RP Received: August 11, 2007 Accepted: September 27, 2007
Address correspondence to: Dr. Kuan-Hui Huang, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, 123, Ta-Pei Road, Niao Sung Hsiang, Kaohsiung, 83305, Taiwan
E-mail: gynh2436@adm.cgmh.org.tw
Tension-free Midurethral Sling Surgeries for Stress Urinary Incontinence
Ming-Ping Wu, M.D.
1,2, Kuan-Hui Huang, M.D.
3Department of Obstetrics and Gynecology1, Chi Mei Foundation Hospital, Tainan, Taiwan; Department of Obstetrics and Gynecology2, College of Medicine,
Taipei Medical University, Taipei, Taiwan; Department of Obstetrics and Gynecology3, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Dynamic kinking with "urethral knee"
s~êáçìë=ê~ÇáçäçÖáÅ=ëíìÇáÉë=ÇÉãçåëíê~íáåÖ=ÑìåÅíáçå~ä=âáåâáåÖ=çÑ=íÜÉ ãáÇìêÉíÜê~=ÇìêáåÖ=ëíêÉëëÑìä=ã~åÉìîÉêë=Ü~îÉ=ÄÉÉå=ÇÉëÅêáÄÉÇK=iç=Éí=~ä éÉêÑçêãÉÇ=ìäíê~ëçìåÇ=~ëëÉëëãÉåí=çÑ=íÜÉ=qsq=ëäáåÖ=~í=PJóÉ~ê=ÑçääçïJìéI
The evolution of anti-incontinence surgeries
Anterior colporrhaphy +
Kelly plication
Burch colposuspension
Iaparotomy & Iaparoscopy
Supra-pubic midurethral slings:
TVT, SPARC, IVS
Trans-obturator midurethral slings:
TVT-O, MONARC
Absorbable sling: SIS
Fig. 1. A brief summary of the evolution of anti-incontinence surgery. IVS: intravaginal slingoplasty; SIS: small intestine submucosa; SPARC: supra-pubic arc; TVT: tension-free vaginal tape; TVT-O: tension-free vaginal tape-obturator system.
Table 1. Brief Summary of Chronological Anti-incontinence Surgeries
Year Author Types of Surgeries
1914 Kelly HA [3] Suburethral fascia plication
1917 Goeball R & Stoeckel W [56] Using a strip of rectus fascia to encircle the urethra 1949 Marshall VF, Marchetti AA & Krantz KE [57] Retro-pubic urethropexy (pubis periosteum)
1959 Pereyra AJ [58] Needle-assisted transvaginal bladder neck suspension
1961 Burch JC [9] Retro-pubic colposuspension (Cooper ligament)
