Approach to Laparoscopic Colposuspension in Cases of Failed Tension-Free Vaginal Tape

Abstract

Video Objective To demonstrate a modified technique of performing a laparoscopic colposuspension in a patient with a failed tension-free vaginal tape (TVT). Setting Tertiary urogynecology department at a University Hospital. Interventions A 58-year old woman with a previous TVT inserted presents with recurrent stress incontinence. Patient declined further use of mesh and bulking agents. Conclusion Mid-urethral slings (MUS) have equivalent cure rates to the more invasive colposuspension. They are preferentially used for stress urinary incontinence (SUI) despite a mesh erosion rate of 3.5% with 2.5% requiring further surgery, sling removal, or revision over 9 years. [1][2] Recent negative publicity concerning synthetic mesh tape has led to a resurgence of interest in mesh free alternatives, including urethral bulking agents, rectus fascia slings and colposuspension. Laparoscopic colposuspension is a well-established minimally-invasive surgery that avoids synthetic mesh, with a quicker recovery, less scarring, and equivalent success to an open approach. [3] Bladder neck mobility is an important marker during selection of this technique. In this video, we demonstrate our transperitoneal technique of colposuspension in the case of a failed TVT. This technique allows clear visualization of the operating field and is faster and less bloody than a full dissection. As complications can ensue from extensive excision and extraction, unless the previous TVT has caused problems such as pain, we normally leave it in situ. Careful dissection is undertaken into Retzius space to the paravaginal tissues where the iliopectineal ligament is located. On each side, we apply two extracorporeally tied non-absorbable Ethibond sutures as recommended [4], caudal and lateral to the TVT, lifting the paravaginal tissues to the ligament. The knot placed on the ligament side to minimize erosion risk. The peritoneal defect is closed with vicryl 2.0. This technique offers a viable mesh free option for treatment of recurrent stress incontinence in women who have had failed TVT.