In compliance with AUA antibiotic prophylaxis guidelines, perioperative antimicrobial treatment should include a first or second generation cephalosporin or an aminoglycoside with clindamycin or metronidazole [4]. Patients should also receive deep vein thrombosis prophylaxis in line with the AUA guidelines and patient risk factors; pneumatic compression devices are generally sufficient [5]. Patient should be placed in the dorsal lithotomy position with close attention to all pressure points and prepped and draped in a standard sterile fashion. A 16 F urethral catheter is placed and the balloon is inflated. Attention is first turned to the facial harvest. The two most commonly utilized autologous slings are the rectus abdominis fascia or fascia lata graft slings. The rectus abdominis fascia sling is preferred by most surgeons due to a greater familiarity with the abdominal wall anatomy and the relative ease of harvesting. Both of these autologous slings have otherwise been shown to be equally effective [6].

A 6–8 cm Pfannenstiel incision is made on the skin approximately 2–4 cm cephalad to the pubic symphysis, extending 3–4 cm on either side of the midline or 1 cm from midline to 6–8 cm on right or left side, depending on surgeon’s preference (Fig. 5.2). The incision is carried down through subcutaneous tissue taking care not to cause any trauma to the rectus fascia. An area sufficient to expose the 2 × 6 cm rectus fascia sling is cleared of overlying adipose and connective tissue. The sling site should follow the direction of the rectus fibers and avoid extending laterally toward the internal inguinal ring or the ileo-inguinal nerve. After marking the sling harvest site, 3-0 absorbable suture is placed on each of the lateral long edges of the sling to minimize manipulation of the fascia (Fig. 5.3). The fascia for the sling is then incised and sharply freed from the underlying muscle. The fascial defect is then closed with running 1-0 poly-dioxanone suture. An injection of local anesthesia (Bupivacaine) may be given for pain control. One cm area cephalad to the pubis bone (and inferior to the fascial incision) is cleared of overlying adipose and connective tissue in the midline for later passage of the suture carrier. The wound is packed with saline soaked gauze and attention turned to the vaginal portion of the case.

The sling is prepared on the back table by sharply removing any remaining adipose tissue and a 1-polypropylene is passed through the lateral edges of the sling in a horizontal mattress fashion. A single suture is used for each edge with the ends kept long for passage through the retropubic space and held with hemostat on each end (Fig. 5.4). The midline of the sling is marked. The sling is then wrapped in sterile saline soaked gauze and set aside. It is important to complete the sling preparation prior to commencing the vaginal portion of the procedure, particularly prior to breaking through the endopelvic fascia and entering the retropubic space, during which bleeding can be occasionally encountered.

In morbidly obese patients, in patients with prior ventral hernia repair and in patients who have had prior abdominoplasty we prefer to harvest fascia lata from the thigh. We ask the patient what side does she usually sleep on and harvest the fascia lata from the opposite side. The thigh is generally prepped in with the general prep of the vagina and lower abdomen with the patient in the dorsal lithotomy position, and the fascia is harvested prior to proceeding with the vaginal incision.

A 2–3 cm longitudinal incision is marked 2 cm above the patella over the ilio-tibial band on the lateral side of the thigh. Dissection is carried down to the level of the fascia lata using electrocautery. We typically do not use a stripper device; however the Crawford fascia lata stripper can be used if one wishes to harvest longer strips of the fascia lata. The distal end of proposed fascia harvest site is transected using electrocautery or knife allowing one free end following which 3-0 absorbable sutures are placed on each end to minimize fascial manipulation. Using electrocautery/scissors, a 6 cm × 1.5–2 cm fascia can be harvested easily by lifting it off the underlying muscle. The harvest area is carefully evaluated for any bleeding before closure. A small Penrose drain is placed and brought out through the corner of the incision. The wound is irrigated and closed in two layers without closing the fascia lata. The skin is closed using 4-0 Nylon in an interrupted manner. The wound is dressed with a Telfa and Tegaderm and inspected at the end of the case for any bleeding.

