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Understanding the mechanics of closure is key to optimal midurethral sling technique

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Abstract

The animal experiments and prototype midurethral sling operations demonstrated that the sling provided new collagen to reinforce weak pubourethral ligaments (PUL). The now strengthened PULs were able to restore the contractile power of the 3 oppositely-acting directional closure forces. By contraction, these three forces exponentially altered the intraurethral resistance to flow when they closed the urethra to sustain continence. Relaxation of the forward force allowed the two posterior forces to uninhibitedly open the posterior urethral wall just prior to detrusor contraction, to facilitate evacuation of urine. The aim of this work is to examine the mechanics of the component anatomical structures which contribute to these functions, to analyse how subtle details impact on the actual surgical technique of the midurethral sling operations to optimize success, contribute to complications and how to prevent and fix them.

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Notes

  1. A striated muscle requires a firm insertion point to contract efficiently [10]; a weak PUL insertion point Fig. 4, weakens both the distal and bladder neck closure mechanisms.

  2. “Zone of Critical Elasticity, Fig. 3 demonstrates two different urethral closure mechanisms, distal and proximal, activated by oppositely-acting muscle forces (arrows). These can only function separately if these is adequate elasticity at “ZCE”, Fig. 3.

  3. A free skin graft is best harvested from an area of elasticity, preferably lower abdominal wall. Another option is a vascular graft, such as skin-on Martius graft, or a “Singapore Flap> a skin-on graft from the groin.

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  1. School of Mechanical and Chemical Engineering University of Western Australia, Crawley, Australia

    Peter Petros

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  1. Peter Petros
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Correspondence to Peter Petros.

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Petros, P. Understanding the mechanics of closure is key to optimal midurethral sling technique. Int Urogynecol J 32, 39–45 (2021). https://doi.org/10.1007/s00192-020-04533-9

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  • DOI: https://doi.org/10.1007/s00192-020-04533-9

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