1973 Stamey TA [59] Endoscopic bladder neck suspension
1980s Raz S [60] Raz bladder neck suspension
1995 Ulmsten U [4] Tension-free Vaginal Tape (TVT) (Gynecare, Ethicon Inc, Summerville, NJ)
2001 Delorme E [23] Trans-obturator Subfascial Hammock, MONARC (American Medical System)
2003 Deval B [17] Supra-pubic arc (SPARC) (American Medical System, Minnetonka, MN)
2003 Petros P [61] Intra-vaginal Slingplasty (IVS) Tunneller (Tyco Healthcare- United States Surgical, Norwalk, CT)
2003 deLeval J [24] Trans-obturator vaginal tape (TVT-O) (Gynecare, Ethicon Inc)
2005 Mostow EN [17] Extracellular matrix graft: absorbable sling (SIS) (Cook Biotech Inc., W. Lafayette, IN)
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RR éçäóéêçéóäÉåÉI= éçäóíÉíê~ÑäìçêçÉíÜóäÉåÉI= mqcbI= éçäóÉíÜóäÉåÉ= íÉêÉJ éÜíÜ~ä~íÉI=mbqmI=ÉíÅFI=Äìí=~äëç=áå=íÉêãë=çÑ=ëíêìÅíìêÉ=EïçîÉåI=âåáííÉÇI ãçåçÑáä~ãÉåí=~åÇ=ãìäíáÑáä~ãÉåíFI=éçêÉ=ëáòÉI=ãÉÅÜ~åáÅ~ä=éêçéÉêíáÉëI ëÜ~éÉ=~åÇ=ëìêÑ~ÅÉ=ÅÜ~ê~ÅíÉêáëíáÅë=xNRzK=qÜÉ=Åä~ëëáÑáÅ~íáçå=çÑ=ëóåíÜÉíáÅ éêçëíÜÉëÉë=ï~ë=äáëíÉÇ=áå=q~ÄäÉ=P=xNSzK=qóéÉ=f=ã~ÅêçéçêçìëI=ãçåçÑáä~J ãÉåíçìë=ãÉëÜ=áë=êÉÖ~êÇÉÇ=áå=ëìêÖÉêó=~ë=íÜÉ=ãçëí=ëìáí~ÄäÉ=ã~íÉêá~ä=Ñçê ëíêÉëë=ìêáå~êó=áåÅçåíáåÉåÅÉ=~åÇ=éÉäîáÅ=Ñäççê=êÉÅçåëíêìÅíáçåK=jçëí=ÅçãJ ãÉêÅá~ääó=~î~áä~ÄäÉ=íÉåëáçåJÑêÉÉ=ãáÇìêÉíÜê~ä=ëäáåÖë=ìëÉ=íóéÉ=f=éçäóéêçJ éóäÉåÉ=ãÉëÜ=í~éÉI=ïáíÜ=íÜÉ=ÉñÅÉéíáçå=çÑ=áåíê~Jî~Öáå~ä=ëäáåÖéä~ëíó íìååÉääÉê=Efsp=íìååÉääÉêF=EqóÅç=eÉ~äíÜÅ~êÉJråáíÉÇ=pí~íÉë=pìêÖáÅ~äI kçêï~äâI=`qFI=ïÜáÅÜ=áë=~=íóéÉ=fff=ãÉëÜK=fí=áë=~äëç=ïçêíÜ=åçíáåÖ=Ñçê=áíë åÉïäó=ÇÉîÉäçéÉÇ=~ÄëçêÄ~ÄäÉ=ã~íÉêá~äëI=Å~ääÉÇ=ëã~ää=áåíÉëíáå~ä=ëìÄãìJ Åçë~=EpfpF=E`ççâ=_áçíÉÅÜ=fåÅKI=tK=i~Ñ~óÉííÉI=fkF=xNTzK=pfp=áë=~=å~íìê~ä Äáçã~íÉêá~ä=Ü~êîÉëíÉÇ=Ñêçã=íÜÉ=éçêÅáåÉ=ëã~ää=áåíÉëíáåÉ=~åÇ=ã~ÇÉ=áåíç=~ ÄáçÅçãé~íáÄäÉ=ãÉÇáÅ~ä=éêçÇìÅí=ìëáåÖ=~=é~íÉåíÉÇ=éêçÅÉëëK=qÜÉ=ÉãÉêJ ÖÉåÅÉ=çÑ=~ÄëçêÄ~ÄäÉ=ã~íÉêá~ä=ã~ó=ã~êâ=íÜÉ=ÄÉÖáååáåÖ=çÑ=~=åÉï=Éê~I ÜçïÉîÉêI=ÇìÉ=íç=äáãáíÉÇ=äáíÉê~íìêÉ=çå=íÜÉ=íçéáÅI=íÜÉ=äçåÖJíÉêã=ÉÑÑÉÅíë=~êÉ ëíáää=ìåâåçïåK
