Discussion:
To our knowledge, this is the first description of the technique of laparoscopic autologous rectus fascial sling insertion under the mid urethra (LMAFS) to treat female stress urinary incontinence. We demonstrated the feasibility and safety of the technique. The advantages of this technique include the small incision in the lower abdomen, with much quicker recovery and reduced wound complications, introduction of the sutures holding the sling under direct laparoscopic guidance, which avoids the complication of bladder, bowel, nerve and vascular injury with blind introduction of the needles. This is particularly important in cases of previous surgery for urinary incontinence where the bladder can be adherent to the pelvic bone. Furthermore, fixation of the strings to the Coopers ligaments maintains the sutures original tension and allows accurate tensioning of the strings, and avoids over lightning of the sling and voiding dysfunction, which can occur with the attachment of the sutures to the rectus fascia.
The safety of mesh devices has been the subject of substantial scrutiny over the past decade owing to patient reports of adverse events during extended follow-up, including tape or mesh exposure, groin or thigh pain, and dyspareunia, with lawsuits filed against mesh manufacturers in various countries6. A recent randomised controlled study by Abdel-Fattah et. al. showed that mini slings were non-inferior to mid-urethral slings in efficacy in managing SUI6. Efficacy, however, was not the reason behind suspension of mesh mid urethral slings in the United Kingdom, but rather concerns over safety and complications. In our technique, the autologous nature of the graft used as mid urethral sling, avoids the mesh related complications of synthetic tapes. Side effects and complications related to mesh use continue to be a major cause of concern, being reported in up to 9.4% of women following mid urethral mesh tape insertion7. Abdel Fattah et. al. reported the same complications related to mesh including vaginal mesh erosion, chronic groin and thigh pain, and revision surgery needing mesh removal6. The above complications were the main reasons behind suspension of the mid urethral mesh tapes in the United Kingdom (ref 6). Hence, surgeons and patients have been looking for non-mesh native tissue surgical options for management of stress urinary incontinence. These options include urethral bulking agents, colposuspension (open or laparoscopic) and the autologous fascial sling. Colposuspension, increases the risk of new onset vaginal prolapse (rectocoele) due to the access of traction by the suspensory sutures of the vagina.
According to the integral theory1, restoring mid urethral support is the most anatomically sound method for treatment of SUI, which has repeatedly shown to be successful in treating SUI with the use of mid urethral tapes. The traditional autologous fascial sling can achieve this but is associated with complications, including high rates of voiding dysfunction, especially as the original techniques involved placing the sling under the bladder neck, rather than the mid urethra2, 3, the need for major abdominal surgery (as shown in the video of this technique by Asfour et. al.4), with resultant wound related complications and prolonged recovery, particularly in patients with raised body mass index. Furthermore, blind introduction of the ends of the fascial sling increases the risk of visceral perforations. We believe that attaching the strings (sutures) to the Cooper’s ligament as a fixed structure is advantageous to attaching the strings to the rectus fascia, which can alter the tension of the sling as the wound is healing with resultant swelling, or loosening of the tension as the rectus fascia gets weaker with age. The novel technique described in this paper and video provide major benefits to patients as described above, and provide the peace of mind of avoiding the short and long-term complications of mesh insertion.
There are limitations to this paper, including the difficulty in assessing the learning curve needed before reaching competence in this technique. Furthermore, the follow up reported here is the 12 months follow up, and although the follow up data have been reassuring, we plan to annually review our patients for any medium to long term recurrences.
Acknowledgement: None.