Stress Urinary Incontinence Treatments

Retropubic Synthetic Sling

Top-down technique

  1. Place patient in high lithotomy, bed in trendelenburg, place catheter and weighted speculum
  2. Grasp vaginal epithelium with allis clamps bilaterally just lateral to midline 1-2cm proximal to urethral meatus, hydrodissect with lido/epi proximally and laterally up towards pubic bone (planned dissection)
  3. Make longitudinal incision starting at least 1cm proximal to urethra and continuing for ~5cm
  4. Using lone star or standalone hooks, retract lateral tissue
  5. Place allis x2 on epithelial edge, use Metzenbaum scissors and forceps to separate epithelium from underlying urethra
  6. After flap separated, stick scissors pointing ~45deg underneath pubic bone and lateral to urethra, spread with jaws up/down to widen space - repeat this and above step on other side
  7. Tip: should be able to feel under pubic tubercle
  8. Make incision 2cm lateral to midline just superior to pubic tubercle
  9. Tip: place butt end of skin marker at clitoris and tip pointed towards head, then draw line at midline to make identification easier
  10. Enter trocar tip into incision with trocar perpendicular to skin and just superior to pubic bone, but once trocar passes along bone torque the handle towards patient's head and pass along edge of bone
  11. Tip: stick finger into vaginal opening to feel tip of trocar and guide into incision to avoid urethral/bladder injury
  12. Once trocars placed, perform cystoscopy to assess for bladder/urethral injury
  13. Attach sling to trocars and retract sling through suprapubic incision
  14. Use pean clamp to create space between sling and urethra while retracting sling bilaterally
  15. Cut off tips, place hemostat over plastic sheath and remove (do not pull on sling), cut sling at skin and pull up skin edges with adson to bury sling
  16. Close incision with 2-0 vicryl, burying the knot and bringing out through distal apex, then running proximally locking with each stitch, then tie proximally
  17. Void trial in PACU then discharge

Bottom-Up Technique

  1. Place patient in high lithotomy, bed in trendelenburg, place catheter and weighted speculum
  2. Grasp vaginal epithelium with allis clamps bilaterally just lateral to midline 1-2cm proximal to urethral meatus, hydrodissect with lido/epi proximally and laterally up towards pubic bone (planned dissection)
  3. Make longitudinal incision starting at least 1cm proximal to urethra and continuing for ~5cm
  4. Using lone star or standalone hooks, retract lateral tissue
  5. Place allis x2 on epithelial edge, use Metzenbaum scissors and forceps to separate epithelium from underlying urethra
  6. After flap separated, stick scissors pointing ~45deg underneath pubic bone and lateral to urethra, spread with jaws up/down to widen space - repeat this and above step on other side
  7. Tip: should be able to feel under pubic tubercle
  8. Make incision 2.5cm lateral to midline just superior to pubic tubercle
  9. Tip: place butt end of skin marker at clitoris and tip pointed towards head, then draw line at midline to make identification easier
  10. Stick large-bore needle (18g) into suprapubic incisions and hydrodissect space behind pubic bone with 15-20mL injectable saline
  11. Place catheter into bladder with catheter guide, then clip catheter guide to drapes on side of intended trocar placement (retracts bladder and urethra away from the side being worked on)
  12. Insert trocar (with sling attached) horizontally into incision and point lateral to urethra, then once behind pubic bone rotate the handle so that trocar points towards ipsilateral shoulder, then use two hands (one on trocar handle one inside incision) to pass trocar along the backside of the pubic bone until it exits the incision
  13. Perform cystoscopy with 70degree lens to ensure no bladder or urethral injury, then detach trocar from sling
  14. Repeat last three steps on opposite side
  15. Take snap off midline sling, remove plastic sleeves from both sides
  16. Use pean clamp to create space between sling and urethra while retracting sling bilaterally
  17. Cut sling at skin and pull up skin edges with adson to bury sling
  18. Close incision with 2-0 vicryl, burying the knot and bringing out through distal apex, then running proximally locking with each stitch, then tie proximally
  19. Void trial in PACU then discharge

Pubovaginal Sling

Fascia lata harvest

  1. Choose side that patient does not sleep on (if she has preference)
  2. Drape in a way to provide access to lateral thigh (usually sticky drapes, can staple extras as needed)
  3. Make 3cm transverse incision over lateral distal thigh, 3-5cm proximal to knee
  4. Expose fascia, make transverse incision using cut, tag corners with prolene, then track proximally to create 2cm x 5-8cm strip
  5. Place penrose drain and stitch in place with nylon
  6. Close subQ with 3-0 vicryl, then close skin with 4-0 nylon sutures (no need to close fascia)
  7. Mark both ends with #1 prolene stitch, mark midline with a pen, place in moistened gauze

Sling placement

  1. Place lone star retractor and vaginal speculum
  2. Make u-flap incision at midurethra (don't go past bladder neck) and create flaps
  3. Create transverse suprapubic incision 1-2cm above pubic symphysis, expose fascia
  4. Expand the periurethral space using sharp/blunt dissection until the posterior pubic bone can be palpated, protect urethra with narrow malleable, should be able to feel fingers connect behind pubic bone with fascia between
  5. Place double-pronged ligature carrier (Raz-Pereyra) from suprapubic to retropubic, aim lateral to avoid bladder/urethra, attach prolene stitches and bring out through suprapubic incision, perform on both sides
  6. Align fascial sling at midline, secure to urethra with 4-0 vicryl x6
  7. Cystoscopy (30 and 70 deg lenses) to confirm no bladder/urethral injury, assess efflux from ureteral orifices
  8. Close vaginal incision with 3-0 vicryl, pack with antibiotic gauze
  9. Rubbershod prolene 2cm above fascia, then tie and release on each side
  10. Close incision with 3-0 vicryl and steristrips

Male sling

Surgical steps

  1. Position patient in dorsal lithotomy, prep/drape perineum and medial thigh crease, give antibiotics (cefazolin +/- gentamicin), place foley for urethral identification
  2. Make midline perineal incision, ensure posterior enough to access central perineal tendon
  3. Identify adductor longus inferior margin, make stab incision 1 fingerbreadth inferior within crease (small stab, do not make too large)
  4. Divide perineal layers, place lone star retractor with blunt hooks, incise bulbospongiosus with metzenbaum scissors until urethra is completely identified
  5. Free urethra (do not need to free dorsal surface), ensure freed proximally from central tendon
  6. Place sling trocar through stab incision with handle at 45deg angle (from midline plane), push straight towards head with hand on handle and trocar itself, feel two pops, then drop hand so handle is at 15deg from midline incision, rotate and try to guide tip into perineal field as high as possible behind pubic bone (should rotate through obturator foramen and pass behind inferior pubic ramus)
  7. Attach sling with blue stripes facing outwards (hear/feel a pop when attaching), then guide sling out through incision, repeat on other side
  8. Gently tension sling so it sits on proximal bulbar urethra (do not place on curve or distal urethra), see the urethra form a "double bubble"
  9. Stitch corners to urethra with 4-0 vicryl x4
  10. Gently tension sling then cut off plastic sleeves, grasp sleeve (but not sling) with hemostat and remove)
  11. Optional: bring tonsil clamp from perineal incision under skin out through stab incision, grab sling and pull backwards into perineal incision then trim excess sling
  12. Close bulbospongiosus with 2-0 monocryl, (can place fibrillar/surgicel), close Colles fascia with 2-0 monocryl (grab correct layer not fat), then close skin with 4-0 monocryl, place bacitracin and dressing, dermabond stab incisions