Stress urinary incontinence is a common condition that has a significant impact on quality of life. The integral theory showed that defective mid urethral support and the resultant low urethral pressure are the main mechanism behind stress urinary incontinence (reference 1). Concerns have been raised about safety and long term complications of vaginal mid urethral mesh tapes. There has been a resurgence in the native tissue surgical management of female stress urinary incontinence. Aldridge fascial sling was describe almost eighty years ago, Despite its high success rate, this procedure needs a laparotomy, and was associated with high rates of voiding dysfunction post operatively (reference 2). More recently the concept of a sling on a string was introduced using a laparotomy, with blind introduction of the strings using a special curved needle (reference 3). The ends of the strings are then sutured to the rectus fascia. In this video, a novel technique of laparoscopic mid urethral fascial sling insertion under vision using rectus sheath fascia is shown in managing recurrent stress incontinence.

Three women with recurrent stress urinary incontinence following colposuspension underwent this new technique of laparoscopic mid urethral rectus fascial sling insertion. All women underwent urodynamics pre operatively, which showed urodynamic stress urinary incontinence with hyper mobile bladder neck. All women consented to this new procedure. Under general anaesthesia, and after urinary catheter insertion, A 4 cm transverse lower abdominal incision is made and a strip of rectus fascia is harvested measuring 6x2 cm. A sling on a string is then formed using 2/0 Ethibond sutured to both ends of the sling. A vaginal incision is made 1.5 cm from the external urethral meatus. Para urethral tunnels are then created with dissecting scissors. After routine laparoscopic entry with three ports, the retropubic space is opened and adhesions between the bladder and the pubic bone are brought down. The endopelvic fascia is then perforated under laparoscopic vision either side of the urethra with scissors. The Ethibond sutures on the end of the sling are then retrieved laparoscopically, and sutured to the Coopers ligaments after tension free adjustment of the sling under the mid urethra. The vaginal skin is then closed with interrupted absorbable sutures and cystoscopy is performed to check bladder integrity.

The procedure was successfully completed in all cases. The duration of the procedure ranged from 90 to 150 minutes. The average blood loss was 100 ml. All subjects resumed normal voiding after urinary catheter removal after 24 hours. All subjects were discharged home after 24 hours. At three months follow up, all subjects reported cure of the stress urinary incontinence with normal voiding.

To our knowledge, this is the first description of the technique of laparoscopic rectus fascial sling insertion under the mid urethra to treat female stress urinary incontinence. We demonstrated the feasibility and safety of the technique. The advantages of this technique include the small incision in the lower abdomen, introduction of the sutures holding the sling under direct, which avoids the complication of bladder perforation with blind introduction of the curved needle. This is particularly important in cases of previous surgery for urinary incontinence where the bladder can be severely adherent to the pelvic bone. Furthermore, fixation of the strings to the Coopers ligaments maintains the sutures original tension, and avoids over lightning of the sling and voiding dysfunction.

Petros P, et. al. An integral theory of female urinary incontinence: Experimental and clinical considerations. Acta Obstet et Gynecol Scand. 1990. 69: 7-31.
Guerrero K. et. al. A randomised controlled trial comparing TVT, Pelvicol and autologous fascial sling for the treatment of stress urinary incontinence in women. BJOG 2010, 117(12): 1493-502.
Asfour V. et. al. Modified autologous fascial sling technique  (sling on a string) for stress incontinence. 2022, International Urogynecol J  2022, 33: 435-8.