Retro-pubic approach: top-down (TVT) or bottom-up (SPARC) qÜÉ=êÉíêçJéìÄáÅ=~ééêç~ÅÜ=Å~å=ÄÉ=ÇçåÉ=íÜêçìÖÜ=~=ÄçííçãJìé=î~ÖáJ å~ä=~ééêç~ÅÜI=ÉKÖK=qsq=ëäáåÖ=EdóåÉÅ~êÉI=bíÜáÅçå=fåÅI=pìããÉêîáääÉI=kgFX çê=íÜêçìÖÜ=~=íçéJÇçïå=äçï=~ÄÇçãáå~ä=~ééêç~ÅÜI=ÉKÖK=ëìéê~éìÄáÅ=~êÅ Epm^o`F=ëäáåÖ=E^ãÉêáÅ~å=jÉÇáÅ~ä=póëíÉãI=jáååÉíçåâ~I=jkFK=qïç=íóéÉë çÑ=êÉíêçJéìÄáÅ=~ééêç~ÅÜÉë=~êÉ=áääìëíê~íÉÇ=áå=cáÖK=OK=káäëëçå=Éí=~ä=êÉJ éçêíÉÇ=íÜÉáê=êÉëìäíë=~ÑíÉê=T=óÉ~êë=çÑ=ÑçääçïJìé=áåîçäîáåÖ=VM=ïçãÉåK=^ ÅìêÉ=ê~íÉ=çÑ=UNKPB=ï~ë=åçíÉÇ=~ÑíÉê=~=ÑçääçïJìé=éÉêáçÇ=çÑ=VN=ãçåíÜë=xNPI NUzK=qïç=ê~åÇçãáòÉÇ=íêá~äë=Eo`qëF=Ü~îÉ=êÉéçêíÉÇ=åç=ÇáÑÑÉêÉåÅÉë=áå=ÉÑJ ÑáÅ~Åó=ÄÉíïÉÉå=pm^o`=~åÇ=qsq=~í=O=óÉ~êëK=qÜÉ=ëìÅÅÉëë=ê~íÉë=Ñçê pm^o`=~åÇ=qsq=ïÉêÉ=UPB=EåZQNF=îë=VRB=EåZQPFI=MKMRY=é=Y=MKN=ENO ãçåíÜëF=xNVzX=~åÇ=UMKTB=EåZPNF=îë=UTKNB=EåZPNFI=éZ=MKTMS=EO=óÉ~êëF xOMzI=åÉáíÜÉê=çåÉ=ÄÉáåÖ=ëáÖåáÑáÅ~åíK
Trans-obturator approach: outside-in (TOT) or inside-out (TVT-O) qsq=Ü~ë=ÄÉÉå=êÉÖ~êÇÉÇ=~ë=~=îÉêó=ë~ÑÉ=éêçÅÉÇìêÉK=eçïÉîÉêI=êÉJ éçêíë=Ñêçã=pÅ~åÇáå~îá~I=^ìëíêá~=~åÇ=çíÜÉê=éä~ÅÉë=Ü~îÉ=Çê~ïå=~ííÉåíáçå íç=ëÉîÉêÉ=ëìêÖáÅ~ä=ÅçãéäáÅ~íáçåë=êÉä~íáåÖ=íç=íÜÉ=éÉåÉíê~íáçå=çÑ=íÜÉ=êÉíêçJ éìÄáÅ=ëé~ÅÉ=xONIOOzK=få=OMMNI=~=íê~åëJçÄíìê~íçê=~ééêç~ÅÜ=ï~ë=éêçJ éçëÉÇ=Ñçê=íÜÉ=ëìêÖáÅ~ä=éä~ÅÉãÉåí=çÑ=ëìÄJìêÉíÜê~ä=í~éÉë=ìåÇÉê=íÜÉ=ãáÇÇäÉ ìêÉíÜê~I=ïáíÜ=íÜÉ=~áã=çÑ=êÉÇìÅáåÖ=çê=ÉîÉå=Éäáãáå~íáåÖ=ÅçãéäáÅ~íáçåë=Äó ëé~êáåÖ=íÜÉ=êÉíêçJéìÄäáÅ=ëé~ÅÉ=xOPzK=`äáåáÅ~ä=êÉëìäíë=~åÇ=~å~íçãáÅ=ëíìÇJ áÉë=ëìÖÖÉëí=íÜáë=~ééêç~ÅÜ=ã~ó=ÄÉ=ë~ÑÉêK=qÜÉ=í~éÉë=é~ëë=Ñêçã=íÜÉ=íÜáÖÜ ÑçäÇI=íÜêçìÖÜ=íÜÉ=çÄíìê~íçê=Ñçê~ãÉåëI=ìåÇÉêåÉ~íÜ=íÜÉ=ìêÉíÜê~I=íçï~êÇë íÜÉ=~åíÉêáçê=î~Öáå~ä=ï~ääI=ïáíÜçìí=ÉåíÉêáåÖ=íÜÉ=éÉäîáÅ=êÉÖáçå=~í=~åó=íáãÉ ÇìêáåÖ=íÜÉ=éêçÅÉÇìêÉK=fí=Å~å=ÄÉ=éÉêÑçêãÉÇ=îá~=~å=çìíëáÇÉJáå=~ééêç~ÅÜ EqlqëFI=ÉKÖK=lÄq~éÉI=rê~q~éÉI=jçå~êÅ=E^ãÉêáÅ~å=jÉÇáÅ~ä=póëíÉãI