Comparison of perioperative adverse events following suburethral sling placement using synthetic mesh, autologous rectus fascia, and autologous fascia lata in a national surgical registry.

AIMS: To assess and compare 30-day perioperative adverse events following suburethral sling surgery using synthetic mesh, autologous rectus fascia, and autologous fascia lata in women. METHODS: This was a retrospective cohort study of patients who underwent fascial or synthetic sling placement for stress urinary incontinence between 2008 and 2021 using the American College of Surgeons' National Surgical Quality Improvement Program database. Current Procedural Terminology codes were used to identify patients undergoing each type of sling procedure. Multivariable regression analysis with stepwise regression was used to assess the odds of composite adverse events (e.g., urinary tract infection, surgical site infection, pulmonary embolism, and other reportable events) between cohorts. RESULTS: Of the 41 533 female patients who underwent isolated suburethral sling placement without concurrent procedures, 41 292 (99.4%) received a synthetic mesh sling, and 241 (0.6%) received an autologous facial sling. In the fascial sling cohort, 160 (66.4%) underwent rectus fascia harvest and 81 (33.6%) underwent fascia lata harvest. Sling surgeries involving autologous fascia were associated with increased odds of adverse events compared to those involving synthetic mesh, even after adjusting for confounders (adjusted odds ratio [aOR]: 3.63, 95% confidence interval [CI]: 2.56-5.15). Compared to fascial slings from rectus fascia, slings from fascia lata were associated with increased odds of composite adverse events (aOR: 2.11, 95% CI: 1.03-4.04). However, with the exclusion of urinary tract infections, the adverse event rate was similar between slings using the two fascial harvest techniques (aOR: 1.93, 95% CI: 0.81-4.63). CONCLUSIONS: In this retrospective database study, suburethral sling surgeries using autologous fascia were independently associated with a 3.6-fold increase in odds of 30-day perioperative adverse events compared to sling surgeries using synthetic mesh.

Autologous Slings in Female Stress Urinary Incontinence Treatment: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to evaluate the efficacy and safety of autologous fascial slings (AFS) compared with other surgical methods for female stress urinary incontinence (SUI) treatment. METHODS: The search was performed on studies published before September 2023 to identify articles assessing the effectiveness and safety of AFS compared with other surgical methods in female SUI. Inclusion criteria were randomized controlled trials (RCTs) and adult women with SUI. Exclusion criteria were other urinary incontinence types, combined pharmacological treatment, pregnancy, and lactation. This systematic review was conducted according to the Population, Intervention, Comparison, and Outcome framework, Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 checklist, and was registered in the Prospective Register of Systematic Reviews. RESULTS: Twenty RCTs were included in the systematic review and 10 RCTs in the meta-analysis. Comparison between AFS and synthetic midurethral slings (SMUS) did not show any statistically significant differences in the cure rate, frequency of urinary retention, or self-catheterization. SMUS showed more long-term postoperative complications (RR = 0.12, 95% CI: 0.03 to 0.50, p = 0.004), AFS had more in de novo urgency cases: (RR = 2.84, 95% CI: 1.13 to 7.10, p = 0.03). Operation time of SMUS was lower: (RR = 2.87, 95% CI: 2.56 to 3.19, p < 0.00001, I2 = 97%). SMUS showed significantly lower hospital stay duration: (RR = 1.92, 95% CI: 1.44 to 2.41, p < 0.00001). CONCLUSIONS: In this systematic review and meta-analysis, autologous slings demonstrated the same efficacy in comparison with SMUS in the management of SUI in women. AFS showed lower incidence of long-term postoperative complications. SMUS demonstrated lower operation time, hospital stay and de novo urgency.

Management of sphincter insufficiency in patients with neurogenic bladder and bladder augmentation.

