A 51-year-old female, G5P2032, who had two spontaneous vaginal deliveries and two ectopic pregnancies, with medical history notable for chronic tobacco use, gastroesophageal reflux, hypercholesterolemia, hypothyroidism, anxiety, depression, and allergic rhinitis, was referred for evaluation of persistent stress urinary incontinence (SUI) after multiple prior surgeries by outside urogynecologists.
At age 40, the patient underwent total vaginal hysterectomy, McCall culdoplasty, anterior repair, and retropubic mesh sling placement for menorrhagia and SUI. One year later, partial mesh exposure was identified, requiring excision. She developed recurrent SUI, confirmed with urodynamics and physical examination. At age 42, she underwent placement of another retropubic mesh sling. At age 45, she had recurrent mesh exposure requiring laparoscopic and vaginal excision of mesh. She underwent urodynamic testing four months later, which demonstrated SUI without intrinsic sphincter deficiency and no detrusor overactivity. Five months after excision of mesh, she underwent a laparoscopic paravaginal cystocele repair and a third retropubic mesh sling placement. Post-operatively she developed urinary retention, requiring clean intermittent catheterization. Three weeks later, 1.5 cm of sub-urethral mesh was excised for urinary obstruction and incision separation. Her SUI returned immediately following sling excision, and she returned to the operating room for further mesh excision and retropubic autologous rectus fascia sling placement. This was complicated by post-operative abdominal wound hematoma, requiring wound exploration and wound VAC for closure.
At age 51, she was referred to our care for mixed urinary incontinence with component of both stress and urge. She also had coital urinary incontinence. She wore incontinence pads during her daily activities. She continued to smoke cigarettes. Physical examination revealed vaginal scarring. She had no urinary retention, and no SUI was elicited while supine or standing. She was started on mirabegron without improvement and underwent urodynamics, notable for low capacity (218 mL), normal compliance, no evidence of detrusor overactivity, and a max flow rate of 4.0 mL/sec at Pdet qmax 26 cm H2O with a non-sustained detrusor contraction characterized as mild detrusor underactivity. Her post-void residual volume was low (10 ml). Urodynamics did not demonstrate SUI, but it was detected upon catheter removal with a full bladder. The decision was made to proceed with urethral bulking injections. This was successful with injections at 3, 6, and 9 o’clock positions with excellent coaptation of the urethra. One month later she had persistent stress and urge urinary incontinence. She was counseled on the limited options that were available after failure of three MUS, one autologous fascia sling with severe infection and one set of urethral bulking injections. She opted to proceed with LAMS.
In preparation for surgery, she was placed on vaginal estrogen cream to facilitate dissection of the tissue layers. She was counseled to stop smoking in order to avoid infection and enhance healing after surgery. After one month, she was taken to the operating room. Under general anesthesia, she was placed in lithotomy position, prepped and draped in the usual manner. 1% Lidocaine with 1/100,000 epinephrine was injected on the midline of the anterior vaginal epithelium from 0.5 cm to approximately 4 cm below the urethral meatus. An incision was then made on the hydro-dissected vaginal epithelium. The vaginal epithelium was then separated from the underlying vesicovaginal fascia sharply and bluntly. The vaginal epithelium was dissected as lateral as possible until it was at least 2-3 cm above the retro-pubic space, allowing space to place serial plication sutures at the level of mid-urethra. A few residual synthetic mesh fibers from previous surgeries were identified and excised. A 0-Vicryl suture on a UR-6 needle was placed in a down to up manner, posterior to anterior, on the vesicovaginal fascia as lateral and as deep as possible on the patient’s left side to include the puborectalis muscle. The same suture was brought to the right side, and placed in a up to down manner, anterior to posterior, again as lateral and as deep as possible to include the contralateral puborectalis muscle (Figure 3). The suture ends of the resulting inverted U shape were then tied together to bring the puborectalis muscle from the two sides to the midline to support the mid-urethra. After the suture was tied, a more lateral portion of the muscle is then accessible. A second suture was then used to make another inverted U plication. This was repeated a third time to include the puborectalis muscle to assure good support of the midurethra. Plication was technically challenging due to the significant scar tissue. The optimal result of complete mobilization of the puborectalis muscles with apposition in the midline (Figures 4-5) was not possible; there was a small suture bridge between the two sides of puborectalis muscle (Figures 6-7). The patient was observed overnight and failed trial of void on post-operative Day 1. She subsequently passed an outpatient voiding trial on post-operative Day 3. She developed recurrent urinary retention requiring temporary clean intermittent catheterization for one month.
At the time of this report, twenty-three months post-operatively, she remains dry except for rare urgency incontinence which is managed with timed voiding every two to three hours. She is very pleased with the outcome of LAMS procedure because she no longer has to use incontinence pads and no longer has coital urinary incontinence. She reported improved sexual satisfaction and no de-novo pelvic pain.