Anatomy based on appearance Pubourethral Ligament PUL Bladder
Anatomy based on appearance Pubo-urethral Ligament (PUL) Bladder Vagina Symphysis Rectum Pubococcygeous Longitudinal Muscle of the Anus Levator plate External anal sphincter
The Mid-Urethra Concept Integral Theory (Petros & Ulmsten, 1993 ) With abdominal pressure Continent Incontinent
The “Hammock” hypothesis PUL § Normal pubourethral ligaments form suburethral hammock of support § Downward force against this hammock causes urethral compression and prevents bladder neck descent § TOS restores anatomical pubourethral ligament support
Physiology PS= Pubic Symphysis PCM= Pubococcygeus muscle LP= Levator Plate LMA= Longitudinal muscle of the anus H= Hammock A= Closed S= Open
Changing trend § IN THE PAST. . . AI: Bladder Neck Suspension - Burch, Stamy, MMK, Raz……. ISD: Sling
Changing trend § IN THE PAST. . . AI: Bladder Neck Suspension - Burch, Stamy, MMK, Raz……. ISD: Sling § NOW. . . All SLING esp. Mid-urethral Sling
Goal of SUI Surgery : Current Concepts § Restore and/or reinforce the pubo-urethral ligaments & sub-urethral vaginal hammock at the mid-urethra § Reinforce the paraurethral connective tissue
Mid-urethral Sling Procedure § Vaginal approach TVT (Gynecare) IRIS (Made in Korea) IVS (Tyco) § Suprapubic approach SPARC (AMS) § Lateral approach Trans-obturator sling
Trans-obturator Sling § Monarc. TM subfascial hammock: AMS § Obtape. R: Mentor
Rationale for a Transobturator Approach § Avoiding the retropubic space reduces the risk of perforation to the bladder, bowel and major pelvic vessels § Hammock-shape mesh with lateral fixation mimics normal pubourethral support
TOS & Normal PU Ligament LA = Levator Ani U = Urethra V = Vagina
Obturator Anatomy Obturator Canal Ischiopubic Ramus Ilium Obturator Foramen Pubic Symphysis Ischium
Obturator Anatomy Adductor longus insertion Urethra Obturator canal SAFE ENTRY ZONE FOR NEEDLE INSERTION
Support Vector of TOT vs. TVT/SPARC Obturator artery and nerve track Obturator muscle and obturator membrane TOT
Needle Passage
Position of Mesh clitoris urethral meatus
Position of Mesh Pubic Symphysis Mesh Obturator Canal
Summary § Mimics normal pubourethral support § Course of needle path is 3 cm to 4 cm from obturator canal and neurovascular bundle § Short “blind” needle passage § Avoidance of retropubic needle passage reduces reliance on cystoscopy in most cases
TVT SECUR PRODUCT
동문 요실금수술 현황 § Complication Urethral injury Vaginal wound problem 5 3 Vagina laceration 2 Urge incontinence 2 Retention 1 Bladder injury 1
Thank you for your attention !!!
- Slides: 33