While synthetic mid urethral slings are certainly the standard and most commonly utilized slings, certain situations necessitate utilization of a biologic material. While these indications are not fully agreed upon, in our practice we feel that autologous rectus fascia bladder neck slings are indicated on the following situations. In patients with stress urinary incontinence who declined to have a synthetic material implanted. In patients who have had prior complications secondary to a synthetic material such as an erosion or extrusion. In patients who have been irradiated. In patients who are currently undergoing simultaneous or have had urethrovaginal fistula repair or diverticular repair in the past. Or in the particular situations where patients have had an unsuccessful mid urethral sling placement and in this situation we feel that it may be best to go back to the bladder neck. In this video we will demonstrate a modality for harvesting the sling from the rectus fascia, discuss the different vaginal incisions possible, mobilization of the bladder neck and entry into the urogenital diaphragm, positioning of the sling and appropriate tensioning. The procedure is started through a suprapubic skin incision. The fat tissue is retracted and the fascia is exposed and identified. The area of the fascia to be excised is marked with a monopolar cautery knowing that the sling should be around 1-2 cm in width and 7-10 cm in length. The abdominal defect is then closed with sutures. The vaginal portion of the procedure is then begun. In this case, the patient had undergone a previous DVT one year earlier and this had eroded into the vagina. After hydrodissection, a midline vaginal incision is made. Some surgeons have a preference for performing an inverted U-shaped incision instead of a midline incision, and this theoretically allows for less contact of the fascial sling with the mucosal closure suture line. During the procedure, a majority of the TVT tape will be excised in the hope of preventing any future erosion. Sharp dissection is utilized to mobilize the tape away from the vagina and subsequently from the urethral tissue. Traction and counter traction facilitate this procedure, and sharp dissection is needed as the tape is adherent to the vaginal tissue. It is advisable to remove the tape back to the level of the inferior pubic ramus if at all possible. The tape in this case is removed on the right side where the erosion had occurred. Care must be taken to avoid injury of the urethra. Here both sides of the mesh have to be excised to the level of the pubic ramus. The dissection is extended approximately to the level of the bladder neck, and the spaces will be created to place the pubovaginal sling. The urogenital diaphragm will be sharply penetrated due to scarification that occurred from the previous TVT tape. The spaces are developed to allow the passage of the rectus fascia sling arms up into the retropubic space. In order to open the spaces, the scissors are placed in direct contact with the inferior pubic ramus, and the urogenital diaphragm is penetrated and enlarged digitally. The fascial edges are then trimmed and the strip is cleaned. Then 0-ethabond suture is attached to each side of the sling. Using a marking pen or hemostat, the sling is marked in the midline to allow for symmetry of the sling arms when placed in the retropubic space. A stamy needle is passed under direct finger guidance through the suprapubic incision to the vaginal incision, and the sutures are passed through openings of the stamy needle. Sutures are then transferred suprapubically and the arm of the sling is passed up into the retropubic space, and this is repeated contralaterally. This portion of the procedure can be done, if needed, with dressing forceps, a parerineedle, or a double-pronged ras needle. Elevating the sutures will bring the sling into direct contact with the urethra. Tensioning of the sling should be done as such, to allow the sling to be loose enough to act as a backboard preventing downward descent of the urethra with provocation. A small sysaseal is placated with two ovicral sutures before the final tightening of the fascial sling. The sling is tied loosely by tying the ethabond sutures across the midline. To prevent excessive tensioning, one can see that we typically place an assistant's finger at the level of the incision abdominally and tie around it. A right angle clamp is also placed between the sling and the urethra to prevent untoward tightening or tensioning of the sling. This maneuver and technique for tensioning has worked well in our hands in regards to preventing voiding dysfunction as well as efficacy of correcting the stress incontinence. For more information visit www.ottobock.com www.ottobock.com www.ottobock.com

autologous rectus fascia bladder neck slings

synthetic mid urethral slings

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