PURPOSE: To investigate the need and efficacy of treatment of bladder neck procedures in patients with neurogenic bladder and augmentation. METHODS: The hospital database was reviewed for patients undergoing enterocystoplasty because of neurogenic bladder during 1990-2019. Diagnoses of patients as well as frequency, type, and efficacy of treatment of sphincter insufficiency were evaluated. RESULTS: Thirty-seven of 87 patients (43%) underwent surgery because of sphincter insufficiency. The median age at bladder augmentation was 11.9 years (IQR 8.5-14.8), and at the last control, 21.8 years (IQR 18.9-31.1). Bladder neck injections (BNI) were performed for 28 patients, fascial sling operation for 14 patients, and bladder neck closure (BNC) was done for five females. Full continence was achieved in 10/28 (36%) patients with one or repeat BNIs and 9/14 (64%) with sling operation. The outcome of BNIs and sling operations was similar in both sexes. All five female patients with BNC became continent. At the end of follow-up, 64 (74%) patients were dry, 19 (22%) had occasional incontinence episodes, and 4 (5%) had daily incontinence episodes necessitating pads. CONCLUSIONS: Treatment of sphincter insufficiency is challenging in patients with bladder augmentation and neurogenic disease. Only 74% of our patients became fully continent despite treatments for sphincter insufficiency.

Impact of a mid-urethral synthetic mesh sling on long-term risk of systemic conditions in women with stress urinary incontinence: a national cohort study.

OBJECTIVE: To compare the incidence of systemic conditions between women who had surgical treatment for stress incontinence with mesh and without mesh. DESIGN: National cohort study. SETTING: English National Health Service. POPULATION: Women with no previous record of systemic disease who had first-time urinary incontinence surgery between 1 January 2006 and 31 December 2013, followed up to the earliest of 10 years or 31 March 2019. METHODS: Competing-risks regression was used to estimate hazard ratios (HR), adjusted for patient characteristics, with HR > 1 indicating increased incidence following mesh surgery. MAIN OUTCOME MEASURES: First postoperative admission with a record of autoimmune disease, fibromyalgia or myalgic encephalomyelitis up to 10 years following the first incontinence procedure. RESULTS: The cohort included 88 947 women who had mesh surgery and 3389 women who had non-mesh surgery. Both treatment groups were similar with respect to age, socio-economic deprivation, comorbidity and ethnicity. The 10-year cumulative incidence of autoimmune disease, fibromyalgia or myalgic encephalomyelitis was 8.1% (95% CI 7.9-8.3%) in the mesh group and 9.0% (95% CI 8.0-10.1%) in the non-mesh group (adjusted HR 0.89, 95% CI 0.79-1.01; P = 0.07). A sensitivity analysis including only autoimmune diseases as an outcome returned a similar result. CONCLUSIONS: These findings do not support claims that synthetic mesh slings cause systemic disease. TWEETABLE ABSTRACT: No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling.

[Autologous fascia pubovaginal slings in women with stress urinary incontinence at high risk of mesh/device-related complications]. / Bandelette aponévrotique pubovaginale pour incontinence urinaire d'effort chez les femmes à risque de complications prothétiques.

INTRODUCTION: Very popular in many parts of the world, autologous fascial pubovaginal sling (AFPVS) remains marginally used in France. However, it may be of particular interest in patients carrying a high risk of mesh-related or device-related related complications. The aim of the present series was to report the outcomes of AFPVS in this high-risk population. MATERIAL AND METHODS: The charts of all female patients who underwent a fascial sling for SUI at a single academic center between April 2019 and May 2021 were reviewed retrospectively. Only patients deemed at high-risk of device/mesh related complications were included in the present analysis: female with a neurological condition who were doing clean intermittent catheterization (CIC), female with SUI after radical cystectomy and ileal neobladder, female with urethral/bladder extrusion of any synthetic material placed for SUI. Success was defined as complete resolution of SUI at 3 months. RESULTS: Sixteen patients were included in this study: 13 rectus fascia slings and 3 fascia lata slings. The success rate was 56.3% (9/16 patients). Four patients were improved but not completely dry (25%). Two patients had major postoperative complications (i.e. Clavien grade 3 or higher, 11.2%). Two patients had a persisting significant post-void residual (PVR) postoperatively, managed by self-catheterization (transition to self-catheterization at 3 months: 2/8, 25%). CONCLUSION: The use of autologous fascia pubovaginal sling is an interesting option in female SUI patients with high risk of device/mesh related complications with satisfactory functional outcomes. LEVEL OF PROOF: 4.

