aavis patient information

RETROPUBIC AND TRANSOBTURATOR SLINGS

1. INTRODUCTION

The decision to undertake surgery is an important one. It must be realized and accepted that complications may occur. Although major complications are not common, they may be disabling and even life threatening, and may require further surgery to correct. This can lead to prolonged recovery time and even permanent disability. The benefits of the operation must be weighted against the risks. A full consideration of alternative treatments should be made including the consequences of no treatment. It is your responsibility to make sure that you understand the proposed surgery and to ask any questions if you are unsure.

2. PROCEDURE

A sub urethral sling is performed to correct urinary incontinence. This occurs because the pubo-urethral ligament, which attaches the urethra to the pubic bone, becomes stretched and loose due to childbirth and age. It cannot counteract the backward pull of the pelvic muscles, which open or funnel the urethra with coughing or straining, and this leads to stress incontinence. In addition the looseness of the urethral supports can lead to premature activation of the micturition reflex, causing frequency and urgency of urine.

In essence, a tape is inserted under the urethra and brought out through two small incisions above the pubic bone (retropubic e.g., IVS, TVT, SPARC) or in the groin (transobturator e.g., Monarc, TVT-O) on each side. There is a fibrous reaction around the tape, which acts as an artificial ligament to strengthen and replace the weakened ligament. A transobturator sling also reduces the risk of bladder or bowel damage by avoiding the retropubic space. The tape also acts as a hammock below the urethra. A small repair is then performed under the urethra to further protect the tape. No vaginal pack or catheter is required.

3. ADMISSION TO HOSPITAL

This normally occurs the morning of the operation. You should have nothing to eat, drink or smoke from midnight the night before. If the operation is to be in the afternoon, you can have a light breakfast before 6.00am eg toast, tea or coffee. If you develop a cough, cold or fever before the operation it may need to be postponed.

The appropriate anaesthesia will be decided by the anaesthetist in discussion with you. The anaesthetist will arrange the appropriate premedication if required. The operation can be performed under local anaesthesia. If you are currently taking Aspirin, Indocid, Naprosyn or other anti-inflammatory drugs, these should be discontinued ten days before the operation. Please bring a packet of sanitary pads with you to the hospital with your own night attire and toiletries.

4. RECOVERY

Your will wake up in the post operative recovery room within the theatre complex. You may have an oxygen mask fitted comfortably over your mouth and nose. There may be an intravenous "drip" (IV) needle in your arm. Analgesic medication will be prescribed to prevent any post operative pain. The pain is usually minimal as local anaesthetic is injected into the operative area.

There may be some nausea and vomiting, although medication to counteract this is routinely given during this operation. If you continue to feel nauseated, notify the nursing staff so that further medication may be administered. The nursing staff will measure the volume of urine left behind each time you empty your bladder to make sure that there is no retention of urine. This is usually done with an ultrasound machine. The amount of vaginal bleeding will be checked on a regular basis. Once fluids are tolerated, the intravenous 'drip' will be removed. You will normally be discharged home the afternoon of the operation or the next morning. A longer hospital stay can be arranged according to personal circumstances.

5. DISCHARGE HOME

The operation was designed for patients to return to work and normal activities as soon as possible i.e. you can usually drive your car, cook, shop, look after your children within a day and return to work within 7-14 days. However, in some patients, recovery may take longer.

Please remember to be sensible. Most operations that fail to do so because sutures tear out of the vagina due to excessive straining and lifting. Vaginal intercourse should be avoided for 6-10 weeks. The sutures will take 3-4 months to dissolve, and if necessary can be removed earlier. Avoid tampons during this time and prevent constipation with orange juice, bran and other fibre products.

It is important to exercise extreme care when getting in and out of a car or getting up from a chair. In particular, the knees should be kept together as much as possible during activity, especially lifting and squatting.

6. FOLLOW-UP

After the operation you should contact your surgeon if there is a problem. There is a follow-up visit at 6 weeks. There may be some vaginal bleeding for the first few days after the operation. You should be able to pass urine normally. For the first few days, you may experience some urgency i.e. a desire to pass urine frequently. this could be a result of the catheter used at the operation or due to swelling around the sutures.

7. RESULTS OF THE OPERATION

The results of any operation cannot be guaranteed, but cure of incontinence is achieved in 90%. A subsequent small operation may be necessary to improve the results. As the fibrous tissue around the tape contracts, the result can continue to improve gradually over many months.

8. COMPLICATIONS

Complications are rare, but it must be understood and accepted that these can occur. These include:

a) Infection - there may be a simple infection of the urine or wound requiring antibiotics alone. However, a pelvic abscess could develop requiring drainage.

b) Haemorrhage - this is extremely rare. May be associated with damage to large veins behind the pubic bone or within the muscles of the thigh.

c) Pain - unlikely to be significant in this day surgery procedure.

d) Injury to Bladder - the instrument inserting the tape may pierce the bladder as it is passed up behind the pubic bone. If seen immediately, it is withdrawn and the bladder heals up without further treatment, much as it does with a supra-pubic catheter.

e) Fistula Formation - if the tape passes through the bladder, there would be a leakage around the abdominal scar. Removal of the tape allows this to heal.

f) Retention of Urine - this is rare but may occur if the sutures have been tied too tight. Removal of one suture will overcome this problem.

g) Deep Venous Thrombosis - a possible complication of any surgery, but much less likely with this type of operation where you are mobilized

almost immediately.

h) Rejection of the Tape - is extremely rare with polypropylene tape. This will lead to a heavy yellow vaginal discharge and the tape will need to be removed. This is a tissue reaction, not an infection.

i) Anaesthetic complication - can occur with any operation but the chance is extremely low.

New techniques are currently under development which reduce the risk of damage to adjacent organs and blood vessels even further.