jáååÉíçåâ~I=jkFI=ÉíÅK=xOPzI=çê=~å=áåëáÇÉJçìí=~ééêç~ÅÜI=áKÉK=qsqJ=çÄíìJ ê~íçê=ëóëíÉã=EqsqJlF=EdóåÉÅ~êÉI=bíÜáÅçå=fåÅI=pìããÉêîáääÉI=kgF=xOQzK qïç=íóéÉë=çÑ=íê~åëJçÄíìê~íçê=~ééêç~ÅÜÉë=~êÉ=áääìëíê~íÉÇ=áå=cáÖK=PK=^ë=Ñçê íÜÉ=ÉÑÑáÅ~Åó=Ñçê=íÜÉ=íïç=íê~åëJçÄíìê~íçê=~ééêç~ÅÜÉëI=íÜÉ=êÉéçêíÉÇ=êÉJ ëìäíë=~êÉ=îÉêó=ëáãáä~êX=VMB=Ñçê=jçå~êÅ=EåZRMF=îÉêëìë=VQB=Ñçê=qsqJl EåZRMF=~í=N=óÉ~ê=ÑçääçïJìéI=ïáíÜ=åç=ëáÖåáÑáÅ~åí=ÇáÑÑÉêÉåÅÉë=xORzK=^äíÜçìÖÜ ëÜçêíJíÉêã=Ç~í~=ëÜçï=åç=ÇáÑÑÉêÉåÅÉ=áå=ÅìêÉ=ê~íÉë=çê=ÅçãéäáÅ~íáçåëI=íÜÉêÉ ~êÉ=åç=äçåÖJíÉêã=ëíìÇáÉë=Åçãé~êáåÖ=íÜÉ=áåëáÇÉJçìí=~åÇ=çìíëáÇÉJáå=íê~åëJ çÄíìê~íçê=~ééêç~ÅÜÉë=xOSzK
Efficacy of retro-pubic versus trans-obturaor approaches ^ÅÅçêÇáåÖ=íç=~=êÉÅÉåí=êÉîáÉï=~êíáÅäÉ=Äó=i~ííÜÉ=ÉíK=~ä=Ä~ëÉÇ=çå=ÑáîÉ o`që=Ñçê=qsqJl=îÉêëìë=qsq=~åÇ=ëáñ=o`që=Ñçê=qlq=îÉêëìë=qsqI=íÜÉ ëìÄàÉÅíáîÉ=ÅìêÉ=ê~íÉë=ïÉêÉ=~ë=ÑçääçïëW=qsqJl=îë=qsq=Elo=MKSVX=VRB=`f MKQOJNKNRFX=qlq=îë=qsq=Elo=NKMQX=VRB=`f=MKSQJNKTMFX=íçí~ä=qsqJlLqlq îë=qsq=Elo=MKURX=VRB=`f=MKSMJNKONFI=~ää=åçí=ëáÖåáÑáÅ~åí=xOTzK=eçïÉîÉêI íÜÉ=íê~åëJçÄíìê~íçê=~ééêç~ÅÜ=áë=äÉëë=ëìÅÅÉëëÑìä=áå=é~íáÉåíë=ïáíÜ=fpa xOUzK=^ÅÅçêÇáåÖ=íç=íÜÉ=éêÉJçéÉê~íáîÉ=ã~ñáã~ä=ìêÉíÜê~ä=ÅäçëìêÉ=éêÉëJ ëìêÉ=Ejr`mFI=íÜÉ=ÅìêÉ=ê~íÉë=ïÉêÉ=åçíÉÇ=~ë=USB=áÑ=íÜÉ=jr`m=ï~ë=ÖêÉ~íÉê íÜ~å=PM=ÅãeOlX=Åçãé~êÉÇ=UNB=áÑ=íÜÉ=jr`m=ï~ë=OMJPM=ÅãeOlX=~åÇ TMB=áÑ=íÜÉ=jr`m=ï~ë=äÉëë=íÜ~å=OM=ÅãeOl=xOUzK=få=ëìãã~êóI=íÜÉ=ëÜçêíJ íÉêã=ÉÑÑáÅ~Åó=çÑ=íê~åëJçÄíìê~íçê=íÉåëáçåJÑêÉÉ=ãáÇìêÉíÜê~ä=ëäáåÖë=áë=ÅçãJ é~ê~ÄäÉ=íç=íÜÉ=êÉíêçJéìÄáÅ=~ééêç~ÅÜK=eçïÉîÉêI=éêÉäáãáå~êó=ÉîáÇÉåÅÉ ëìÖÖÉëíë=íÜ~í=íê~åëJçÄíìê~íçê=íÉåëáçåJÑêÉÉ=ãáÇìêÉíÜê~ä=ëäáåÖë=ã~ó=Ü~îÉ ~=äçïÉê=ëìÅÅÉëë=ê~íÉ=Ñçê=íêÉ~íãÉåí=çÑ=fpa=xOTzK
Table 3. Classification of Synthetic Prostheses [16]
Type Characteristics Pore size Brand names
Type 1 Monofilament, macroporous > 75 µ Gynemesh, TVT, TVT-O SPARC, Monarc, Perigee, Apogee, Prolift
