Midurethral Sling
Table of contents
Operative Note
_ indicates a section that needs to be reviewed or completed.
I (or a fellow) will do the operative notes for procedures that I perform (and you assist). These notes are included here so that you can read about the procedure before we get to the OR - allowing you to familiarize yourself with both the steps of the procedure and nuances/dogma of my technique compared to another surgeon’s that you may have seen in the past. As you read the note, consider the instruments and anatomy. Consider how we maximize exposure and where the high risk portions of the procedure lie. Bonus points if you can customize the risk to the patients and their anatomy/history.
Retropubic Sling
After informed consent was obtained, the patient was taken to the operating room with IV fluids running. Anesthesia was achieved without difficulty. She was placed in the dorsal lithotomy position in Allen type stirrups. She was prepped and draped in the normal sterile fashion. A surgical timeout was performed. The bladder was then drained using a 16 Fr catheter. The midline pubic symphysis was identified and the eventual trocar exit points were marked at the superior ridge of the pubic symphysis 1.5cm from the midline bilaterally. A spinal needle was then inserted and 60mL of dilute (1:800,000) epinephrine solution was injected posterior to the pubic bone and lateral to the urethra and bladder in order to hydrodissect the space of Retzius.
An Allis clamp was then used to grasp the vaginal epithelium 1.5cm cephalad to the urethral meatus. The spinal needle was then bent to mimic the curve of the sling’s path and a small amount dilute epinephrine solution was injected on each side of the urethra. The curved needle was then passed through the endopelvic fascia behind the pubic bone and into the space of Retzius once again and 60mL of the dilute epinephrine solution was injected while the needle was withdrawn.
A one and a half centimeter incision was made vertically at mid urethra level through the epithelium. The connective tissues were dissected to allow placement of the trocar. The trocar was then placed through the endopelvic fascia and along the posterior aspect of the pubic bone until the trocar was brought out through the suprapubic skin. A similar procedure was performed on the opposite side. The Foley was removed and the bladder was inspected for perforation with the 70-degree cystoscope. The bladder was examined in a clock like and systematic fashion from the dome to the urethrovesical junction. There was no evidence of stone, foreign body, or malignancy. The sling sheaths were freely mobile in the space of Retzius. The urethra was examined on withdrawal of the cystocsope and found to be intact.
The sling was then pulled up to a point lying loosely under the urethra that freely admitted the base of a mayo scissors clamp. The plastic sheaths were removed. The ends of the sling were cut at the skin level at the lower abdomen exit points and the skin was elevated to cover the remaining mesh. The skin punctures were closed with dermabond. The vaginal epithelium was closed in two layers, first with a horizontal mattress suture of 2-0 vicryl followed by a running 2-0 vicryl running stitch. The bladder was backfilled with 100mL of fluid and the catheter was removed. The patient was awakened from anesthesia without complications and transferred to the post anesthesia care unit (PACU). The patient arrived to the PACU in stable condition and without complications.
Single Incision Sling
After informed consent was obtained, the patient was taken to the operating room with IV fluids running. She underwent induction of anesthesia without difficulty. She was placed in lithotomy position in Allen type stirrups and was prepped and draped in the normal sterile fashion.
A surgical timeout was performed and a Foley catheter was placed in the bladder. A self-retaining vaginal retractor was then placed. Markings were made along a horizontal line at the level of the clitoris to mark the eventual target sites of the single incision sling. Allis clamps were then used to grasp the suburethral vaginal tissue to demarcate the location of the mid urethra. I then injected a dilute solution of epinephrine and saline along this suburethral space and carried the hydrodissection out laterally toward the obturator internus muscle with special attention to be full-thickness, especially at the level of the vaginal fornices.
A 2 cm skin incision was then made under the urethra and Metzenbaum scissors were used to dissect the path of the trocar. The site of placement was palpated with the surgeon’s index finger and the sling was deployed on the patient’s right. The handle was at a 45 degree angle and cephalad drift was used to prevent interaction of the trocar tip with the inferior pubic ramus. The exact procedure was carried out on the patient’s left. Cystoscopy was then performed. The bladder was filled to complete distension. It was examined in a clock-like and sysematic fashion from dome to bladder neck. There was no evidence of stone, foreign body, or malignancy. The urethra was normal on withdrawal of the cystoscope. The tensioning suture was then used to tension the sling to a point where the mesh was in direct apposition with the underlying suburethral tissue. The tensioning suture was then trimmed, the wound was irrigated, and the skin was closed in 2 layers using 2-0 Vicryl suture. Packing was placed in the vagina. The bladder was backfilled with 100 mL of fluid to allow for postoperative voiding trial.
The patient tolerated the procedure well. Instrument, sponge, and needle counts were correct. The patient was awakened from anesthesia and taken to the recovery room in good condition.
Postoperative Considerations
| Follow Up | 6 Weeks |
| Voiding Requirements | Passive Voiding Trial, PVR < 150mL |
| Opioids | AS NEEDED: Oxycodone 5mg PO Q6H #6 |
| Pain Control | SCHEDULED: 1g acetaminophen and 600mg ibuprofen Q6H x 4 days, ALTERNATE |
| Precautions | Urinary tract infection, Urinary retention, Bleeding |
| Restrictions | Pelvic Rest x 6 weeks, Resume other activity slowly and as tolerated |
Patient Education
Preop
- Voices for PFD (AUGS) - Midurethral Sling for Stress Urinary Incontinence
- Your Pelvic Floor (IUGA) - Mid-urethral Sling (MUS) Procedures for Stress Incontinence
- Mesh Sling for Stress Urinary Incontinence - PreOp Patient Education [VIDEO]
- AUGS Position Statement on Mesh Midurethral Slings for Stress Urinary Incontinence
- Considerations about Surgical Mesh for SUI (FDA)
Postop
Patient Education
Cerner > Discharge Tab > Patient Education > Custom
- Stewart - Sling Postop (Custom)
- Stewart - Postop Pain Control (Custom)
- Stewart - Contacting IU Urogyn (Custom)
- ANY/ALL LEAFLETS FOR PRESCRIBED MEDICATIONS
Patient Instructions
.jrs-postop-sling
Implants & Devices
- Boston Scientific Advantage Fit™ Transvaginal Mid-Urethral Sling System
- Coloplast Altis® Single Incision Mid-Urethral Sling
Instruments
Retropubic Sling
- Foley catheter (16fr, no bag)
- Marking pen
- 60cc syringe with 18ga spinal needle
- filled with a 1:800,000 solution of epinephrine in normal saline
- Allis clamp x 4
- Kelly clamp x 2
- Knife handle with #15 blade
- Metzenbaum scissors
- Cystoscopy
- Camera & light cord
- 17fr sheath
- 70-degree cystoscope with bridge
- Jackson retractor
- Needle holder
- Rat tooth forcep
- Adson forcep
- Disposables
- Suction tubing & Yankauer
- 3/4 sheet
- under buttock drape
- leg drapes
- 1/2 sheet
- 2-0 vicryl SH x 1
- Dermabond
- Boston Scientific Advantage Fit™ Transvaginal Mid-Urethral Sling System
Single Incision Sling
- Same as above PLUS Lone Star 3304G self-retaining retractor with SHARP hooks
- Coloplast Altis® Single Incision Mid-Urethral Sling