Risk of reoperation 10 years after surgical treatment for stress urinary incontinence: a national population-based cohort study.

BACKGROUND: There is a debate about the safety and effectiveness of surgical treatments for stress urinary incontinence. Controversy about the use of synthetic mesh sling insertion has led to an increased uptake of retropubic colposuspension and autologous sling procedures. Comparative evidence on the long-term outcomes from these procedures is needed. OBJECTIVE: To compare the risk of reoperation at 10 years after operation between women treated for stress urinary incontinence with retropubic colposuspension, mesh sling insertion, and autologous sling procedures. STUDY DESIGN: The records of admissions to National Health Service hosptials were used to identify women who had first-time stress incontinence surgery between 2006 and 2013 in England. The first incidence of the following outcomes was assessed: further stress incontinence surgery, surgery for a complication (either mesh removal, prolapse repair, or incisional hernia repair), and any reoperation (either further stress incontinence surgery, mesh removal, prolapse repair, or incisional hernia repair). The cumulative incidence of each of these outcomes up to 10 years after surgery was calculated, considering death as a competing event. Multivariable modeling was then used to estimate the reoperation hazard ratios for the different initial surgery types with adjustments for patient characteristics and concurrent prolapse surgery or hysterectomy. RESULTS: The analysis included 2262 women treated with retropubic colposuspension, 92,524 treated with mesh sling insertion, and 1234 treated with autologous sling. The cumulative incidence of any first reoperation at 10 years was 21.3% (95% confidence interval, 19.5-23.0) after retropubic colposuspension, 10.9% (10.7-11.1) after mesh sling insertion, and 12.0% (10.2-13.9) after autologous sling procedures. The women who had a retropubic colposuspension were significantly more likely to have a reoperation than women who had an autologous sling (adjusted hazard ratio for any reoperation: 1.79 [1.47-2.17]; for further stress incontinence surgery: 1.64 [1.19-2.26]; for surgery for complications: 1.89 [1.49-2.40]), whereas the women who had mesh slings had a similar hazard (for any reoperation: 0.90 [0.76-1.07]; for further stress incontinence surgery: 0.75 [0.57-0.99]; for surgery for complications: 1.11 [0.89-1.36]). A sensitivity analysis excluding the women who had concurrent prolapse surgery or hysterectomy produced similar results. CONCLUSION: Retropubic colposuspension is associated with higher risk of reoperation at 10 years after surgery than mesh sling insertion or autologous sling procedures, with 1 in 5 women requiring reoperation.

A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling.

BACKGROUND: Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision with urethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling. OBJECTIVE: The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling. STUDY DESIGN: This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05. RESULTS: We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups. CONCLUSION: This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was a considerable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group.

"Voice your choice": a study of women's choice of surgery for primary stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: This was an observational study aiming to determine factors which influence women's choice of surgery for primary stress urinary incontinence (SUI). METHODS: Two hundred twelve women undergoing a primary SUI procedure were recruited to this study from 12 hospitals in the north of England. After choosing a procedure, women were asked to complete a standardized semi-structured questionnaire about their health, demographics and a free text box to record factors important to them when choosing their procedure. Statistical analysis was performed to determine the impact of demographic, lifestyle or healthcare factors on women's decision-making. Thematic analysis of the free text data was performed to identify factors important for women when choosing a surgical procedure. RESULTS: Sixty-four percent of women chose urethral bulking. There was no significant difference among age, BMI, smoking status or previous laparotomy between women choosing the four types of surgery. Women were less likely to choose urethral bulking if seen in a tertiary centre compared with a secondary centre (p < 001). Major themes in decision-making were efficacy, invasiveness, recovery, risk of complications, use of mesh, the clinician, the media, hierarchy of treatments and type of anaesthetic. Some women expressed a hierarchical approach to treatment. CONCLUSIONS: Our findings suggest decision-making is not influenced by patient factors such as age, BMI, smoking status or previous laparotomies. Women's choices are a complex mix of factors and not simply related to efficacy.