The patient is placed in mild to moderate Trendelenburg position. A weighted speculum is placed in the vagina and a ring retractor (we prefer a Lone Star retractor) is used to expose the vagina. By placing traction on the Foley balloon the bladder neck is marked horizontally with a marking pen in the vagina. Saline or lidocaine with 1 % epinephrine is used by some for hydro-dissection. An inverted U shaped incision is made in the suburethral portion of the vagina extending to the bladder neck following the rugae. The vaginal flap is raised to the level of the bladder neck. It is important to stay in the correct plane as to not devascularize the vaginal flap.

At this point, the periurethral fascia is incised lateral to the urethra and dissection is carried out toward the ipsilateral shoulder to perforate the endopelvic fascia. Should bleeding be encountered with perforation of the endopelvic fascia, pressure with a sponge stick or digitally from vagina in combination with retropubic pressure can tamponade the venous bleeding. However, prompt placement of the sling and closure of the wound will generally control bleeding and prolonged attempts to stop retropubic bleeding from dissection and needle passage are discouraged. Therefore, prior to perforation of the endopelvic fascia, ensure that the sling is prepared. The bladder is emptied and the endopelvic fascia is perforated bluntly with the index finger sweeping medially to laterally and hugging the pubic bone until the bladder neck and proximal urethra are freed from their retropubic attachments and two finger tips can nearly meet each other (one from the suprapubic incision and one in the vaginal incision) with only fascia intervening. In the setting of significant retropubic scarring the endopelvic fascia may require sharp dissection with Metzenbaum scissors.

For passage of the sling a double prong needle passer (Pereyra-Raz Ligature Carrier™) is passed from the suprapubic incision, below the prior fascial harvest site, about one finger breadth lateral to the midline, to the vaginal incision. The needle should be palpated by the opposite index finger and directed out of the vaginal incision over this finger. The ends of the Prolene suture on the harvested fascial sling are passed through the eyes of the ligature carrier and pulled above the fascia. The same procedure is carried out on the contralateral side. If there is an extensive scarring in the retropubic space a single prong (Pereyra Ligature Carrier™) is passed using the same technique as above and both the ends of the Prolene suture are passed through only one eye of the ligature carrier. The urethral catheter is removed. A female cystoscope with a 30° lens is passed into the urethra and ureteral orifices checked for efflux bilaterally. The lens is changed to a 70° lens and the bladder filled to where there are no folds in the mucosa. The mucosa is inspected for perforation, with close attention to the anterior bladder wall from 10 to 2 o’clock position. Should a perforation be encountered, the sutures should be pulled out and the needle should be re-passed more laterally and the procedure be continued as planned, with rechecking of the bladder after each pass. After confirming no bladder entry, the urethral catheter is replaced. The suprapubic ends of the sutures are clamped with a hemostat and the sling is centered at the proximal urethra and secured to the peri-urethral fascia proximally, distally as well as laterally with of 4–5 interrupted 4-0 absorbable sutures to keep the sling flat against the urethra (Fig. 5.5). The vaginal incision is then closed with running 2-0 absorbable suture.

It is well accepted that autologous fascial sling can be more obstructive in nature as compared to Burch colposuspension procedure and tensioning of the sutures is more an art than a true science. A booted right angle clamp is applied to the sutures approximately 2 cm above the rectus fascia on each side and the sutures are tied. The sling should be placed loosely being careful not to tie the sling sutures down to the rectus fascia. However in patients who are already on CIC or who are willing to perform CIC and who have severe SUI with low VLPP, the sutures can be tied at the level of rectus fascia. When a single needle passer is used, the sutures are tied to one another with approximately two finger-breaths between the rectus fascia and the knot. The suprapubic incision is then closed using two layers of absorbable sutures and antimicrobial moistened vaginal packing is placed into the vagina.