobturator in the retropubic approach, going away?
Alex Gomelsky: I am personally, I don't know if you would call it a late adopter or a pragmatist, but I like to see the longer-term results.
Alan Wein: Yeah, of course. Yeah.
Alex Gomelsky: I think especially with some of the experiences we've had in sling materials and pelvic floor reconstruction, I'm not convinced at this point that you can say because the results of the single incision sling are similar to the transobturator sling, and then transobturator sling is similar to retropubic sling. I'm not sure we can say yet that single incision slings are similar to retropubic slings, which, in my opinion, I believe are the gold standard of the mid-urethral slings. I'm intrigued by the procedure mainly because I think that there is potentially a role at some point for doing these under, and maybe now a bare modicum of anesthesia. And so we may be able to expand our offerings to patients that cannot be placed under long anesthesia, who would otherwise maybe not be candidates for a traditional sling. And that's where I think we're going to find the greatest use for these procedures going forward.
Alan Wein: So it sounds like currently your go to procedure is basically the retropubic?
Alex Gomelsky: It is. It is. And my main reason for that is I feel very comfortable in the retropubic space and if there's any reason that I need to do a sling revision, whether it's for exposure, whether it's for pain or whether it's for recurrent symptoms, I think I have a greater chance of getting the entire sling out in the worst case scenario with a retropubic sling than going into the thigh or a transobturator sling.
Alan Wein: So let me ask you about the coexistence of stress urinary incontinence, which is pretty demonstrable on a physical exam, and detrusor underactivity. A person that comes in that has residual urine, maybe 200, 300, you do a urodynamic study, and you find that, hey, I'm not even sure I can see a detrusor contraction when this person voids. I mean, what do you tell those people, or what's your normal practice about how to treat those people?
Alex Gomelsky: That's a great question. And these are very challenging patients because what you'll see with a lot of them is you'll also see them voiding with Valsalva. And the biggest concern is if I don't see at least some detrusor contraction and they're voiding mainly by Valsalva, that I'm going to be putting a sling that's going to tighten up potentially when they Valsalva void, in which it may impair their emptying. I speak to them openly about it. It's not a deal breaker to do a sling on them, but if I feel that they don't have a detrusor contraction, I think I would strongly consider bulking them at least initially to see how they do. I would also see if they're able to do intermittent catheterization, again, teach them beforehand, again, to have that in our back pocket in case they do have some difficulty with emptying, but they are a challenge to counsel, definitely.
Alan Wein: If you do a bulking procedure first and it fails, does it make putting a sling in any more difficult or not?
Alex Gomelsky: I haven't had that experience of it being any more difficult. I will say I've gotten into some bulking deposits that were placed incorrectly on other patients that were treated elsewhere. That's always a concern.
Alan Wein: So last question. I read a consensus about how people adjust tension for slings. And I was actually thinking of doing a UroToday with just a stock picture of maybe 10 experts like yourself and saying, "Okay, how do you adjust it?" So how do you adjust it?
Alex Gomelsky: And you're talking about intraoperatively?
Alan Wein: Yeah, intraoperatively.
Alex Gomelsky: So for mid-urethral slings, I will use a Kelly clamp. I will hold it parallel to the urethra, and once I release the sheaths on the sling and I take my Kelly out, I want to make sure that there is no rebound, no rubber banding effect, and I know that's very vague. If there is, then I will adjust the sling. I will pull it down until there is no rubber banding. I don't leave a preset amount of space between the urethra and the sling, but I want to make sure that there's nothing that indicates that it's going to kind of rubber band back. For my autologous slings, I will be watching from below, or I'll have my assistant watching from below and recheck it. I do want to make sure that there's a generous knot above the rectus fascia when I tie the slings over. My mentor would call it a Texas air knot, and that must mean that it's bigger than other air knots or there's more space between it and the rectus fascia.
Alan Wein: Any place with adjustable tension devices in your practice?
Alex Gomelsky: Say that again. I'm sorry.
Alan Wein: The devices where you can adjust the tension after the procedure. Any place for those in your practice?
Alex Gomelsky: I have not. The adjustable slings look very interesting. I'm still trying to reconcile that in my brain.
Alan Wein: Gotcha. Well, listen, thanks for a great presentation and thanks for some spectacular answers that should help people who manage these patients with stress urinary incontinence, and hope to see you as a neighbor in Florida at one of the meetings or others.
Alex Gomelsky: Absolutely, Alan. Thank you so much.
Alan Wein: Sure Alex.