Subfascial Breast Augmentation with Crossed Fascial Sling, Under Tumescent Anaesthesia With or Without Sedation and Lower Periareolar Access.

The tumescent technique is very effective for subfascial breast implant surgery. A total amount volume of 330 cc (120/160 cc for each breast) ensures a clean and bloodless field, leading to less postoperative bruising and prolonged local anaesthesia effects. The surgical procedure can be performed with or without associated sedation. Lower periareolar anaesthesia allows for good and painless infiltration of the surgical field, up to the prepectoralis plane. A smooth, vertical dissection reached the pectoralis fascia, which was smoothly opened, leaving the gland adhesions in place. Subfascial pocket dissection was performed, and the implant was then inserted. The fascial sling, consisting of 2 strips of approximately 4/5 cm × 2 cm each, was prepared superiorly and crossed for inferior fixation. One hundred patients were included over 18 months, and all surgeries were performed under tumescent anaesthesia with general sedation. Overall, we did not need to convert from local anaesthesia in general. No complications were observed, and good cosmetic results were achieved. The follow-up periods lasted for 6 months or, in a few cases, for 1 year.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

National BSUG audit of stress urinary incontinence surgery in England.

INTRODUCTION AND HYPOTHESIS: The aim of the British Society of Urogynaecology (BSUG) 2013 audit for stress urinary incontinence (SUI) surgery was to conduct a national clinical audit looking at the intra- and postoperative complications and provide outcomes for these procedures. This audit was supported by the Healthcare Quality Improvement Partnership (HQIP) and National Health Service (NHS) England. METHODS: Data were collected for all continence procedures performed in 2013 through the BSUG database. All clinicians in England performing SUI surgery were invited to submit data to a central database. Outcomes data for the different continence procedures were collected and included intraoperative and postoperative complications and the change in continence scores at postoperative follow-up Changing trends in stress incontinence surgery were also assessed. RESULTS: We recorded 4993 urinary incontinence procedures from 177 consultants at 110 centres in England: 94.6% were midurethral slings; 86.7% (4331) were submitted by BSUG members with the remaining 13.3% submitted by non-BSUG members. Postoperative follow-up data were available for 3983 (80%) patients: 92.3% (3676) were very much better/much better postoperatively, and 4806 (96.3%) proceeded with no reported complications. There were 187 cases (3.7%) in which a perioperative complication was recorded. Pain persisting >30 days was reported in 1.9% of all patients. CONCLUSIONS: Surgery for SUI has good outcomes in the short term. Midurethral synthetic slings have been shown to be safe and effective as a treatment option, with >90% being very much/much better at their postoperative follow-up.

Salvage autologous fascial sling after failed synthetic midurethral sling: Greater than 3-year outcomes.

OBJECTIVE: To determine long-term surgical outcomes of salvage autologous fascial sling placement after a failed synthetic midurethral sling. METHODS: Women who had undergone autologous fascial sling placement without concomitant pelvic surgery for a failed synthetic midurethral sling utilizing mesh with a minimum follow up of 36 months were identified. Charts were reviewed, and patients were contacted by telephone. Success was determined by the Patient Global Impression of Improvement. Secondary measures included the Incontinence Severity Index questionnaire, patient recommendation of the autologous fascial sling and need for further incontinence surgery. RESULTS: A total of 35 patients met the criteria, and 21 were successfully contacted. Of those contacted, the median age at surgery was 67 years (range 53-81 years) and at the time of the survey was 75 years (range 63-84 years) with median follow up of 74 months (range 36-127 years). Preoperatively, 12 patients (57.1%) had urethral hypermobility and 13 patients (61.9%) had mixed urinary incontinence. Eight patients (38.1%) had concomitant sling excision with five of those combined with urethrolysis at the time of the salvage operation. Patient Global Impression of Improvement success was noted in 16 patients (76.2%). A total of 11 patients (52.4%) were dry or had slight incontinence by the Incontinence Severity Index. One patient required additional anti-incontinence surgery (4.8%). A total of 18 patients (85.7%) recommended the autologous fascial sling. No statistical impact was noted with sling excision (P = 0.62), mixed urinary incontinence (P = 0.61), age at surgery (P = 0.23), age at follow up (P = 0.15), length of follow up (P = 0.71) or first surgery type (transobturator tape vs retropubic; P = 1.00). CONCLUSIONS: Autologous fascial sling provides reasonable long-term success as a salvage operation for failed midurethral slings.