Type 2 Monofilament, microporous < 10 µ GORE TEX
Type 3 Macroporous with multifilaments or microporous IVS tunneller, URATAPE, SURGIPRO, MERSILENE, PARIETEX
Type 4 Submicronic < 1 µ
Table 2. Outcomes Using Tension-free Vaginal Tape (TVT) at Major Institutions in Various Countries
Case No. Successful Follow-up (Mons)
Ulmsten U (Sweden) [62] 50 86% 36 Olsson U (Sweden) [63] 51 90% 36 Wang AC (Taiwan) [64] 70 84% 3-18 Jacquetin B (France) [65] 156 89.1% 12-36 Soulie M (France) [66] 120 86.7% 15.2 (6-36) Nilsson CG (Finland) [18] 85 85% 56 (48-70)
RS
Fig. 3. The trans-obturator approach can be done outside-in with initial incisions at the groin/thigh (A, B, C), or inside-out with initial incisions at the anterior vaginal wall (D, E, F).
Fig. 2. Retro-pubic tension-free midurethral slings can be performed via a bottom-up vaginal approach (upper panel), e.g. TVT (A, B, C), or via a top-down low abdominal approach (lower panel), e.g. SPARC (D, E, F).
RT Proposed Indication for retro-pubic
versus trans-obturator approaches qÜÉêÉ=áë=~=é~ìÅáíó=çÑ=Ç~í~=áå=íÜÉ=äáíÉê~J íìêÉ=íç=ÇáêÉÅí=éÜóëáÅá~åë=êÉÖ~êÇáåÖ=íÜÉ=ÄÉëí áåÇáÅ~íáçåë=Ñçê=íÜÉ=ìëÉ=çÑ=î~êáçìë=íÉåëáçåJÑêÉÉ ãáÇìêÉíÜê~ä=ëäáåÖëK=få=~ÇÇáíáçåI=íÜÉ=áåÇáÅ~íáçåë ~êÉ=çÑíÉå=ÇÉéÉåÇÉåí=çå=ÅäáåáÅ~ä=ÉñéÉêáÉåÅÉ ~åÇ=íÜÉ=äÉîÉä=çÑ=ÅçãÑçêí=ïáíÜ=íÜÉ=ìëÉ=çÑ=íÜÉ î~êáçìë=íÉÅÜåáèìÉëK=fåÇáÅ~íáçåë=Ñçê=íÜÉ=ÄÉíJ íÉê=ÅÜçáÅÉ=~ãçåÖ=íÜÉëÉ=~ééêç~ÅÜÉë=ïÉêÉ éêçéçëÉÇ=Äó=páäî~=Ä~ëÉÇ=çå=Åçããçå=ëÉåëÉ éêáåÅáéäÉë=ê~íÜÉê=íÜ~å=êáÖçêçìë=ëíìÇó=~ë=o`që xOVzK qÜÉ=êÉíêçJéìÄáÅ=~ééêç~ÅÜ=ã~ó=ÄÉ=éêÉJ ÑÉêêÉÇ=çîÉê=íÜÉ=íê~åëJçÄíìê~íçê=~ééêç~ÅÜ=áå óçìåÖI=éÜóëáÅ~ääó=~ÅíáîÉ=é~íáÉåíë=çê=é~íáÉåíë ïáíÜ=fpaI=ÄÉÅ~ìëÉ=áí=ÜÉäéë=éêÉîÉåí=íÜáÖÜLÖêçáå ÇáëÅçãÑçêí=ïáíÜ=ÉñÉêÅáëÉ=~åÇ=íÜÉ=îÉÅíçêë=çÑ ëìééçêí=ÅêÉ~íÉ=ãçêÉ=ìêÉíÜê~ä=íÉåëáçå=xPMIPNzK qÜÉ=íê~åëJçÄíìê~íçê=~ééêç~ÅÜ=ã~ó=ÄÉ éêÉÑÉêêÉÇ=çîÉê=íÜÉ=êÉíêçJéìÄáÅ=~ééêç~ÅÜ=Ñçê çÄÉëÉ=é~íáÉåíëI=ÉäÇÉêäó=é~íáÉåíëI=é~íáÉåíë=ïáíÜ éêÉîáçìë= êÉíêçJéìÄáÅ= çê= ã~àçê= ~ÄÇçãáå~ä ëìêÖÉêóI=çê=ïáíÜ=ãáñÉÇ=áåÅçåíáåÉåÅÉK=fí=Å~å ã~âÉ=é~ëëáåÖ=åÉÉÇäÉë=É~ëáÉêI=êÉÇìÅáåÖ=íÜÉ êáëâ=çÑ=çêÖ~å=áåàìêóI=êÉÇìÅáåÖ=íÜÉ=êáëâ=çÑ=îçáÇJ áåÖ=ÇóëÑìåÅíáçåI=~åÇ=íÜÉ=êáëâ=çÑ=ìêÉíÜê~ä=çÄJ ëíêìÅíáçå=xOVzK råíáä=åçïI=íÜÉêÉ=~êÉ=åç=ÅçåÅäìëáîÉ=Ç~í~ íç=êÉÅçããÉåÇ=íÜÉ=áåëáÇÉJçìí=EqsqJlF=çîÉê íÜÉ=çìíëáÇÉJáå=EqlqF=~ééêç~ÅÜX=çê=íÜÉ=ÄçíJ íçãJìé=EqsqF=îÉêëìë=íÜÉ=íçéJÇçïå=~ééêç~ÅÜ Epm^o`FK=rëì~ääóI=ëìêÖÉçå=éêÉÑÉêÉåÅÉ=~åÇ íê~áåáåÖ= éä~óë= ~= ëáÖåáÑáÅ~åí= êçäÉ= áå= íÜáë ÇÉÅáëáçåK `ljmif`^qflkp= colj= qbkpflkJ cobb=jfarobqeo^i=pifkdp ^=å~íáçåïáÇÉ=~å~äóëáë=íç=Éî~äì~íÉ=íÜÉ íÜÉê~éóJ~ëëçÅá~íÉÇ=ãçêÄáÇáíó=Ñêçã=qsq=çéJ Éê~íáçåë=ï~ë=ÅçåÇìÅíÉÇ=áå=cáåä~åÇI=ïÜÉêÉ NIQRR=é~íáÉåíë=ïÜç=ìåÇÉêïÉåí=qsq=Ñêçã=PU Üçëéáí~äë=ïÉêÉ=êÉÅêìáíÉÇ=xONzK=fåíê~JçéÉê~íáîÉ ÅçãéäáÅ~íáçåë= ïÉêÉ= ~ë= ÑçääçïëW= Ää~ÇÇÉê éÉêÑçê~íáçåX=PULNIMMMX=~ÅíáîÉ=ÄäÉÉÇáåÖ=EÄäççÇ äçëë[OMM= ãiFW= NVLNIMMMX= áåàìêó= íç= ã~àçê îÉëëÉäëW=MKTLNIMMMX=åÉêîÉ=áåàìêóW=MKTLNIMMMX ìêÉíÜê~ä=äÉëáçåëW=MKTLNIMMMK=mçëíJçéÉê~íáîÉ ÅçãéäáÅ~íáçåë= áåÅäìÇÉÇW= êÉíêçJéìÄáÅ= ÜÉJ ã~íçã~=ENVLNIMMMFX=ãáåçê=éçëíJçéÉê~íáîÉ îçáÇáåÖ=ÇáÑÑáÅìäíó=ETSLNIMMMFX=éçëíJçéÉê~íáîÉ ìêáåÉ=êÉíÉåíáçå=EOPLNIMMMFX=éçëíJçéÉê~íáîÉ=ìêáJ å~êó=íê~Åí=áåÑÉÅíáçå=EQNLNIMMMFX=ÇÉÑÉÅí=áå=î~ÖáJ å~ä=ÜÉ~äáåÖ=ETLNIMMMFX=~åÇ=ÅçãéäáÅ~íáçåë=êÉJ èìáêáåÖ= ä~é~êçíçãó= EPKQLNIMMMF= xONzK= qÜÉ ëíìÇó=ÅçåÅäìÇÉÇ=íÜ~í=íÜÉ=qsq=éêçÅÉÇìêÉ=áë=~
Fig. 4. Comparison of retro-pubic versus trans-obturator approach. The retro-pubic approach (A), e.g. TVT (C), SPARC (D) as the two most common commercially available kits, passes the tape through the retro-pubic space with the incision wounds located low on the abdominal wall (G). The trans-obturator approach (B), e.g. Monarc (E), TVT-O (F), passes the tape through the trans-obturator foramen with the incision wounds located in the groin/thigh areas (H).
