V2-02: Autologous Fascial Pubovaginal Sling: Contemporary Indications, Techniques, and Challenges

Video

Introductions and Objectives
The autologous rectus abdominus fascial pubovaginal sling has been widely used since McGuire and Lytton’s description in 1978. _x000D_ _x000D_ A recent series of 66 women from our institution with complex incontinence after failed synthetic midurethral sling showed that with a mean follow-up of 14.5 months, treatment with autologous fasical pubovaginal sling achieved a 69.7% cure rate of stress urinary incontinence using this technique._x000D_ _x000D_ This video will demonstrate the detailed surgical technique for autologous rectus abdominis fasial pubovaginal sling and its variations, and will review contemporary indications for this procedure, as well as situations that may be challenging to the surgeon.

Methods
We provide detailed photographic and videographic description of the steps of the procedure, including harvest of rectus abdominis fasica which is attached to sutures at either end, vaginal dissection of the bladder neck location of the sling, passage of the fascial sling under the bladder neck into the retropubic space, and passing of the suture ends passed through the abdominal wall to be tied above the rectus fascia. _x000D_ _x000D_ Prior vaginal or retropubic surgery can make dissection more challenging, and exposure vaginally and abdominally is facilitated by appropriate instrumentation. Lateral dissection in the retropubic space and the use of a vaginal inverted U flap incision can help facilitate safe dissection in previously operated areas. Difficulty passing the sling can be avoided by slight dilation of the tract with an instrument, or by passing an instrument along side the sling as it is brought into the retropubic space. The use of a free needle can aid in precision and save time when passing the sling sutures through the abdominal wall fascia to be tied. The sling is tensioned while observing the mobility of the bladder neck by placing traction on the foley catheter.

Results
We provide a description of contemporary variations and tips for streamlining autologous fascial pubovaginal sling for the surgeon who treats female stress urinary incontinence.

Conclusions
Autologous fascial pubovaginal sling is an effective procedure in the treatment of complex incontinence or selected primary incontinence patients in the era of synthetic sling complications and failures.

Funding: None