Surgery is performed under epidural block. With the patient in a lithotomy position and 18 Ch Foley bladder catheter inserted, two 1 cm incisions are made lateral to the neck of the bladder via the vaginal fissures.
If cystocele-associated, a longitudinal mid-section vaginal incision is made instead, and the cystocele is corrected beforehand. The introduction of the index finger into the incision in a corkscrew movement retropubically and bilaterally prepares the paraurethral space, detaching the endopelvic fascia from the ischiopubic branch. The suburethral vaginal mucous membrane is then detached, at this level creating a tunnel connecting the two lateral incisions, through which the Herniamesh sling is passed. At this point, action shifts towards the suprapubic region: two small, 1 cm transverse skin incisions are made here, at the level of the upper symphysis pubis margin, through which, first from one side, then from the other, the suprapubic needle is passed with a marked sideways movement, guided through the paraurethral space with the index finger of the other hand, until it emerges through the vaginal incision. The steps described above are performed with the bladder empty and a mandatory cystoscopy after the passage of each needle to exclude accidental injury to the bladder.
Once the prosthesis has been positioned to support the mid-urethral section, the plastic protective sheaths are removed, taking care to place a closed, blunt instrument behind the central, or not, absorbable section to ensure an adequate distance from the urethra is maintained so as to avoid urinary retention as a result of compression of the urethra.
The actual absence of sling tension is checked at urethral level, and continence is checked by filling the bladder with 250-300 cc of saline solution and inviting the patient to cough after removal of the catheter. After all necessary adjustments have been made, the excess at the ends of the sling is removed and the vaginal and suprapubic incisions are sutured.
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