Single Puncture Laparoscopic Sling Procedure

Abstract

The sling procedure has become the procedure of choice for women with recurrent stress incontinence with a poorly mobile, fibrotic urethra and for women with primary incontinence and very low urethral closure pressures consistent with inadequate intrinsic urethral tone. In addition to the increased risk of graft infection or postoperative rejection associated with the use of synthetic materials, the technical drawback of traditional sling procedures is that the placement of the graft through the space of Retzius is carried out blindly, increasing the risk of bladder and urethral injury, hemorrhage, infection and nerve trauma. We had the opportunity to perform the first successful laparoscopic sling procedure using a single puncture technique in a 43 year-old woman at the time of laparoscopic hysterectomy for large symptomatic leiomyomata. In addition to her gynecologic problem, the patient had very low proximal urethral pressure. The procedure was performed under direct laparoscopic view, avoiding the blind placement of the sling under the proximal urethra and bladder neck and avoiding injury to the bladder and urethra. The procedure was almost bloodless. The patient was discharged 24 hours postoperatively. The Foley catheter was removed on the third postoperative day. No voiding difficulties occurred. Her postoperative course was uneventful. Postoperative evaluation 6 months after surgery demonstrated normal urethral closure pressure, urinary continence, and absence of reaction to the sling graft material. This singular experience appears to demonstrate that laparoscopy may play an important role in improving the surgical performance and outcome of the sling procedure.