Concomitant repair of stress urinary incontinence with proximal urethrovaginal fistula: Our experience.

INTRODUCTION: Proximal urethrovaginal fistula (UVF) located close to the bladder neck may cause extensive sphincter damage and is usually associated with continuous incontinence, which may mask the associated stress urinary incontinence (SUI). Simultaneous correction of SUI avoids a second surgery for SUI, which needs dissection in ischemic fields and carries a high risk of failure. The aim of this study is to describe our technique of concomitant repair of SUI with proximal UVF and our results. METHODS: Between July 2010 and August 2014, 14 patients underwent UVF repair in Jackknife position by the interposition of a Martius flap and simultaneous correction of SUI by modified McGuire pubovaginal autologous fascial sling. The procedure was carried out a minimum of 3 months of presentation and after detailed preoperative evaluation. RESULTS: After a mean follow-up of 28 months, all 14 patients were continent. None of the patients developed recurrence of the UVF. Two patients presented with retention immediately after catheter removal and clean intermittent catheterization training was given to both of them. Two patients became pregnant during the follow-up period and were advised cesarean section near term. CONCLUSIONS: Repair of proximal UVF and correction of SUI can be performed in the same session to avoid the operation in an ischemic field.

Midurethral autologous fascial sling surgery with reconstruction of the lower abdominal wall using the tensor fascia lata muscle flap for post-hemipelvectomy stress urinary incontinence.

Hemipelvectomy is surgery for pelvic bone neoplasms. In the case of pubic bone osteosarcoma, the distal end of the rectus abdominis muscle is severed from the pubic and ischium bones, and the pelvic floor muscles are resected en bloc with the bone, which leads to stress urinary incontinence. Cancer control is prioritized over complications, and stress urinary incontinence is generally disregarded. A 25-year-old woman presented with stress urinary incontinence. She had undergone a hemipelvectomy for left pubic bone osteosarcoma, and stress urinary incontinence appeared and persisted since the surgery. We carried out a reconstruction of the tissue deficit of the rectus abdominis using the tensor fascia lata muscle flap simultaneously with a midurethral autologous fascial sling anchoring to the tensor fascia lata flap. Stress incontinence was successfully improved without morbidity. This is the first reported case of midurethral suspension with reconstruction of the lower abdominal wall with the tensor fascia lata flap for post-hemipelvectomy stress urinary incontinence.

Use of autogenous fascia lata slings in the surgical correction of ptosis: a systematic review of the literature and meta-analysis.

Ptosis is an abnormally low-positioned upper eyelid. Management depends on severity, aetiology, and function of the levator palpebrae superioris muscle (LPS). This review evaluates the success of autogenous fascia lata slings (AFLS) in the surgical management of ptosis, together with complication and reoperation/revision rates. A literature search was conducted on PubMed, Google Scholar PROSPERO, Dynamed, DARE, EMBASE, Cochrane, and BMJ databases (PROSPERO registration: CRD42023475090), and 30 studies (3690 patients and 5059 eyes) were included. The average age of the patients was 14.2 years with a ratio of male:female patients of 1:0.7. A total of 2532 eyes had undergone a fascial sling with autogenous fascia lata. The average follow-up period was 32.6 months. Improvement in the margin to reflex distance 1 (MRD1) with fascial sling surgery was 2.79 mm. The rate of complications from surgery involving autogenous fascia lata was 21.3%. The most common complications included lagophthalmos (19.8%), residual ptosis (11.5%), and corneal damage (10.4%). The reoperation rate was 13.4%. Most common indications for reoperation were cosmetic, with asymmetry (18%), lid crease abnormalities (30%), and upper eyelid trimming (18%). The overall complication rate in AFLS patients was 20% (95% CI: 6 to 35, p < 0.01; I2 = 89%) versus 27% (95% CI: 14 to 40, p < 0.01; I2 = 90%) in non-AFLS patients. AFLSs are prudent in the surgical management of ptosis. The results of this review demonstrate that their use is associated with similar complication rates but fewer reoperations than other traditional techniques.

