The minimum invasion surgical procedure for sling positioning uses the transobturator approach which guarantees, with respect to pubovaginal approaches, identical effectiveness yet greater safety and rapidity of performance.
The transobturator approach, in fact, reduces the risk of lesions to regional organs due to the blind passage of needles used in pubovaginal approaches, avoiding the abdominal incisions that could prove painful at post-operative stage. Furthermore, the final position of the sling via the transobturator approach proves to be more gentle and anatomic as the angle formed by the sling to the horizontal plane is less accentuated than that formed by a pubovaginal sling. The risk of transitory post-operative urinary obstruction due to excessive sling tension is therefore minimised.
Slings positioned using this approach pass through the obturator foramen, a muscular membrane located completely outside the abdomen. The foramen is easily located, after the vaginal incision and mini-surgical preparation of the area to the side of the urethra and bladder, via digital palpation of the internal and external sections at the level of the labium majus, near the thigh line.
The needle is passed through the obturator foramen, with the urethra and bladder physically protected by the finger of the operator, on a direct path well away from the obturator vascular and nerve structures (out-in approach).
Once the path has been created, the suture pre-assembled on to the side margin of the prosthesis is loaded on to the the hooked or helical needle and moved upwards to meet the cutaneous emergence at skin level of the labius majus, close to the thigh line. A similar procedure is then followed from the other side. No check cystoscopy is needed. At this point, the side margins of the prosthesis are moved symmetrically so that the central section corresponds exactly with the central section of the urethro-bladder axis; the ends of the mesh are cut and the protective sheaths are removed, after placing a closed, blunt instrument behind the absorbable central section to ensure that a suitable distance from the urethra is maintained to avoid urinary retention as a result of compression of the urethra.
The two ends of the sling are cut below skin level and surgery is completed with suture of the vaginal wall and the two inguinal incisions.
In simple sling positioning surgery, i.e. without concomitant prolapsed bladder correction, the post-operative stay in hospital can be limited to one day, with return to normal physical activity after 15 days. When transobturator or pubovaginal sling positioning is associated with corrective prolapsed bladder plastic surgery, the post-operative stay is limited to 3 days with return to normal activity after 30 days.
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