Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK.
Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK; University of Dammam, Kingdom of Saudi Arabia.
Eur Urol. 2018 Aug;74(2):191-196. doi: 10.1016/j.eururo.2018.04.031. Epub 2018 May 24.
Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms.
The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of data on patients undergoing AFS at a tertiary referral unit.
AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD.
Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC).
A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24-83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery.
A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate.
A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material.
最近，用于治疗压力性尿失禁（SUI）的手术主要采用合成型尿道中段吊带。由于人们越来越意识到与不可吸收的聚丙烯网片相关的严重并发症，因此重新对替代方法产生了兴趣，例如自体筋膜吊带（AFS）。尽管对于复发性和复杂性 SUI 女性患者，AFS 是一种有效且持久的选择，但由于人们认为它仅适用于治疗伴有固有括约肌缺陷（ISD）的患者，并且与高发生率的尿潴留和新发储尿症状相关，因此在原发性 SUI 女性患者中使用 AFS 时存在一定的抵触情绪。
本视频演示了一种宽松应用的尿道中段 AFS 技术。与应用于膀胱颈部的 AFS 不同，这种技术修改适用于表现为原发性 SUI 且无 ISD 的患者，可以避免新发储尿症状和尿潴留的高发生率。
设计、地点和参与者：对在三级转诊中心接受 AFS 治疗的患者数据进行回顾性分析。
在尿道中段水平，将一段短的筋膜以双侧缝线悬吊，形成一种“宽松”的 AFS，而不是在膀胱颈部，仅在伴有 ISD 的患者中使用更多的张力。
主观治愈率、术后储尿症状发生率以及需要间歇性自我导尿（ISC）的尿潴留率。
共 106 例患者接受了 AFS 治疗；平均随访时间为 9 个月。患者的平均年龄为 52.6（24-83）岁。共有 46.2%的患者为原发性 SUI，而其余 53.8%的患者均接受过先前的手术干预。总体主观治愈率为 79.2%；另有 15.1%的患者描述症状有明显的主观改善，而 5.7%的患者报告症状无变化。在原发性 SUI 患者中，主观治愈率、改善率和症状未缓解率分别为 87.8%、12.2%和 0%。在有先前手术干预的患者中，主观治愈率、改善率和症状未缓解率分别为 72.0%、17.5%和 10.5%。与有先前手术干预的患者（14.0%）相比，原发性 SUI 患者新发储尿症状发生率为 8.2%。与有先前手术干预的患者（10.5%）相比，仅 2.0%的原发性 SUI 患者需要在 2 周后进行 ISC。
在希望避免使用永久性材料及其相关风险的原发性 SUI 女性患者中，尿道中段 AFS 似乎是一种有效且安全的方法，在更复杂的情况下，这种方法不太适用。
对于需要手术治疗压力性尿失禁的女性患者，可以选择从腹部肌肉或大腿外侧取出的移植物来替代合成型阴道网片。将移植物松散地放置在尿道管的中点，而不是膀胱颈部，可以降低术后排尿困难和逼尿过度症状的风险。长期数据表明，其结果至少与不可吸收的合成非吸收性吊带一样好，而不会出现吊带侵蚀到相邻结构的潜在风险，因为它避免了使用不可吸收的材料。
