Autologous pubovaginal fascial sling from external oblique muscle aponeurosis in the treatment of urodynamic stress urinary incontinence in women: a surgical technique

Introduction

Surgical treatment of female stress urinary incontinence (SUI) has taken more than a century using many surgical techniques with more prevalent retropubic colposuspension and sling procedures. Of the sling methods, the use of synthetic tapes under the middle of the urethra (MUS) is so widespread due to its effectiveness and easy placement, that it is considered by the majority as the “gold standard” for the treatment of urinary incontinence in women (1). However, the immediate complications and, especially, the long-term ones, as well as the difficulty in removing them, which is oftentimes impossible, has resulted in scrutiny and criticism, which has led to restriction of its use (2). According to the Food and Drug Administration (FDA) and Health Canada, concerns regarding the use of mesh in vaginal surgery has led the thoughts of urogynecologists in the application of methods, using a pubovaginal sling with autologous fascia, either as a first- or as a second-choice treatment (3).

This knowledge will help patients make decisions with the aid of the doctor in choosing most appropriate method for their case. The aim of the present video is to highlight important technical considerations, as well as to evaluate the efficacy, safety and patient satisfaction of the operative procedure of autologous pubovaginal fascial sling (AFPVS) as an alternative technique for the treatment of SUI in women. The innovation of this specific surgical technique lies in the inability to use the fascia of the rectus abdominis muscle due to its unsuitability, caused by multiple tears, such as those resulting from previous surgeries or a postoperative hernia.

The video will begin with a detailed visual guide on the preparation of the external oblique muscle aponeurosis, including the harvesting technique for the fascial strip and the necessary tools for the procedure. The step-by-step process of creating the vaginal incision and accessing the retropubic space will be shown, highlighting the importance of precise tissue handling and maintaining proper anatomical orientation. Visual aids will demonstrate the insertion of the autologous fascial strip through the retropubic space, ensuring correct positioning of the sling under the bladder neck to provide adequate support. This will emphasize the role of the introducer needle and precise placement to avoid complications. The video will provide a clear view of the technique used to secure the fascial sling with Prolene 3-0 sutures, explaining the suture technique, spacing, and the importance of ensuring no obstruction at the bladder neck. We present this article in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-39/rc).

Preoperative preparations and requirements

The patient is an elderly woman with SUI. She underwent anterior and posterior colporrhaphy two years ago. Urodynamics revealed urodynamic stress urinary incontinence (USUI), flow rate >20 mL/sec, post-void residual 30 mL, Q-tip test: urethral hypermobility, clinical examination: cystocele grade I.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The authors have made the best efforts to contact the relative, but a signed consent has been unable to be obtained. The article has been sufficiently anonymized to cause no harm to the patient or her family. For the procedure to be performed, a minimum of 2 surgeons (the lead surgeon and the assistant), 2 members of the anesthesia team (an anesthesiologist and an anesthesia assistant), and 2 nurses (instrument nurse and circulating nurse) are required. The minimum recommended number of operations for learning the technique is 15 operations.

A low bowel enema is required the day before the procedure. A venous catheter must be placed in the patient. For the surgery, the patient is positioned in the lithotomy position. Elastic compression stockings are applied up to the thigh. Vaginal and abdominal surgical field antisepsis is performed.

Step-by-step description

The operation is performed in four steps (Video 1).

• 1^st step: the external oblique muscle aponeurosis is prepared in 10–12 cm length or more and 5–7 mm width, 3 cm above the pubic symphysis. Prolene 3-0 sutures are placed at each end of the harvested muscle aponeurosis and then the retropubic space is prepared.
• 2^nd step: a mixture of 10–20 mL lidocaine and 2 mL epinephrine are injected into the anterior vaginal wall. A small vertical incision 2–3 cm below the distal urethral orifice is performed. A Foley catheter is placed.
• 3^rd step: a metal guide is inserted through the catheter for the movement of the urethral bladder neck. The introducer needle is placed on the lower lip of the pubic symphysis and advanced along its posterior surface until it penetrates the pubocervical fascia. The end of the tape is inserted into the hole of the introducer needle and then exits to the vagina. The same sequence of movements is repeated on the other side.
• 4^th step: the strips of the fascia are placed under the bladder neck. Then, the ends of the strips are sutured with 3 stitches of Prolene 3-0 interrupting sutures with suture spacing less than 1 cm below the bladder neck, so as to avoid obstruction. Hegar dilator No. 12 is placed below the urethra and the pubocervical fascia, keeping one fingerbreadth distance. Finally, the walls of the vagina and the skin of the abdomen are closed. This video describes the important technical details of this method. The mean duration of the operation is approximately 90 minutes.

