Apical Sling for for Site Specific Pelvic Organ Prolapse Repair

INTRODUCTION AND OBJECTIVES: We present a video of a novel transobturator approach to autologous urethral sling placement. METHODS: A 55-year old female presented with worsening pure stress urinary incontinence. She had significant bother from her leakage and after discussion of potential management options preferred an autologous urethral sling, however did not want an intra-abdominal portion of the procedure. Thus, we utilized a transobturator approach to autologous urethral sling placement. Following hydrodissection with injectable saline a midline incision was made in the anterior vaginal wall. Dissection was carried to the obturator foramen bilaterally. Next, a transverse abdominal incision was made and an 8cm x 1cm strip of rectus fascia was harvested and prepared with two stay sutures on each lateral end of the fascial sling. A small incision was made in the medial thigh bilaterally and dissection carried to the obturator foramen. A helical trocar was passed twice through each obturator foramen and the stay sutures retracted through the incision. The sling was secured proximally and distally with interrupted sutures. Careful attention was paid to tensioning the sling, which was left flush with the urethra. The stay sutures were then tied down and cut at the skin level. The anterior vaginal wall and skin incisions were then closed. RESULTS: The patient had an uncomplicated postoperative course and was able to spontaneously empty her bladder with low postvoid residual. She was seen back 2 weeks following her procedure noting no leakage, requiringzeropadsandsubjectivelypleasedwithheroutcome. CONCLUSIONS: Given this result, a transobturator approach to urethral sling placement appears technically feasible in appropriately selected candidates. Longer follow up and larger case series will be needed to validate this finding.