Abstract
The aim of this study was to investigate the course of midurethral slings using tension-free vaginal tape. The TVT procedure was performed on six fresh pelves, measurements were obtained, and the structures were cross-referenced in 16 embalmed pelves. The midurethral sling enters the suburethral tissue 2.2–3 cm caudad to the internal urethral meatus, pierces the paraurethral musculature and vascular plexus, and exits 2±0.5 cm from the midline lateral to the point of insertion of the arcus tendineus fasciae pelvis. On the pubic tubercle the sling is 4±0.5 cm, 4±1 cm and 6±1 cm from the accessory obturator, the inferior epigastric and the external iliac vessels, respectively. The critical angle of error resulting in the external iliac vessel injury is 7–15°. A current knowledge of pelvic anatomy may help the surgeon avoid the neural and vascular structures that are in the path of the sling.
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References
Petros PE, Ulmsten UI (1990) An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand (Suppl) 153:7–31
Meschia M, Pifarotti P, Bernasconi F et al. (2001) Tension-free vaginal tape: analysis of outcome and complications in 404 stress incontinent women. Int Urogynecol J 12(Suppl 2):S24–S27
Tamussino K, Hanzal E, Kolle D et al. (2001) The Austrian Tension-Free Vaginal Tape registry. Int Urogynecol J 12(Suppl 2):S28–S29
DeLancey JO (1994) Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 170:1713–23
Zacharin RF (1963) The suspensory mechanism of the female urethra. J Anat 97:423–427
Jeffcoate TNA, Roberts H (1952) Observations on stress incontinence of urine. Am J Obstet Gynecol 64:721–738
Hodgkinson CP (1953) Relationships of the female urethra and bladder in urinary stress incontinence. Am J Obstet Gynecol 65:560–575
Lapides J, Ajemian EP, Steward BH, Lichtwardt JR, Breakey BA (1960) Physiopathology of stress incontinence. Surg Gynecol Obstet 111:224–231
Enhorning G (1961) Simultaneous recording of the intravesical and intraurethral pressure. Acta Obstet Gynecol Scand 276(Suppl):1–69
Ulmsten U, Petros P (1995) Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol 29:75–82
Petros PE (1997) New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying. Int Urogynecol J 8:270–278
Petros PP, Ulmsten U (1998) An anatomical classification a new paradigm for management of female lower urinary tract dysfunction. Eur J Obstet Gynecol Reprod Biol 80:87–94
DeLancey JO (1988) Structural aspects of the extrinsic continence mechanism. Obstet Gynecol 72:296–301
DeLancey JO (1986) Correlative study of paraurethral anatomy. Obstet Gynecol 68:91–97
Oelrich TM (1983) The striated urogenital sphincter muscle in the female. Anat Rec 205:223–232
Shobeiri SA, Garely AD, Chesson RR et al. (2002) Recognition of occult bladder injury during the tension-free vaginal tape procedure. ObstetGynecol 99:1067–1072
Fitzpatrick CC, Elkins TE, DeLancey JO (1996). The surgical anatomy of needle bladder neck suspension. Obstet Gynecol 87:44–49
Nilsson G, Kuuva N, Falconer C et al. (2001) Long-term results of the Tension-Free Vaginal Tape procedure for surgical treatment of female stress incontinence. Int Urogynecol J 12(Suppl 2):S5–S8
Petros PP (1999) Medium-term follow-up of the intravaginal slingplasty operation indicates minimal deterioration of urinary continence with time. Aust NZ J Obstet Gynaecol 39:354–356
Hurd WW, Bude Ro, DeLancey JO, Newman JS (1994) The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy. Am J Obstet Gynecol 171:642–646
Petros PE, Ulmsten U (1997) Role of the pelvic floor in bladder neck opening and closure I: muscle forces. Int Urogynecol J 8:74–80
Petros P, Von Konsky B (1999) Anchoring the midurethra restores bladder-neck anatomy and continence. Lancet 354:997–998
Westby M. Asmussen M. Ulmsten U (1982) Location of maximum intraurethral pressure related to urogenital diaphragm in the female subject as studied by simultaneous urethrocystometry and voiding urethrocystography. Am J Obstet Gynecol 144:408–412
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Editorial Comment: The authors are to be commended for the completion of a detailed observational study further investigating the course of the TVT tunneler during placement of the sling material. An unpublished study reported by Walters et al. found similar relationships between the TVT tunneler and the surrounding pelvic vasculature. Both of these studies highlight the importance of avoiding excessive lateral deviation or rotation of the TVT tunneler during placement.
The conceptualization of a dynamic pelvic anatomy in relation to the advancing tip of a midurethral sling trocar is advocated to lessen intraoperative complications.
S. Abbas Shobeiri can also be reached at http://www.urogynecologist.com
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Abbas Shobeiri, S., Gasser, R.F., Chesson, R.R. et al. The anatomy of midurethral slings and dynamics of neurovascular injury. Int Urogynecol J 14, 185–190 (2003). https://doi.org/10.1007/s00192-003-1060-5
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DOI: https://doi.org/10.1007/s00192-003-1060-5