Stress urinary incontinence is an involuntary leakage of urine with physical activity that increases intra-abdominal pressure. 40% of women will have stress incontinence in their lifetime. The pathophysiology is usually due to a loss of urethral support. If conservative management, such as pelvic floor muscle training or pessaries, fail, the surgical treatment is a mid-urethral sling. 12-20% of women may experience recurrent or persistent stress incontinence after a sling. After failure or complications with synthetic mesh, many surgeons choose to move toward autologous graft slings. A recent study showed a 70% cure in stress incontinence using a fascial sling after mesh failure. Another study looked at women who had removal of the failed mesh prior to placement of the fascial sling. This study showed a 91% success rate. There was no difference in outcomes of women who had a staged surgery versus women who had mesh excision at the same time as replacement with a fascial sling. A recent randomized controlled trial showed that outcomes with autologous fascial slings were better than porcine slings and were no different from mesh slings. The limitations of autologous fascial slings are the longer operating times and longer hospitalizations. Therefore, they are usually used only as second line treatments in patients who have already failed mesh. Patient LW is a 45-year-old G3P2012. Ten years ago, she underwent a total vaginal hysterectomy, high uterosacral ligament suspension, and transopterator sling. LW returned complaining of urinary urgency, frequency, voiding dysfunction, and recurrent UTI and was found to have transurethral erosion of the mesh. She underwent total transvaginal removal of the midurethral sling along with urethroplasty. Although her urge incontinence improved, the stress component of her mixed incontinence severely worsened. After three months of conservative management, LW desired more definitive treatment. She was counseled regarding options of repeat mesh sling or pubovaginal sling with choice of allograft, xenograft, or autograft. LW chose to have an autologous fascial sling using the fascia lata. Patient was positioned in the left lateral decubitus. The three incisions were marked at 2 centimeters above the lateral epicondyle, the mid-thigh, and at the level of the greater trochanter. Injections were made after being injected with 1% lidocaine. Long Metzenbaum scissors were used to bluntly dissect the subcutaneous fat off of the superficial fascia lata to the level of the greater trochanter. The fascia was then incised approximately 2 centimeters above its insertion at the epicondyle. The fascia lata was bluntly freed from the underlying muscle. The distal fascia lata was incised up to the middle incision approximately 1 centimeter wide using long Metzenbaum scissors. The distal fascia lata was then passed up to the middle incision. We then repeated the incision and passage of the sling. From the middle incision to the upper incision. The fascia lata was then severed at the most proximal incision. The strip was approximately 22 centimeters long. The leg incisions were irrigated. The subcutaneous fat was closed with 2-O-Vicryl and the skin was closed with 4-O-Monocryl. The leg was wrapped tightly in a large ace bandage. The patient was then repositioned into dorsal lithotomy. A 6-centimeter suprapubic incision was made. The fascia was perforated 4 centimeters from the midline bilaterally. We then relocated vaginally. The anterior vagina was injected with 1% lidocaine and a vertical incision was made under the mid urethra. This was sharply dissected to separate the urethra from the vagina bilaterally until the retropubic space was entered. Uterine dressing forceps were passed through the left fascial opening in the suprapubic incision down through the retropubic space adjacent to the pubis and the tip was guided in the tunnel created vaginally and through the suburethral incision. The sulcus of the vagina was inspected and found to be intact. 2-O-proline suture had been attached to the end of the sling and was grasped with uterine dressing forceps and pulled back through the abdomen where it was tagged. This was repeated on the right fascial incision. Cystoscopy was then performed, revealing no evidence of perforation or foreign body in the bladder. Bilateral ureteral orifices were effluxing normally and the urethra was noted to be intact and normal. Once the bladder was drained, the fascia lata arms were brought through the openings in the rectus fascia and were adjusted to secure the sling against the urethra. A Kelly clamp was used to help tension the sling appropriately. The sling arms were secured to the rectus fascia using 2-O-proline. The suprapubic incision was closed with 2-O-vicryl subcutaneously and 4-O-monocryl for the skin. The midurethral incision was closed with 2-O-vicryl. Patient L.W. tolerated the procedure well. She was discharged home on post-op day four with a Foley catheter. She returned to the office on post-op day seven where the Foley was removed. L.W. passed her voiding trial without complication. After one month, L.W. reports a 70% improvement in her urinary incontinence with no stress incontinence. In conclusion, tensor fascia lata harvest for pubovaginal sling is a viable option for women who have failed previous slings. Although the operation time and hospital stay may be longer, the outcomes with regards to cure rate and patient satisfaction are similar to patients with synthetic slings. Therefore, autologous fascial slings are a great second-line treatment for women who have already failed mesh slings.

stress urinary incontinence

urethral support

autologous fascial slings

mesh failure

case study