Author Information
Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Abstract
Urinary stress incontinence is treated conservatively with exercises and bladder training to start with. If the conservative treatment fails, operative treatment is given. A large number of operations have been developed to treat this condition. Their results are variable. Birch colposuspension is considered the gold standard. Transobturator tape insertion is considered equivalent to it in terms of results, and is currently the first line of operative treatment. There are two methods of performing the operation – inside out and outside in. A method of performing an inside out procedure using Shirodkar’s sling needles is described here. This is the first report of the use of these needles for this procedure.
Introduction
Urinary stress incontinence (SUI) occurs in about 15% cases between the age of 30 and 60 years.[1,2] It is managed conservatively with pelvic floor exercises and bladder training. If this treatment fails, surgical treatment is given. Insertion of transobturator tape (TOT) is the surgical treatment currently approved as the primary surgical treatment. Its results are like those of Birch colposuspension. Delorme developed the procedure of transobturator tape insertion for SUI in 2001.[3] It was an outside in technique. de Laval developed the first inside out technique of TOT insertion in 2003.[4] TOT insertion takes significantly shorter operative time and is associated with much less risk of bladder injury, postoperative retention of urine and urge incontinence as compared to other sling procedures. [5,6] It does away with the need to correct urethral hypermotility too.[7] It reduces the incidence of coital urinary incontinence significantly too. [8] There are two methods of performing the operation – inside out and outside in. A method of performing an inside out procedure using Shirodkar sling needles is described here. This is the first report of the use of these needles for this procedure.
Urinary stress incontinence is treated conservatively with exercises and bladder training to start with. If the conservative treatment fails, operative treatment is given. A large number of operations have been developed to treat this condition. Their results are variable. Birch colposuspension is considered the gold standard. Transobturator tape insertion is considered equivalent to it in terms of results, and is currently the first line of operative treatment. There are two methods of performing the operation – inside out and outside in. A method of performing an inside out procedure using Shirodkar’s sling needles is described here. This is the first report of the use of these needles for this procedure.
Introduction
Urinary stress incontinence (SUI) occurs in about 15% cases between the age of 30 and 60 years.[1,2] It is managed conservatively with pelvic floor exercises and bladder training. If this treatment fails, surgical treatment is given. Insertion of transobturator tape (TOT) is the surgical treatment currently approved as the primary surgical treatment. Its results are like those of Birch colposuspension. Delorme developed the procedure of transobturator tape insertion for SUI in 2001.[3] It was an outside in technique. de Laval developed the first inside out technique of TOT insertion in 2003.[4] TOT insertion takes significantly shorter operative time and is associated with much less risk of bladder injury, postoperative retention of urine and urge incontinence as compared to other sling procedures. [5,6] It does away with the need to correct urethral hypermotility too.[7] It reduces the incidence of coital urinary incontinence significantly too. [8] There are two methods of performing the operation – inside out and outside in. A method of performing an inside out procedure using Shirodkar sling needles is described here. This is the first report of the use of these needles for this procedure.
Operative Technique
- Local (1:1 mixture of 0.5% bupivacaine hydrochloride and 1% lidocaine hydrochloride with epinephrine (1:100000) under the anterior vaginal wall), general, or regional anesthesia is used.
- The patient is placed in the lithotomy position.
- The points where the needles will exit at the skin level are marked on a horizontal line 2 centimeters above the urethral meatus and 2 centimeters outside the inguinal folds.
- Epinephrine in normal saline (1:300000) is infiltrated under the anterior vaginal wall over the middle of the urethra.
- A 2 cm long incision is made in the anterior vaginal wall mucosa starting 1 cm proximal to the urethral meatus.
- Sharp dissection done under the mucosa with Steele’s scissors in the direction of the marked exit point on the skin, until the inferior border of the ischiopubic ramus is reached. The fascia on its lower ends is penetrated with the tip of the scissors.
- The end of the strip of 1 cm wide polypropylene mesh is secured to No. 1-0 polypropylene or No 30 linen thread, which is then passed through the eye of the Shirodkar’s sling needle.
- The needle is passed through the vaginal incision into the space dissected and is passed behind the ischipubic ramus maintaining close contact with it until its tip passes just beyond the ramus. It that point its direction is changed so that it penetrates the obturator membrane and exits into the subcutaneous tissue of the thigh.
- The tip of the needle is passed out through the marked exit point by incising the skin over the tip of the needle. The suture is removed from the eye of the needle and the needle is withdrawn.
- The procedure is repeated on the opposite side.
