Re: “Necessity the mother of invention”-wider significance of novel mid-urethral rectus fascial sling. Petros, Peter. Response letter.Author: Abdalla Fayyad.Centre of Urogynaecology and Advanced Laparoscopic Surgery. 12 Khalidi Street, Amman, Jordan 11180.E mail: [email protected] Dr Aris Papageorghiou,We thank Professor Petros for the letter to the editor titled “Necessity is the mother of invention”-wider significance of novel mid-urethral rectus fascial sling1 and the interest shown in our novel technique of laparoscopic mid-urethral autologous fascial sling (LMAFS)2. In his letter to the editor, Professor Petros supports our novel approach of using the autologous rectus fascia as mid-urethral sling inserted laparoscopically. We are honored to have our technique endorsed by the discoverer of the integral theory (IT), and the co-developer of the mid-urethral sling (MUS).We agree with Professor Petros that restoring vaginal support does improve pelvic floor symptoms related to prolapse, lower urinary tract symptoms and obstructive daefecation3. We are currently examining the feasibility of using autologous rectus fascia laparoscopically to restore apical support as a non-mesh option. We agree that the potentials of using the rectus fascia laparoscopically can be numerous, but does indeed need further evaluation.It is important, however, to emphasize that surgical interventions for pelvic floor dysfunction should be considered after conservative measures have failed to improve patient’s bothersome symptoms. Regarding the symptoms of overactive bladder (OAB), e.g. urgency and urgency incontinence, we agree with Professor Petros that many patients with OAB do improve following corrective reconstruction of the support of the bladder base and trigone, as the stretch receptors in the bladder are no longer activated at low bladder volumes3. However, it is important to recognise that OAB is a nonspecific, complex and multifactorial symptom syndrome frequent in the general population, and among men as well4,5. There appear to be several distinct subtypes of OAB with different pathophysiology, with overlapping underlying factors including metabolic syndrome, affective disorders, gastrointestinal disorders, hormonal deficiency, and subclinical autonomic nervous dysfunction5. Surgery for prolapse does not necessarily address these potential underlying causes. The mainstay of managing this sub group of patients with OAB, is through conservative measures and medical treatment.In conclusion, we thank Professor Petros for his letter, and agree that understanding the IT provides an important insight into majority of pelvic floor dysfunction symptoms. We used the principles of the IT when we developed the technique of LMAFS1. We are certainly looking for further uses of laparoscopic rectus fascial sling in pelvic floor reconstruction.Word count: 368Conflict of interest: NoneFunding information: None

Serious concerns have been raised over safety of vaginal mesh tapes for stress urinary incontinence (SUI). Autologous rectus fascial sling and the more recent “sling on a string” through a laparotomy are gaining popularity as native tissue options for SUI. We describe a novel technique of laparoscopic mid-urethral autologous rectus fascial sling for SUI. Ten patients underwent this new technique safely. At six months, all subjects reported cure of SUI with normal voiding. The advantages of this technique include the minimal access approach, introduction of the sutures under laparoscopic guidance, and avoidance of over tightening of the sling.