Hello and welcome to this video on multi-compartment ultrasound imaging of mid-retinal slings, the good, the bad and the ugly. Mid-retinal slings are the mainstay in the treatment of SUI, however success rates are highly variable. Reasons for failure following sling surgery include incorrect diagnosis, poor placement technique, mesh related problems. Multi-compartment ultrasound imaging can help understand the in vivo behavior of slings and help clarify the reasons for failure. Multi-compartment imaging includes transperineal two-dimensional functional imaging with the 8802 transducer, 180 degree scan of the anterior pelvic compartment with the 8848 transducer and 360 degree scan of the pelvis with the 2052 transducer. Dynamic functional assessment can also be done during cough, squeeze and valsalva maneuvers. Now what constitutes a good mid-retinal sling? This is a dynamic film in the sagittal plane with the transperineal probe 8802. Here you can see the bladder, the urethra, the symphysis pubis and the vagina. The sling is seen as a slightly curved eco-dense structure beneath mid-urethra. On dynamic assessment, the sling and the urethra are seen to move in a concordant manner. The sling bends into a C-shape and achieves dynamic compression of the urethra. Here you can see the same sling in the axial plane using the transperineal probe. You can see that the sling hugs the urethra in a hammock-shaped manner. This is urethra and this is the bladder. On dynamic assessment, the sling is seen to compress urethra in a dynamic fashion. Now let's look at the same sling with the endovaginal probe 8848 in the sagittal plane. The probe is in the vagina looking up at the anterior pelvic compartment. Here you can see the bladder, the symphysis pubis and the urethra. The sling can be seen mid-urethrally casting a shadow across the urethra. On dynamic assessment, the sling and the urethra can be seen to move in a concordant manner. However, this is a dynamic film in the sagittal plane obtained with a transperineal probe. Here you can see the bladder, the urethra and the sling. The sling is located proximally beneath proximal urethra. On dynamic assessment, the bladder moves independent of the sling. The urethrovesicle junction shifts distal to the sling and the sling exerts no effect on the urethra. This is a failed sling. Now let's look at this transperineal dynamic film of a failed TVT sling in the sagittal plane. Here, you can see that the sling is located mid-urethrally beneath the urethra. On dynamic assessment, the bladder moves independent of the sling. The urethrovesicle junction shifts distal to the sling. Often, in patients with failed slings, the location of the sling as seen on transperineal ultrasound differs from that seen on endovaginal ultrasound. Now this is a dynamic transperineal film in a patient with failed TBT sling. The sling is located proximally beneath proximal urethra. However, on dynamic endovaginal assessment of the same patient, here to reorient ourselves, one can see the bladder and the urethra. The sling is seen to be located proximal to the urethrovesicle junction and is non-functional. It may be that the sling has not fixated or has been inserted so loosely that it has got in independent of the urethra and therefore, when the probe is inserted into the vagina, the bladder moves independent of the sling. Often, in patients with failed slings, the location of the sling can vary. In this film with failed TOT sling, the sling is seen to be bunched and located proximally. In this film, the sling is situated distally and hence is non-functional. Here we see the same sling in the axial plane. It is evident here that the sling is non-functional during Valsalva maneuver. Dynamic assessment of the sling offers useful information in case of voiding dysfunction. This is the endovaginal dynamic film in a patient with voiding dysfunction following TBT sling. Here it is seen that the sling impinges on the urethra and causes compression of the urethra during Valsalva maneuver. We are offering therefore patients with history of multiple failed slings or multiple sling surgeries and bulking agent injection. It is prudent to map out the location of the slings to plan future treatment. This is a transperineal dynamic film of a failed TOT sling and a failed TBT sling. It is evident during dynamic assessment that both slings are non-functional. This is a dynamic endovaginal film of two slings located next to each other. You can see the slings casting a shadow across the urethra. Here you can see two failed slings located distally, one on top of the other. A curved TBT sling lying posterior to a flat TOT sling. In this dynamic endovaginal film, one can see three failed slings and bulking agent injected proximally. This is the proximally located proline pad sling, mid-urethral TBT sling and the distal TOT sling. This is the bulking agent injected in the posterior wall of proximal urethra. Three-dimensional ultrasound gives us a 3D cube that can be manipulated in any plane to follow the course of the sling. This is a 3D cube in a patient with a failed single incision sling. The probe is in the vagina and the pelvis has been scanned 360 degrees. When the cube is manipulated in a keflap direction, the urethra comes into view. Even vocaflap, one can see the sling hugging the urethra. On the right of the patient, the self-fixating tip can be seen detached from the obturator membrane. On the left of the patient, when we manipulate the cube in an oblique plane, the sling can be seen to follow a tortuous course towards its insertion in the obturator membrane. In conclusion, multi-compartment ultrasound imaging is a useful diagnostic tool in the follow-up of patients with failed sling surgeries. Causes for failure of sling surgery evident in this video are overly loose placement, lack of lateral fixation, placement in a non-flat configuration, and lack of fixation to the mid-urethral soft tissue. Thank you.

multi-compartment ultrasound imaging

mid-retinal slings

stress urinary incontinence

sling surgery

sling mapping