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RU MBJPB=Ñçê=ìêáå~êó=êÉíÉåíáçå=xPRzK=qÜÉ=êÉÅçãJ ãÉåÇÉÇ=ëìêÖáÅ~ä=ã~å~ÖÉãÉåí=çÑ=ìêáåÉ=êÉJ íÉåíáçå=Åçåëáëíë=çÑ=íê~åëî~Öáå~ä=íê~åë~Åíáçå çê=äççëÉåáåÖ=xPPzI=ìêÉíÜê~ä=Çáä~í~áçå=ìëáåÖ eÉÖ~ê=Çáä~í~íáçå=xPSzI=çê=ä~íÉê~ä=ÉñÅáëáçå=xPTzK s~êáçìë=ëìêÖáÅ~ä=~ééêç~ÅÜÉë=ã~ó=ÄÉ=ìëÉÇ íç=íêÉ~í=îçáÇáåÖ=ÇóëÑìåÅíáçåë=ÑçääçïáåÖ=~å=~åíáJ áåÅçåíáåÉåÅÉ=éêçÅÉÇìêÉK=cçääçïáåÖ=~=î~Öáå~ä çê=êÉíêçJéìÄáÅ=ìêÉíÜêçäóëáë=çê=êÉãçî~ä=çÑ=~ ëóåíÜÉíáÅ=ëìÄìêÉíÜê~ä=ëäáåÖI=çÄëíêìÅíáîÉ=ëóãéJ íçãë=~êÉ=äáâÉäó=íç=áãéêçîÉI=ëóãéíçãë=çÑ=áêêáJ í~íáçå=ã~ó=êÉã~áå=ìåÅÜ~åÖÉÇI=~åÇ=~äãçëí Ü~äÑ=ïáää=ÇÉîÉäçé=~=êÉÅìêêÉåÅÉ=çÑ=prfK=^ÇJ Çáíáçå~ääóI=íÜÉêÉ=ï~ë=~=ëí~íáëíáÅ~ääó=ëáÖåáÑáÅ~åí áãéêçîÉãÉåí=çå=ÄçíÜ=èì~äáíó=çÑ=äáÑÉ=EnçiF èìÉëíáçåå~áêÉë=xPUzK Bladder perforation ^=î~êá~ÄäÉ=~åÇ=ÜáÖÜ=áåÅáÇÉåÅÉ=çÑ=Ää~ÇJ ÇÉê=áåàìêó=Ü~ë=ÄÉÉå=êÉéçêíÉÇ=áå=íÜÉ=äáíÉê~íìêÉI ê~åÖáåÖ=Ñêçã=M=íç=ORB=xSIPVzK=fí=ï~ë=~äëç=êÉJ éçêíÉÇ=~ë=MKUB=ERLSMMF=áå=~=ëíìÇó=Äó=t~åÖ xQMzK=qÜÉêÉ=~êÉ=êáëâ=Ñ~Åíçêë=êÉëéçåëáÄäÉ=Ñçê éÉêÑçê~íáçåI=ëìÅÜ=~ë=éêÉîáçìë=éÉäîáÅ=ëìêÖÉêóI êÉéÉ~íÉÇ=~åíáJáåÅçåíáåÉåÅÉ=ëìêÖÉêóI=ÉëéK=éêÉJ îáçìë=ÅçäéçëìëéÉåëáçå=xQNzK=jÉ~åïÜáäÉI=~ äÉ~êåáåÖ=ÅìêîÉ=áë=~äëç=ÉîáÇÉåí=~ë=êÉÖ~êÇë Ää~ÇÇÉê=áåàìêóX=íÜÉ=êÉä~íáçåëÜáé=ÄÉíïÉÉå=íÜÉ áåÅáÇÉåÅÉ=çÑ=Åóëíçíçãó=~åÇ=íÜÉ=Åìãìä~íáîÉ åìãÄÉê= çÑ= Å~ëÉë= éÉêÑçêãÉÇ= áë= áåîÉêëÉäó