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.