- Traction is made on the polypropylene sutures on both the sides simultaneously such that the tape lies under the urethra without any twist in it. Distance between the tape and the urethra is adjusted such that closed blades of scissors lie between the two, or a loop of 5 mm long loop is held under the urethra with Babcock’s forceps while the remaining tape is taut.
- The ends of the tape are cut while depressing the skin around them without making further traction on the tape.
- Vaginal incision is closed with interrupted sutures of No. 1-0 Polyglactin.
- Skin punctures are covered with dressing.
Figure 1. Exit point on the skin of the left thigh is marked.
Figure 2. Vaginal mucosal incision is made.
Figure 3. Vaginal mucosa is dissected off the underlying urethra.
Figure 4. Dissection is continued laterally up to the ischiopubic ramus.
Figure 5. Shirodkar's sling needle of the left side is passed into the tunnel, carrying the tape.
Figure 6. The needle is advanced to behind the left ischiopubic ramus.
Figure 7. The needle is rotated once beyond the ischiopubic ramus, so that its tip passes through the left obturator foramen into the left thigh near the point of exit marked earlier. The skin is cut over its tip so that the tip exits.
Figure 8. The thread is removed from the eye of the needle. Then the needle will be withdrawn.
Figure 9. Shirodkar's sling needle of the right side is passed into the tunnel, carrying the tape.
Figure 10. The needle is advanced to behind the right ischiopubic ramus and made to exit in the right thigh.
Figure 11. The needle on the right side has been withdrawn. The threads on the ends of the tape are seen exiting from the skin incisions on the two sides. The tape is seen hanging loose under the urethra.
Figure 12. Traction is made on the threads on both the sides simultaneously so that the tape is drawn in. An index finger is placed under the tape so that it does not become tight.
Figure 13. The tape is tightened under the urethra until there is no slack left when closed blades of a pair of stout curved scissors lie between it and the urethra.
Figure 14. Mild traction is made on the threads such that the tape does not get pulled, and then the threads are cut flush with the skin, so that the ends recede in the subcutaneous tissue of the thighs.
Figure 15. Suburethral incision in the vagina is sutured with interrupted sutures of No. 1-0 polyglactin.
Figure 16. The end result.
Discussion
The inside out technique of TOT insertion is preferred to the outside in technique because it is more precise and reproducible, involves less dissection, and is associated with a lower rate of injuries to the bladder and the urethra.[9-12] Though the retropubic space is not penetrated in TOT insertion, the tip of the inserter can cause an injury to the bladder or the urethra if it is directed improperly.[13] This can be avoided by directing the tip of the inserter towards the exit point marked in advance and keeping the tip under the epithelium of the vestibule in the first part of its passage and in contact with the back of the ischiopubic ramus in the second part of its passage. Thus if due care is taken, a cystoscopy is not required in TOT insertion.
Shirodkar’s sling needles are used for performing Shirodkar’s sling operation for uterine prolapse. There are two needles – one for the right side and one for the left. There are some reasons for use of these needles for TOT insertion. One reason is that the size and shape of the needles are suitable for this purpose. The tip is pointed so that it can pass easily through a tunnel created for the passage of the needle carrying the tape. Each needle has a stout handle so that the needle can be rotated once its tip is beyond the lower border of the ischiopubic ramus. Thus the needle pierces the obturator fascia and muscles near the medial border of the obturator foramen and does not injure the obturator nerve and vessels. The eye of the needle is too small to permit passage of the tape through it. But the difficulty is overcome by passing a No. 1 polyamide or polypropylene suture or No. 30 thread through the tape near its end, tying two knots so that the suture does not come off during the passage of the needle, and then threading both ends of the suture into the eye of the needle. After passage of the needle and its exit in the thigh at the designated point, the sutures are removed from the eye of the needle so that the needle can be withdrawn. Traction on the threads results in the tape passing along the tunnel into the thigh. Another reason for using this needle for TOT insertion is that it is preferable to have surgical instruments with multiple uses rather than a single use. That keeps the cost of running surgical services down, which is important in resource poor healthcare facilities.
Conclusion
TOT insertion for SUI can be performed using Shirodkar’s sling needles easily and accurately. This instrument is a suitable substitute for the expensive inserters used for this purpose alone.