Postoperative considerations and tasks

The patient remained in the hospital for one day and she was discharged the next day. No postoperative complications, such as bleeding, bladder/urethral injury, infection etc. had occurred. Before her discharge and after the removal of catheter, the voided volume was measured at every urination after drinking 4 or more glasses of water. The residual urine was consistently less than 100 mL. The patient was requested to visit the hospital 6 weeks postoperatively for reevaluation. The urodynamic study showed no SUI, as well as no detrusor instability, and the post-void residual urine volume was found to be 40 mL. The patient feels no leakage, with no leakage occurring during coughing, sneezing, or walking, which corresponds to the patient satisfaction mentioned in the Introduction.

Tips and pearls

The length of the strips from the external oblique aponeurosis should be at least 12 cm from midline. The gap between the bladder neck and the autologous tape should be one finger breath. The hole at the top of the needle should have an opening of 5–7 mm and a small rhomboid swelling a few mm thicker than the needle, a few centimeters from the top (in order to avoid overtightening of the strips by pubocervical fascia). Potential intraoperative complications include difficulty in dissecting the retropubic space (Retzius space) when the patient has previously undergone surgeries in the prevesical space, and the possibility for intraoperative bleeding. These complications can be prevented by careful dissection during tissue preparation and meticulous hemostasis.

Discussion

This video article describes the new operative technique of autologous fascial pubovaginal sling (AFPVS) from external oblique muscle aponeurosis for the treatment of SUI as the procedure of first or second choice.

Many operative modalities have been described to cure SUI, such as Kelly plication, Burch colposuspension and bulking agents injections. Recently, the wide application of tension-free vaginal tapes has superseded the aforementioned methods, due to their efficacy and ease of placement (1).

The long-term complications, such as tape erosions, chronic pelvic pain, foul-smelling vaginal discharge, vaginal bleeding and dyspareunia, as well as the possible inability of tape removal, had as a consequence the involvement of gynecologists in court. Consequently, the application of the autologous fascia to correct SUI, regained popularity amongst specialists of healthcare professionals (2). AFPVS incorporates the use of autologous materials. Biological graft materials are used primarily to reduce operative time, morbidity, pain, and hospital stay. The risk of transmitting disease or infection from autologous biological grafts is extremely low. Autologous material has very little tissue reaction, with a very low risk of erosion, and is usually easily harvested (2).

The autologous fascia, which has been traditionally used until today, is harvested from the rectus fascia and previously the fascia lata of the inner surface of the thigh (4). The long-term results are considered very satisfactory with minor complications, according to the relevant published literature (5).

Recent systematic reviews and meta-analyses have provided further evidence supporting the effectiveness of autologous slings. A meta-analysis by Grigoryan et al. demonstrated that autologous slings remain a viable alternative to synthetic options, offering long-term durability with fewer complications (6). Additionally, Fusco et al. conducted a comparative analysis of colposuspensions, pubovaginal slings, and midurethral tapes, providing valuable insights into their respective success rates, complications, and indications (6,7). These findings emphasize the importance of individualized treatment selection, considering factors such as urethral mobility, intrinsic sphincter deficiency, and prior surgical failure.

The autologous pubovaginal fascial sling can be used either as a treatment of recurrent SUI in cases of failure of tension-free vaginal tape or Burch colposuspension, to intrinsic sphincter deficiency, urethral hypermobility, removal of urethral diverticulum and occurrence of urinary incontinence in repair of urethral fistula, history of previous radiation or urethral erosion from the mesh. The contraindications for this technique include advanced age of the patient, limited mobility, and severe cardiopulmonary issues. Any complications arising immediately after the application of the autologous fascia, such as voiding difficulties should be treated with Foley catheter insertion or intermitted catheterizations for a few days, as the disadvantages of the method include the potential occurrence of de novo urgency and urge incontinence.

According to a recently published retrospective study, 58.8% of patients were cured by the implementation of an AFPVS procedure, after the failure of established mid-urethral sling procedures, and 23.5% of patients showed improvement, resulting in an overall effectiveness rate of 82.3% (8). The complications of AFPVS are less frequent and less significant compared to the placement of synthetic tapes. Although, the best results are described in prospective randomized studies with a satisfactory sample size in homogeneous populations, the existing studies do not strictly meet the aforementioned criteria, but advocate for the use of AFPVS as more effective and with fewer complications. The very limited mobility of the urethra and the severe deficiency of the intrinsic sphincter mechanism of the urethra significantly reduce the effectiveness of AFPVS in the surgical treatment of SUI. When these previous limitations are not present, AFPVS is considered the gold standard (1). The use of the aponeurosis of the external oblique abdominal muscle provides a solution when the aponeurosis of the rectus abdominal muscle is unavailable.

Conclusions

Autologous pubovaginal fascial sling from the external oblique muscle aponeurosis seems to be an effective and well tolerated procedure for the treatment of female SUI as a primary or secondary choice.

Acknowledgments

We would like to thank the senior and junior staff of the Aretaieion Hospital.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-39/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-39/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-39/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The authors have made the best efforts to contact the relative, but have been unable to obtain signed consent. The article has been sufficiently anonymized to cause no harm to the patient or her family.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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