JOURNAL OF FEMALE
PURPOSE: The aim of this article is to review
the current state and technique of pubovaginal sling construction using cadaveric
allograft fascia lata.
The author made
a research through MEDLINE to identify the most relevant publications referring to
pubovaginal sling surgery. The need of this was to make an evaluation about the results
with the use of cadaver fascia lata.
Normally, to do a pubovaginal sling, a tape or strip of the fascia of the muscle of the abdominal rectum, thus, using and autologous material. Meanwhile, many studies have been made in the sense that heterogonous materials are used, or even synthetic ones. Among the biological materials we find fascias of human muscle, silastic or polypropilene and the polytetrafluorothylene. Even though there exist several accounts of treatment with the use of these materials, there is still a preoccupation that refers to the erosion of the urethra, which, through surgical procedure, remains in contact with these materials.
In relation to the heterology fascia, the authors refers to the importance of the preparation of the material, which I believe is important to mention: washing of the material in antibacterial solutions and antiviral, cold washing, lyophilization dry cooling it, dehydration of the material and radiation with gamma rays. Meanwhile, this processing of the heterogonous material does not totally eliminate the possibility of antigenicity, because, among other cellular elements, the nucleic acids may persist in the material.
When we use animal fascia we must consider the possibility of several infections common to these that may eventually contaminate human beings. On the other side, using human cadaver fascias, the preoccupation lies also in the possibility of transmitting HIV, hepatitis virus, the transmission of cancer cells, bacteria, syphilis, rabies and so on.
The author considers that the possibilities of any complications that may occur are minimum with the utilization of these materials, once all the care is taken in preparation of the materials. He also makes clear that even though many techniques are used for the placement of the pubovaginal sling, there are still doubts to the choice of the incision, the extension of he perforation of the urethropelvic ligament, to the degree of urethrolysis, the dimensions of the sling and the choice of the place of fixation. He considers that there are two critical factors for the success of the surgery in womens urinary incontinence: the exact identification of the urethrovesicle junction and the correct placement of the sling.
The author talks about six projects done with the fascia lata of a cadaver, between 1996 and 2000. In these, the percent of subjective improvement (post-operative use of none to two pads a day) changed from 83 to 98% and the percent of cure from 63 to 79% in a post-operative follow up that varied from 6 to 19 months.
These projects were compared with other six published between 1997 and 2000 and were done with an autologous fascia lata. In these, the percent of subjective improvement varied from 85 to 94% and the cure was of 46 to 82%, in a segment of 3 months to 4 years.
He concluded that the results were similar, which would justify more debates in relation to the use of cadaver fascia lata that, among other advantages would diminish the surgical time and death. Notwithstanding, he has his reservations; the data was compared in an evolution of post-operative of short duration, since there are no available data of evolution of a long term, when a fascia lata of a cadaver is used.
In my opinion, more studies are necessary to have the exact knowledge of the use of the autologous fascia lata (of a human cadaver) and heterogonous (from animals). Besides the preparation of the material, as mentioned above, it is necessary to establish (in accordance with each laboratorial technique of the preparation of the material) the specific reactions of the host in the presence of a homologous or heterogonous grafting, and if these reactions would not be responsible, eventually, for the unsuccessful surgical procedures.
Aparecido Donizeti Agostinho
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