ÅçêêÉä~íÉÇK=^ë=íÜÉ=åìãÄÉê=çÑ=Å~ëÉë=~=êÉëáJ ÇÉåí=ÅçãéäÉíÉÇ=áåÅêÉ~ëÉÇI=íÜÉêÉ=ï~ë=~=ëäáÖÜí íÉåÇÉåÅó= Ñçê= Åóëíçíçãó= íç= ÇÉÅêÉ~ëÉ= EéZ MKMPPF=xQOzK=qÜÉêÉÑçêÉI=ÅçêêÉÅí=áåëÉêíáçå=çÑ=íÜÉ íêçÅ~ê=~åÇ=áåíê~çéÉê~íáîÉ=ìêÉíÜêçÅóëíçëÅçéó áë=áãéÉê~íáîÉ=áå=qsqë=xQMzK ^=éêçëéÉÅíáîÉ=o`q=ëÜçïÉÇ=íÜ~í=Ää~ÇJ ÇÉê=áåàìêó=ï~ë=ëáÖåáÑáÅ~åíäó=ãçêÉ=ÑêÉèìÉåí=ïáíÜ íÜÉ=êÉíêçJéìÄáÅ=~ééêç~ÅÜ=Åçãé~êÉÇ=ïáíÜ=íÜÉ íê~åëJçÄíìê~íçê=~ééêç~ÅÜ=EVKR=îëK=MKMBI=mZ MKMPF=xQPzK=eçïÉîÉêI=ìåêÉÅçÖåáòÉÇ=Ää~ÇÇÉê áåàìêáÉë=Ü~îÉ=~äëç=ÄÉÉå=êÉéçêíÉÇ=ïáíÜ=íÜÉ íê~åëJçÄíìê~íçê=~ééêç~ÅÜ=xOUzK=^äíÜçìÖÜ=áåJ íê~JçéÉê~íáîÉ=ÅóëíçëÅçéó=ï~ë=åçí=êÉÅçãJ ãÉåÇÉÇ= Ñçê= êçìíáåÉ= ìëÉI= áåëíÉ~Ç= êÉÅçãJ ãÉåÇÉÇ=çåäó=Ñçê=ëÉäÉÅíÉÇ=Å~ëÉë=áå=íÜÉ=çêáÖáJ å~ä=ëíìÇó=ÇÉëáÖå=xPOzI=ëçãÉ=Å~ëÉë=çÑ=áå~ÇJ îÉêíÉåí=Åóëíçíçãó=ïÉêÉ=åçíÉÇ=ÇìêáåÖ=êçìíáåÉ ÅóëíçëÅçéóK=qÜÉêÉÑçêÉI=ëçãÉ=~ìíÜçêë=êÉÅçãJ ãÉåÇÉÇ=êçìíáåÉ=ÅóëíçëÅçéó=Ñçê=íÜÉ=íê~åëJ çÄíìê~íçê=éêçÅÉÇìêÉI=é~êíáÅìä~êäó=áÑ=íÜÉ=çìíJ ëáÇÉJáå=~ééêç~ÅÜ=áë=ìëÉÇ=xQQzK
Fig. 5. Two common complications of tension-free midurethral sling surgery include bladder injury and sling erosion. Bladder perforation can either be detected (A) or undetected (B) intra-operatively in a patient with concomitant pelvic organ prolapse. Partial (C) or complete vaginal exposure (D) of sling erosions are illustrated here.
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