Autologous Pubovaginal Sling for the Treatment of Stress Urinary Incontinence in a Patient With High Risk of Mesh Erosion.

OBJECTIVE: Autologous pubovaginal sling is a surgical option for patients with stress urinary incontinence (SUI), either as primary treatment, or in those who have failed synthetic sling placement.1,2 It is also favorable for patients at high risk of mesh erosion, for example, in those who are immunocompromised or postradiation.3-5 This video reviews the technical considerations in performing an autologous pubovaginal sling fashioned from rectus fascia in an immunocompromised patient with multiple previous abdominal surgeries. METHODS: The patient is a 63-year-old woman with SUI refractory to conservative management, with a background of Behcet's disease on long-term steroids. First, a 12  ×  2 cm rectus sheath graft was harvested through a Pfannenstiel incision. Stay sutures were placed to aid in subsequent sling placement. A vertical incision was made in the anterior vaginal wall after hydro-dissection with lignocaine/adrenaline solution and the plane was developed with a combination of blunt and sharp dissection. The trocars with the attached fascial sling were passed retropubically. Sling tensioning was assessed with a Q-tip test. An inadvertent bladder perforation was noted during the passage of the left trocar on intraoperative cystoscopy, which was managed conservatively with urinary catheterization for one week postoperatively. RESULTS: The patient was discharged well on postoperative day 2 and underwent a successful trial off catheter on postoperative day 7. At 1-month follow-up, the patient reported complete resolution of her SUI with no de-novo urgency or voiding dysfunction. CONCLUSION: Autologous pubovaginal slings are an effective treatment option for SUI with minimal morbidity especially in patients with high risk of mesh erosion.

Wunderlich syndrome secondary to cyst rupture and concurrent anticoagulation.

Wunderlich syndrome (WS) is a rare triad of flank pain, flank mass and hypovolemic shock and is classically attributed to angiomyolipomata or neoplasms. Treatment is guided by clinical severity: conservative, selective arterial embolization, or nephrectomy. We report an atypical case of a 69-year old man with a pre-existing 9 cm left renal tumor who developed WS secondary to anticoagulation and simple cyst rupture from his contralateral kidney, complicated by abdominal compartment syndrome with hemodynamic instability despite inotropic support and robust resuscitation. Early recognition and source control via radical nephrectomy were essential in securing a positive outcome.