Female Stress Urinary Incontinence (SUI)
The use of tape in order to treat urinary incontinence is rightly known. There are different techniques and the retropubic transobturator is a better and new way to avoid bladder and urethra perforation during the surgery.
The retroischiatic approach allows easier bladder perforation and tape migration to the bladder neck, whitch leads to voiding dysfunction. In this new approach, the surgeon index finger does not enter laterally, but upward and forward, behind the pubis. In this position, the finger will protect the bladder and urethra.
Suburethral tapes are placed "tension-free" and should be in the distance between 3 and 5 millimeters below the urethra in order to avoid an obstruction - if too many tight - or had no effect on urinary incontinence - if too many loose. Hence, we standardized the procedure using a Hegar dilator of 8 millimiters diameter in the urethra and another Hegar dilator of 4 millimeters diameter between the urethra and the tape during the retropubic transobturator tape adjustment.
The first step is empty the bladder with a vesical catheter. After that, we put Allis clamp on both sides of the urethral meatus and make hydrodissection of the vaginal wall. Then we performe a vertical vaginal incision in the whole thickness of the wall. After that, the periurethral fascia was dissected until the ischiopubic ramus. The surgeon index finger does not enter laterally, but upward and forward, behind the pubis.
A small incision was performed horizontally at the genitalfemoral fold at the level of the clitoris. The surgeon's index finger then protects the urethra and bladder and we entered the needle through the incision in the horizontal position. The first resistance is from gracilis aponeurosis and the second one is from the obturator membrane.
The next step is to pass the tape extremity through the needle and take of it. The same procedure was performed on the other side. The horizontal route puts the tape behind the middle third of urethra. On the other hand, oblique route tends to insert the tape at the bladder neck.
The sling's 8/4 adjustment is made using two Hegar dilators (8 millimeters on the urethra and 4 millimeters between the urethra and the tape). The excess of tape was cut and the vaginal wall is closed with interrupted absorbable suture. At the end of the procedure, we take of the vesical catheter.
We evaluated the patients after surgery for 6 months and realized Computerized Tomography (CT) to see the tape position.
The procedure allows the surgeon protect noble structures and is easy to reproduce. The technique is secure and none of the patients had bladder or urethra perforation. It was made CT with 3D reconstruction, which shows that the tape is well located. Using 8/4 adjustment there was no occurrence of voiding obstruction.
A systematized technique of retropubic transobturator tape with 8/4 adjustment looks like to be secure and better than other techniques in order to prevent bladder or urethra perforation and post-surgical voiding obstruction.