The following is a summary of the technique we have chosen to use in performing this surgical procedure. Obviously, there are variations on this procedure performed in other centers that may enhance the operation. This is not intended to teach a surgeon how to perform the surgery but simply to show our way of approaching this surgery.
Urodynamic evaluation is performed in any patient that has a history of mixed incontinence, urinary frequency and urgency, previous GU procedures, or neurologic diseases. In patients with pure stress incontinence, we are not always obtaining an urodynamic evaluation. Cystoscopy is not routinely performed in patients prior to a sling procedure.
Candy cane stirrups have proven to provide the best positioning during surgery. Allen stirrups are used if there is a history of lower extremity joint disorders. We do not use a weighted vaginal speculum as deep visualization of the vagina is not necessary and the work is performed very distal in the vagina.
Anesthesia is usually general endotracheal anesthesia as per the patient’s requests. However this procedure is easily performed under sedation, regional block or local anesthesia. If performed under local anesthesia, an EMLA or other form of cutaneous lidocaine packing is placed in the vagina placed under the urethra for approximately 20 minutes. After sterile preparation, lidocaine with epinephrine is injected into the anterior vaginal wall under the urethra and slowly laterally under the vaginal wall to the level of the obturator internus muscle. The patient usually has no perceptible discomfort until the levator muscle is infiltrated. Occasionally, patients undergoing surgery under pure local anesthesia will note an increase in heart rate after infiltration due to the epinephrine. If the patient has cardiac issues, lidocaine without epinephrine should be considered. We do not routinely perform cleisis with saline or lidocaine prior to incision unless the patient is undergoing the procedure under local anesthesia.
We do not usually place a catheter prior to surgery to drain the bladder nor do we leave one in place to identify the urethra. However, early in the learning curve for this operation, any tool to assist with appropriate dissection and sling placement can helpful.
Allis clamps are placed one centimeter and approximately three centimeters proximal to the urethral meatus in the midline of the anterior vaginal wall. An incision is made between the clamps creating a two centimeter incision in the vaginal wall. Generally some dissection is required to create a deep enough path for sling placement. The flaps created are thick enough to prevent extrusion of the mesh in the midline. Dissection onto the finger of the vaginal wall can give some digital feedback regarding depth of dissection. Dissection is carried out on both sides laterally toward, but not through, the obturator internus muscle. The path of the dissection is the same as if one were performing a transobturator sling. If the dissection is carried into the muscle, increased and troublesome bleeding may be encountered.
The MiniArc sling kit is then obtained. It contains the sling and the sling inserter. After placing he sling on the inserter, the sling is slowly and deliberately placed into the right side along the path of the previous dissection. This will be a path that roughly would aim to the insertion site for a transobturator sling. Palpation of the vaginal wall by the hand not involved with passing the sling will assure the sling is passing deep into the tissues and not through the vaginal wall. With passage into the obturator internus muscle there is often a “pop” noted. Occasionally this will require some extra pressure to place. If the sling does not seem pass, move the inserter somewhat posteriorly as the pubic bone is likely in the path of the sling. It is important to remember the sling will come off the inserter if it is backed out even slightly. The sling will continue to be passed until the midpoint line on the sling or the midpoint line on the inserter is lateral to the urethra on the current side of sling passage. Gentle retraction of the inserter leaves the sling in appropriate position.
The left side is then passed by inserting the free end of the sling into the inserter and passing it in a similar fashion to the right side. When the sling is passed in this fashion there will essentially no gap between the sling and the urethra. The sling will lie flush against the urethra but will not crimp the urethra.
We are not routinely doing cystoscopy after these procedures. If one is doing their first 10-15 procedures, cystoscopy should be performed to assure that inadvertent urethral injury has not occurred. Palpation of the anterior vaginal wall should be performed to rule out injury to the vaginal wall by the sling. The vaginal wall is closed using a running 2-0 Vicryl suture. Vaginal packing and a catheter are not placed if only a sling is performed.
The patient is discharged from the day surgery unit after voiding. A PVR using a bladder scanner can confirm complete emptying. We send the patients home with Lortab and Keflex for five days. Most patients will not require much analgesia after surgery. Patients are asked to refrain from heavy lifting and straining for four weeks. Intercourse should be avoided for 4 weeks. Post-operative visits are scheduled for two weeks and three months after surgery.