References
The inside out technique of TOT insertion is preferred to the outside in technique because it is more precise and reproducible, involves less dissection, and is associated with a lower rate of injuries to the bladder and the urethra.[9-12] Though the retropubic space is not penetrated in TOT insertion, the tip of the inserter can cause an injury to the bladder or the urethra if it is directed improperly.[13] This can be avoided by directing the tip of the inserter towards the exit point marked in advance and keeping the tip under the epithelium of the vestibule in the first part of its passage and in contact with the back of the ischiopubic ramus in the second part of its passage. Thus if due care is taken, a cystoscopy is not required in TOT insertion.
Shirodkar’s sling needles are used for performing Shirodkar’s sling operation for uterine prolapse. There are two needles – one for the right side and one for the left. There are some reasons for use of these needles for TOT insertion. One reason is that the size and shape of the needles are suitable for this purpose. The tip is pointed so that it can pass easily through a tunnel created for the passage of the needle carrying the tape. Each needle has a stout handle so that the needle can be rotated once its tip is beyond the lower border of the ischiopubic ramus. Thus the needle pierces the obturator fascia and muscles near the medial border of the obturator foramen and does not injure the obturator nerve and vessels. The eye of the needle is too small to permit passage of the tape through it. But the difficulty is overcome by passing a No. 1 polyamide or polypropylene suture or No. 30 thread through the tape near its end, tying two knots so that the suture does not come off during the passage of the needle, and then threading both ends of the suture into the eye of the needle. After passage of the needle and its exit in the thigh at the designated point, the sutures are removed from the eye of the needle so that the needle can be withdrawn. Traction on the threads results in the tape passing along the tunnel into the thigh. Another reason for using this needle for TOT insertion is that it is preferable to have surgical instruments with multiple uses rather than a single use. That keeps the cost of running surgical services down, which is important in resource poor healthcare facilities.
Conclusion
TOT insertion for SUI can be performed using Shirodkar’s sling needles easily and accurately. This instrument is a suitable substitute for the expensive inserters used for this purpose alone.
References
- Hampel C, Weinhold D, Benken N Eggersmann C, Thuroff JW. Definition of overactive bladder and epidemiology of urinary incontinence. Urology. 1997;50:4.
- Hampel C, Artibani W, Espuña Pons M, Haab F, Jackson S, Romero J, et al. Understanding the burden of stress urinary incontinence in Europe: A qualitative review of the literature. Eur Urol. 2004;46:15.
- Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol. 2001;11:1306–1313.
- de Leval J. Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol. 2003;44:724–730.
- DeTayrac R, Deffieux X, Droupy S, Chauveaud-Lambling A, Calvanese-Benamour L, Fernandez H. A prospective randomized trial comparing tension-free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence. Am J Obstet Gynecol. 2004;190:602–8.
- Juma S, Brito CG. Transobturator tape: Two years follow-up. Neurourol Urodyn. 2007;26:37.
- Minaglia S, Ozel B, Hurtado E, Klutke CG, Klutke JJ. Effect of Transobturator tape procedure on proximal urethral mobility. Urology. 2005;65:55–9.
- Abdel-Fattah M, Ramsay I, Pringle S, Bjornsson S, Hardwick C, Tierney J, et al. Transobturator suburethral tapes in the management of urinary incontinence: Success, safety and impact on sexual life. Gynecol Surg. 2007;4:267–73.
- Debodinance P. Trans-obturator urethral sling for the surgical correction of female stress urinary incontinence: outside-in (Monarc) versus inside-out (TVT-O). Are the two ways reassuring? Eur J Obstet Gynecol Reprod Biol. 2007;133:232–238.
- Lee KS, Choo MS, Lee YS, Han JY, Kim JY, Jung BJ, et al. Prospective comparison of the 'inside-out' and 'outside-in' transobturator-tape procedures for the treatment of female stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:577–582.
- But I, Faganelj M. Complications and short-term results of two different transobturator techniques for surgical treatment of women with urinary incontinence: a randomized study. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:857–861.
- Cho MK, Kim CH, Kang WD, Kim JW, Kim SM, Kim YH. Complications Following Outside-in and Inside-out Transobturator-Tape Procedures with Concomitant Gynecologic Operations. Chonnam Medical Journal. 2011;47(3):165-169. doi:10.4068/cmj.2011.47.3.165.
- Delmas V, Hermieu JF, Dompeyre P, Messas A, Dumonceau O, Ravery V, et al. The transobturator sling tape uratape: anatomical dangers. Eur Urol Suppl. 2003;2:197.
Parulekar SV. Inside Out Transobturator Tape Insertion Using Shirodkar’s Sling Needles. JPGO 2017. Volume 4 No.9. Available from: http://www.jpgo.org/2017/09/inside-out-transobturator-tape.html