In patients with complex urological conditions with the need for clean intermittent self-catheterization (ISC), the surgical management of stress urinary incontinence (SUI) presents unique challenges, particularly in the context of elevated risks for complications like mesh erosion. This case report describes an innovative approach employing a synthetic tension-free vaginal tape (TVT) sling combined with autologous fascia lata (hybrid) in a patient requiring ISC with concomitant SUI.

A 33-year-old woman with a history including fibromyalgia, epilepsy and chronic vulvodynia, presents with SUI as her primary complaint. Urodynamic testing revealed minor instabilities and significant SUI during filling and different problems during emptying phase, including voiding with strain, acontractile bladder, lack of sphincter relaxation, and significant residual volume. 

Several interventions were initiated alongside ISC. Percutaneous tibial nerve stimulation initially reduced need for ISC but became less effective over time. A trial with Onabotulinum Toxin A injections in the detrusor resulted in the need for increased ISC, with persisting urinary incontinence. The patient was intolerant to a urethral pessary. Given the persistent and predominant SUI, along with vulvodynia and an elevated risk of mesh erosion due to ISC, a hybrid sling procedure with fascia lata was proposed. Informed consent was obtained for the operation and publication of this case report. 

The surgical intervention began with harvesting the fascia lata. Under general anesthesia, the patient was positioned supine to ensure optimal visualization of the lateral thigh. The anatomical landmarks, including the lateral condyle of the tibia - insertion of the iliotibial band - were marked. The edges of the fascia lata were delineated. Starting 10cm above the lateral condyle, a 4cm incision was made. Dissection proceeded towards the fascia, which was then marked (4x2cm), harvested, and subsequently closed again. The skin incision was sutured in a conventional manner.

Following the fascia lata harvest, preparation of the mesh commenced. This involved attaching the harvested fascia lata to the synthetic mesh with a non-absorbable polypropylene monofilament suture, without yet removing the overlapping synthetic portion. The hybrid sling, now a composite of synthetic and autologous materials, was then placed as in a standard TVT procedure. Care was taken to position the fascia lata portion of the sling to the urethral side. 

A cystoscopy was performed to exclude any bladder perforation. Once placement was confirmed as accurate, the mesh was tension-free adjusted, and the excess synthetic portion overlapping the fascia lata was trimmed away. The surgical site was then closed in a classical manner.

There were no peroperative complications and minimal blood loss. The harvest itself took approximately 15 minutes. Postoperatively, the urinary catheter was successfully removed the day following surgery and the patient was able to perform ISC by herself without any issues. She experienced only minimal pain and was able to leave the hospital the day after the operation. At the first check-up, she reported no incontinence, had smooth ISC, without deterioration of vulvodynia complaints.

The hybrid TVT sling with fascia lata represents a tailored surgical intervention for patients with SUI performing ISC, offering a potential minimalization in long-term complications such as mesh erosion and pain-related issues due to prosthetic material, in a context of growing mesh-bashing worldwide. This case underscores the importance of individualized treatment plans in urological surgery, especially for patients with complex clinical backgrounds. Further studies are warranted to evaluate the long-term outcomes.

Continence 12S (2024) 101639
DOI: 10.1016/j.cont.2024.101639