Prior studies have shown that autologous pubovaginal slings are efficacious for the management of stress urinary incontinence with success rates of 66% compared to 49% with Burch colposuspension. However, they are also associated with higher rates of voiding dysfunction, urinary tract infections, and postoperative urge incontinence. Despite this, they still serve an important role in recurrent SUI or instances where mesh is contraindicated. 

A major issue with fascial slings is that there is no standardized method of how to precisely tension them, specifically in recurrent or severe SUI cases where one is trying to balance effective treatment with preventing voiding dysfunction.  

A potential solution to this issue is the use of a system that allows for individualized sling tensioning. The adjustable mid-urethral sling used in the video is a unique system that utilizes a permanent subcutaneous implant or “varitensor” that rests above the rectus fascia and can be utilized to tension the sling postoperatively using an external manipulator.  Evidence has shown that this device can be highly effective for the treatment of stress urinary incontinence with multiple studies citing cure rates of 70-90%. By combining a fascial sling with this tensioning system, we have provided a unique modification for women with severe or recurrent stress urinary incontinence with risk factors for mesh complications, while balancing the undesirable side effects of voiding dysfunction and de novo urgency.

This video describes the case of a 59-year-old female with a history of chronic pain and current tobacco use who presented with severe, recurrent stress urinary incontinence after a prior Burch colposuspension. Her post-void residual volume was 60 ml. Given the challenge between resolving her severe stress incontinence symptoms and limiting the risks of urinary retention and mesh complications, the decision was made to proceed with a pubovaginal autologous sling attached to a suprapubic tensioning device that belongs to an adjustable mesh sling system.  This component permits personalized post-operative tensioning.

This video provides an educational resource demonstrating key surgical steps for this specific modification to a pubovaginal fascial sling procedure as well as postoperative outcomes in similar patients. In the past year we have performed this combined procedure on 7 patients and have seen promising results, including no cases of recurrent SUI or voiding dysfunction.

The use of a personalized tensioning device in combination with an autologous pubovaginal sling may balance efficacy with unwanted side effects.