Rectus fascial sling (RFS) is an anti-incontinence procedure resorted to in spinal patients with stress urinary incontinence (SUI) that have failed conservative management and are clean-intermittent catheterization (CIC) trained or dependent. Historically, the advancement of the sling is through a retropubic approach that risks possible urethral, urinary bladder and rectal injury [1-2]. We describe a modified pre-pubic approach that avoids such injuries by offering an alternative course of advancing the sling.

Existing literature on RFS techniques was reviewed and modified sling insertion approach was prepared and described. Patient referrals for urodynamic assessment of neurogenic urinary incontinence from the provincial spinal services were reviewed. Preoperative assessment including urodynamic assessment and the Michigan Incontinence Symptom Index (M-ISI). Inclusion criteria were dexterous males, trained or utilizing CIC, with cystometric evidence of neurogenic SUI. Patient informed consent for primary sling procedure and modification of approach was obtained. RFS was harvested as previously described [3]. Modified prepubic insertion of the RFS was performed as described in the video, with the mainstay of the procedure being pre-pubic passage of RFS avoiding pelvic organs injury. Post-operative follow-up included successful trial of CIC, Patient Global Impression of Improvement (PGI-I), and M-ISI at 6 weeks and at annual follow-ups. Primary outcomes were perioperative complications per Clavien-Dindo score and subjective and objective SUI resolution. The secondary outcomes were patient satisfaction and recurrence of SUI or need for procedure revision.

Five patients were enrolled (summary patient data and self-reported outcomes in table 1). No intra- or major post-operative complications (Clavien ≥3) occurred. All patients successfully passed the trial of CIC at 2-weeks post-operatively. All patients reported complete subjective resolution of SUI, low scores of PGI-I and improvements in ISI scores post-operatively. At a median of 25 months follow-up, satisfactory results are maintained with no issues with CIC. Only two patients required revision of the tightness of the sling through the abdominal wound only for recurrence of mild SUI within the first to second years post-operatively, with SUI only occurring on major physical movements and revision done to match early post-operative satisfaction and complete continence.

Initial experience with this modified pre-pubic insertion of RFS shows it’s a safe and effective technique in management of male neurogenic SUI.

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Daneshmand, S., Ginsberg, D. A., Bennet, J. K., Foote, J., Killorin, W., Rozas, K. P., & Green, B. G. (2003). Puboprostatic sling repair for treatment of urethral incompetence in adult neurogenic incontinence. The Journal of urology, 169(1), 199–202. https://doi.org/10.1016/S0022-5347(05)64067-0
Raz, S., McGuire, E. J., Ehrlich, R. M., Zeidman, E. J., Wang, S. C., Alarcon, A., Schmidtbauer, C., & McLaughlin, S. (1988). Fascial sling to correct male neurogenic sphincter incompetence: the McGuire/Raz approach. The Journal of urology, 139(3), 528–531. https://doi.org/10.1016/s0022-5347(17)42511-0