07: A minimally-invasive modification for fascia lata mid-urethral sling

Abstract

The aim of this video is to demonstrate modifications which permit an autologous fascial sling to be performed in a minimally-invasive way. Both the Crawford and Masson fascial strippers are demonstrated on a cadaver. A 4cm transverse incision on the lateral aspect of the thigh approximately 6cm superior to the lateral femoral epicondyle is made. The stripper is advanced for fascial harvest. The “sling on a string” is prepared with a 2-0 monofilament suture transfixed at each end. A tie is placed around the suture insertion points to bind the fascia and provide greater tensile strength. A 1cm midline suprapubic incision is made in preparation for a single trocar exit site. Bilateral tunnels are created extending from the mid-urethra to the inferior aspect of the pubic symphysis in the usual fashion. The monofilament suture leader is then placed in a groove on the retropubic sling trocar. The trocar is advanced through the vaginal incision, aiming initially for the ipsilateral shoulder. Once the tip reaches the abdominal fascia, but before it pierces it, the trocar is directed medially to allow exit via the 1cm midline suprapubic incision. The sling is placed flat under the mid-urethra. A clamp resting between the mid-urethra and graft ensures the desired degree of tension. The sutures are tied suprapubically to each other across the midline over the fascia while the desired loose placement is maintained at the mid-urethra. These are techniques which preserve both function of the leg and maintain high patient satisfaction. Loose placement of “sling on a string” at the mid-urethra likely lowers risk of voiding dysfunction and urinary retention compared to urethrovesical junction under tension. This minimally-invasive technique is appropriate to consider as a primary sling for patients seeking to avoid mesh.