While synthetic midurethral slings are the current gold standard for surgical treatment of stress urinary incontinence in the United States, fascial slings remain an important surgical technique. These are useful in cases where synthetic mesh is inappropriate or for salvage procedures when a midurethral sling has failed. While the standard pubovaginal sling includes a rectus fascia graft, a fascia lata graft is an excellent alternative procedure. This video presents our technique for a minimally invasive fascia lata graft harvest and pubovaginal sling procedure. The patient is a 56-year-old woman with refractory mixed urinary incontinence. She had previously undergone a trans-obtrator sling but had recurrent stress urinary incontinence. She underwent a repeat synthetic midurethral sling. This sling was complicated by a mesh erosion managed by a revision and then excision of the vaginal portion of the sling, which led to recurrent stress urinary incontinence. She desired repeat surgical management but wanted to avoid mesh. Her past medical history was significant for tobacco use and obesity, and her surgical history was notable for three prior fan and steel incisions, two cesarean sections, and an abdominal hysterectomy. Given her prior sling failures and the patient's desire for surgical treatment, she was counseled regarding a fascial sling with a plan to use fascia lata instead of a rectus fascia graft due to concerns about her rectus fascia quality. Prior to fascia lata harvest, it is essential to pay attention to patient positioning as well as anatomy before draping. The patient is placed in low lathotomy position with internal hip rotation of the leg for better access to the planned harvest site. The relevant bony anatomy is marked, including the greater trochanter and the lateral epicondyle. The intended area for harvest is approximately three to four centimeters medial to the iliotibial band that connects these two important landmarks. Once the patient is prepped and draped, the incision site is marked. This incision is approximately six centimeters superior and four centimeters medial to the lateral epicondyle. This incision measures four centimeters. We prefer this transverse incision over the alternative, a long longitudinal incision. Saline, or a local anesthetic if preferred, is injected. An incision is made with the scalpel which is carried down to the fascia with careful electrosurgery. Skin hooks are useful throughout the case as they allow excellent visualization of the fascia despite the small skin incision. One could consider the use of a small wound protector. Once the fascia is visualized, it is further cleaned off using a sponge and blunt dissection. Hydrodissection between the fascia and overlying fat is performed with injectable saline or local anesthetic which facilitates dissection and minimizes blood loss. Dissection is achieved by advancing a closed metzenbaum scissors against the fascia and spreading the blades. Care is taken to advance dissection in the same direction, avoiding lateral or medial deviation. Palpation with the surgeon's finger confirms adequate clearing of the fascia and adequate length of the intended graft. The incision is extended inferiorly as well, approximately one to two centimeters, to allow maximum graft size. The intended incision on the fascia is measured and marked approximately two centimeters wide. An incision is made with a knife. Care is taken not to disrupt the subfascial muscle. The superior rectangular graft extended with the metzenbaum scissors. A retractor under the prefascial fat and skin is utilized to visualize the superior aspect of the fascia, and the rectangular graft is extended with the metzenbaum scissors. We prefer to use this technique, but a fascial stripper device could also be used for this step. This dissection is continued until the graft measures at least eight centimeters. This is imperative, as this length will allow the graft to reach the retropubic space in order to adequately scar. The graft is then cut at the base and excised. Hemostasis is achieved. A surgeon could consider closing this potential space with barbed absorbable suture to prevent seroma or hematoma formation. The subcutaneous tissues are closed in multiple layers. After bandages are applied, the patient is undraped and the leg is wrapped in an elastic bandage. The purpose of this pressure bandage, which will remain in place for at least 24 hours, is to avoid bleeding and potential seroma formation. The patient is then repositioned into high lithotomy position, reprepped, and redraped. We then proceed with the vaginal portion of the case for standard placement of a pubovaginal sling. During this portion of the procedure, we pay attention to three key steps, creation of adequate periurethral pockets, penetration into the retropubic space, and appropriate tensioning when tying the anchoring sutures. After injection of dilute lidocaine and epinephrine, a midline vaginal incision is made, and the vaginal epithelial flaps are mobilized bilaterally to create periurethral pockets. Alternatively, an inverted U-incision could be used. The retropubic space is entered sharply with Mayo scissors. To ensure adequate space for the graft, the scissors are spread in a longitudinal fashion. A small transverse abdominal incision, three centimeters or less, is made two finger breadths above the pubic bone, and blunt dissection is used to take this dissection down to the fascia. Minimal dissection is needed compared to a rectus fascia sling. One stamy needle passer is then passed on each side, two centimeters lateral to the midline, and passed under fingertip control behind the pubic bone and into the vaginal incision. We prefer to use either 15 or 30 degree needle passers. Cystoscopy is performed to confer no bladder perforation. The graft had previously been prepared with anchoring stitches on the lateral ends. Using the stamy needles, these suture ends are brought through the incision, bringing up the graft as well. As discussed previously, it is imperative that the graft ends reach the retropubic space in order for appropriate scarring to occur. This length is typically at least eight centimeters, although anatomy may vary. The sling is then appropriately tensioned in the midline by tying the two anchoring sutures together in the abdominal incision. Surgical techniques vary, but we prefer to tension the sling with three finger breadths between the knot and the fascia. We secure the sling proximally and distally to the urethra using a 3-0 polygalactin suture. The abdominal and vaginal incisions are closed. The patient had an uncomplicated hospital course and was discharged on postoperative day number one with minimal pain requirements. In summary, pubovaginal slings are important procedures for FPMRS surgeons to be able to offer patients. This could be in cases where synthetic midurethral slings fail or if patients have contraindications or aversion to mesh. Although fasciolata slings do require a second incision, in our hands we feel that this technique of fasciolata harvest and pubovaginal sling may provide a shorter recovery time than a traditional rectus fascial graft.

minimally invasive

fascia lata graft

pubovaginal sling procedure

stress urinary incontinence

harvesting technique