Since the vaginal tape meshes for stress urinary incontinence have been banned in many countries and patients are skeptical about the use of mesh, alternative methods using native tissue for treating stress urinary incontinence are being developed. Colposuspension is a well established procedure for stress urinary incontinence. It has similar efficacy to the tension free vaginal tape (1), and laparoscopic colposuspension is comparable to open colposuspension in efficacy with the advantages of the minimal access surgery approach (2). Modifications are being developed in the surgical technique to reduce complications particularly voiding dysfunction and de novo overactive bladder. In addition, new onset rectocele formation is a known complication of colposuspension (1). Since the introduction of the tension free concept in surgical management of stress urinary incontinence with  vaginal tapes to reduce post operative avoiding dysfunction, we developed the tension free laparoscopic colposuspension (LC) technique to treat female urodynamic stress incontinence. To achieve tension free suspension LC with sutures, the intra corporeal sliding knot technique was used to achieve more accurate tensioning of the suspension sutures. The aim of this study and video is to demonstrate the tension free LC with intracorporeal sliding knot technique as surgical treatment for stress urinary incontinence.

110 women with stress urinary incontinence (SUI) who underwent tension free laparoscopic colposuspension (LC) with sliding knot technique were prospectively evaluated. The procedure involved a 10 mm supra umbilical camera port and two lateral 5 mm ports. The retropubic space was entered and a low 10 mm suprapubic port was inserted after dissecting the bladder from the anterior abdominal wall. The bladder neck was dissected from the vagina with finger in the vagina and endoscopic suction creating counter traction on the bladder which is introduced through the supra pubic port. Two Ethibond sutures were placed at the level of the mid urethra and bladder neck and passed through the iliopectineal ligament. The sutures were tied with intracorporeal sliding knot technique to allow for accurate tensioning. All sutures were tied in a tension free fashion with sliding knot technique. A urethral catheter was used in all cases (no suprapubic catheter), which was removed the next morning. Women filled the King’s Health Questionnaire for incontinence pre operatively and three, six and twelve months post operatively. Post operatively, women filled the patient global impression of improvement questionnaire (PGII) for urinary incontinence. We report the outcomes at twelve months. In this video, the tension free LC with sliding knot technique for accurate suture tensioning and tissue elevation is demonstrated.

The procedure was completed laparoscopically in all cases. There were no cases of urinary tract injury nor post operative voiding dysfunction. All women resumed normal voiding the day after surgery, and no woman needed to perform clean intermittent self catheterisation (CISC) post operatively. 86% of women reported cure of SUI defined as "none" or "a little" as the response to the question of stress urinary incontinence. 88% reported feeling “much better” or “very much better” on PGII post operatively. 15% of women developed de novo overactive bladder symptoms post operatively. No women needed surgery for new onset rectocele up to twelve months post operatively.

Following concerns about vaginal mesh tapes for SUI, tension free LC with intracoporeal sliding knot technique has high success rate in treating SUI with low complications particularly voiding dysfunction and overactive bladder. In addition, tension free LC is less likely to cause new onset rectocele that needed surgical intervention.

Ward K, Hilton P. Prospective multicentre randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. BMJ 2002;325:67
Kitchener H, Dunn G, Lawton V. et. al. Laparoscopic versus open colposuspension--results of a prospective randomised controlled trial. BJOG 2006 Sep;113(9):1007-13.