07 Fascia lata autologous transobturator midurethral sling

Abstract

The objective of this video is to demonstrate a minimally invasive approach to transobturator autologous sling placement with a novel anchoring system. Autologous fascia slings are typically placed using a retropubic approach1 but there is little data on use of fascial slings with a transobturator approach.2,3 This may be secondary to difficulty anchoring the sling at the desired tension, a technical challenge we aim to address. Fascia lata is a viable resource for sling graft, which can be harvested in a minimally invasive fashion, avoiding abdominal incision. Using a 3 cm transverse incision on the lateral thigh, a Crawford fascial stripper is used to harvest a 12 cm by 1.5 cm graft. The length of the graft is purposefully 12 cm to include the 6.4 cm obturator-to-obturator distance4 and approximately 3 cm on either end for anchoring. The graft is prepared for insertion by removing fat and creating frictional ends (inspired by “hook and loop” technology) with delayed-absorbable monofilament barbed suture. A 0-Vicryl tie is used to further secure the barbed suture and increase tensile strength of the graft. A 2-0 monofilament suture is used to create a loop at each end of the graft for tensioning. The graft is passed from a mid-urethral vaginal incision through the obturator foramen in a similar fashion to polypropylene mesh for stress incontinence. Loose tensioning is maintained by holding a knuckle of graft with an atraumatic instrument, while guiding the middle of the graft to the mid-urethra. The tensioning loops and the knuckle are then released, leaving a tension-free autologous mid-urethral sling. Loose placement at the mid-urethra through a transobturator approach likely decreases the risk of urinary retention5, irritative voiding symptoms6, and voiding dysfunction7. This minimally invasive technique is a practical approach to the patient with aversion to mesh, risk factors for poor healing and higher likelihood for de novo or exacerbation of voiding dysfunction.