One challenge in functional urology is the treatment of recurrent urinary incontinence (UI) after failed mid-urethral sling (MUS). Furthermore particularly difficult is the treatment of recurrent UI when the previous MUS mesh has been removed for intraurethral erosion. In these cases the positioning of a new synthetic sling is contraindicated and the surgical alternatives are controversial and disappointing. One possible option is an autologous sling but the crucial point remains how much tension is necessary to obtain satisfactory results. In this video we showed a innovative technique in which readjustability is obtained connecting a fascial autologous sling with a varitensor, allowing a modulating tension in the immediate and eventually also in the late post-operative period.

The video shows the case of a female patient with recurrent UI due to mesh complication. The patient was 65 years old, she underwent a Trans-obturator tape in 2012, with post-operative revision for obstruction although no surgical data were available. She presented immediate voiding dysfunction and urinary incontinence. In 2015 and 2017 she underwent urethral dilatations without improvement of the symptoms. She arrived at our observation in January 2022 for continuous leakage, voiding symptoms and pain. Clinical examination showed a transverse suburethral swelling of about 2 cm and urethrocistoscopy confirmed a intraurethral mesh covered by a calculus. In february 2022 the patient underwent the removal of the mesh and adhesus calculus with a triple layers urethroplasty. Pain disappeared but UI persisted so after six months we proceeded with the re-adjustable autologous sling application. The video shows the preparation of the abdominal 4x2 cm fascial sling. The rectangular fascial sling was connected to the varitensor of the readjustable Remeex system through two prolene not-absorbable sutures positioned on the two lateral sides of the isolated rectangular fascia. The abdominal incision was closed leaving the manipulator outside the suture to allow adjustment in the following days. After 24 hours the catheter was removed and the adjustment was performed at day 1 and 2 till the patient became continent. The manipulator was removed 48 hours after surgery.

At 6 months follow-up the patient is continent and satisfied. The pain and voiding symptoms disappeared. Uroflowmetry after 3 months demonstrated normal parameters and no post-void residual.
The re-adjiustable autologous sling was performed in other 4 cases and the results are satisfactory at 1 year follow-up

In these complex cases the use of a syntethic sling is contraindicated. All the available options do not guarantee the results and overall they are not without complications. Only case reports are reported, each one with different solutions.
Re-adjustable autologous sling represents a good option in this difficult scenario because it combines the use of an autologous sling and the possibility of modulating the tension and to readjust in the time.

Continence 7S1 (2023) 101022
DOI: 10.1016/j.cont.2023.101022