V-248 Presentación: Vídeo

RESUMEN DE COMUNICACIÓN
Fascia Lata Autologous Transobturator Midurethral Sling
Miguel Marques Monteiro; Mariana Madanelo; Avelino Fraga; Paulo Príncipe; Carlos Ferreira
Centro Hospitalar Universitário de Santo António

Introduction

Female stress urinary incontinence is a public health problem associated with an enormous psychologic and social burden. Surgical options for uncomplicated stress urinary incontinence include synthetic midurethral slings (MUS), autologous slings, bulking agents and Burch colposuspension. 

Debate on the use of synthetic mesh in MUS has increased the interest in traditional SUI surgery that use autologous slings. Also, it should be preferred over MUS in patients at risk of poor wound healing, including prior pelvic irradiation or extensive tissue fibrosis.

Regarding voiding dysfunction, studies compared transobturator MUS with retropubic MUS, favouring the former. 

The aim of this study was to describe transobturator autologous sling surgery technique by using fascia lata.

Methods

A 71-year-old female was referred to urology due to mixed urinary incontinence complaints.  She had history of pelvic surgery and radiotherapy. The urodynamic study revealed presence of cough induced leakage (with abdominal leak point pressure of 110 cmH2O), without detrusor overactivity. Her detrusor pressure at a maximum flow rate of 11 mL/s was 18 cmH2O.

After discussion of the options, she underwent a Fascia Lata Transobturator Midurethral Sling.

Two lines were made in the thigh (one 5 cm cranially from the femoral lateral epicondyle and the other 13cm in the same direction).

A 8x2 cm fascia lata graft was collected. Two non-absorbable polypropylene barbed sutures were placed on each corner of fascial graft.

Labia were retracted with stay sutures and Foley catheter was inserted. A two-centimeter vertical suburethral incision was performed on anterior vaginal wall after hydrodissection with lidocaine plus adrenaline.

Blind and sharp dissection was performed until inferior ischiopubic rami and obturator membrane was palpated. Two small punctures were made at the level of the clitoris, on groin skin.

C-shaped trocar was inserted via groin puncture, obturator membrane was perforated after medial rotation and trocar was palpated on the tip of index finger. 

First stay suture was attached to trocars and pulled out through groin incision. The procedure was repeated for the second stay suture. This procedure was repeated on the right side.

Before sutures tied, graft was secured to the periurethral tissue with two absorbable sutures to avoid migration and graft folding. Adjustment of the sling was done in a tension-free manner by placing scissors between the graft and the urethra. After checking midurethral position of the graft and appropriate tension, sutures of the groin were tied.

Incisions were closed and vaginal tampon was placed.

The surgery had a duration of 90 minutes, and the blood loss was approximately 50 milliliters. 

Results

Six months after surgery, patient was totally dry and did not have any voiding complaints. 

Conclusion

Autologous transobturator midurethral sling is a feasible and effective procedure for SUI and should be considered in patients with risks poor wound healing, preferring the transobturator route if a greater risk of voiding disfunction is suspected, as in cases with detrusor underactivity. Further long-term studies are needed to confirm these outcomes.