The modified fascial sling technique for ulnar nerve anterior transposition: surgical techniques and results.

Background: Approaches to surgical treatment to cubital tunnel syndrome include simple decompression, decompression with medial epicondylectomy, and decompression with anterior transposition of the ulnar nerve. Transposition of the ulnar nerve involves decompression and transposition of the nerve anteriorly to a subcutaneous, intramuscular, or submuscular position. However, transposing the ulnar nerve to subcutaneous plane renders it more susceptible to external trauma. Hence, this technique article introduces the use of a modified fascial sling. Methodology: The modified fascial sling technique for anterior transposition of the ulnar nerve involves careful dissection to identify the ulnar nerve, decompression of the nerve, then transposition of the ulnar nerve anterior to the medial epicondyle. An AlloWrap (Stryker, Kalamazoo, MI, USA) is first wrapped around the ulnar nerve, followed by wrapping a fascial sling fashioned from the flexor carpi ulnaris fascia. A prospective case series for this surgical technique was conducted. Wilcoxon signed-rank test compared preoperative and postoperative qDASH-9 scores, an abbreviated questionnaire to assess functional limitations of the upper limb. Results: Five patients were included in this study, with a mean duration of follow-up of 530.4 days. The mean QuickDASH-9 functional disability score was 36.5 ± 25.1 preoperatively and 20.6 ± 12.8 postoperatively, demonstrating statistically significant improvement (P = .008). Conclusion: The modified fascial sling technique for anterior transposition of the ulnar nerve was developed to address the complications of perineural adhesions after transposition causing tethering of the ulnar nerve. At the same time, the fascial sling prevents posterior subluxation of the ulnar nerve back to its original location, thereby reducing the risk of recurrent symptoms.

Managing Ulnar Nerve Subluxation With a Medial Intermuscular Septum Sling.

BACKGROUND: Cubital tunnel syndrome (CuTS) is a lifestyle-altering peripheral neuropathy lacking a consensus for optimal surgical management. We describe creation of a fascial "V-sling" without ulnar nerve transposition, which is associated with increased surgical morbidity compared with decompression. The purpose of this study is to evaluate a novel technique with effective ulnar nerve decompression and subluxation prevention by creating a fascial sling in patients with CuTS and ulnar nerve subluxation. METHODS: We reviewed records of 39 elbows in 35 patients who underwent in situ ulnar nerve decompression and creation of a fascial sling in a "V" configuration to stabilize the nerve in its native position. We examined patient demographics, Single Assessment Numeric Evaluation (SANE) scores, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and patient outcomes. Chi-square and student's t test were used for all analysis. RESULTS: A total of 37 extremities in 33 patients undergoing nerve decompression had nerve subluxation confirmed intraoperatively. There was a statistically significant change in preoperative and postoperative SANE scores of 64.5 and 82.3, respectively. Mean QuickDASH scores decreased significantly from 49.3 preoperative to 10.8 postoperative. The long-term QuickDASH scores obtained at mean of 564 days were maintained at 10.76. CONCLUSIONS: This study describes a novel technique for treating CuTS by achieving in situ nerve decompression and addressing ulnar nerve subluxation with creation of an intermuscular septal sling. The technique improved functional outcomes and provided symptomatic relief, while avoiding risks commonly associated with nerve transposition.

Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment.

BACKGROUND: Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI. METHODS: A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions. DISCUSSION: There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.

A novel approach to identification and excision of a persistent sinus tract following a rectus fascial sling: A case report.

BACKGROUND: While Gore-Tex® sutures have excellent handling and cause minimal fibroblast activity and a less inflammatory response compared with other materials, they carry a risk of persistent sinus tract formation. CASE: A patient underwent an autologous rectus fascial sling using Gore-Tex® and we describe a novel technique for identification and excision of the sinus tract. CONCLUSION: Preoperative imaging and staining of the sinus tract with methylene blue can aid in successful identification of the tract during surgery and may improve rates of successful treatment.