Volume 44, Issue 6, Pages 724-730 (December 2003) Novel Surgical Technique for the Treatment of Female Stress Urinary Incontinence: Transobturator Vaginal Tape Inside-Out  Jean de Leval  European Urology  Volume 44, Issue 6, Pages 724-730 (December 2003) DOI: 10.1016/j.eururo.2003.09.003

Fig. 1 Specifically designed instruments for performing the transobturator inside-out tension-free urethral suspension: one pair of metallic “helical passers”, plastic tubes, and an introducer. European Urology 2003 44, 724-730DOI: (10.1016/j.eururo.2003.09.003)

Fig. 2 (A) Identification of the skin exit points of the needles by tracing a horizontal line at the level of the urethral meatus. The exit points (asterisk) are located 2 centimeters above this line and 2 centimeters outside the thigh folds. (B) After suspension of the anterior vaginal wall with two Allis clamps on either side of the midline, a median sagittal incision of the vaginal wall is started 1cm proximally to the urethral meatus and is continued proximally over a 1cm distance. (C) While one Allis clamp grasps minor and major labia to expose the vulvar vestibulum, a minimal lateral para-urethral sub-vaginal dissection is carried out with a cold knife blade over a few millimeters distance. European Urology 2003 44, 724-730DOI: (10.1016/j.eururo.2003.09.003)

Fig. 3 (A) Introduction of fine dissection scissors through the blade-initiated dissection path towards the upper part of ischio-pubic ramus, on a horizontal plane with a 45° angle relatively to the urethral sagittal plane, as indicated in (B), to perforate the obturator membrane with the tip of the scissors. (C) The introducer, with its open side facing the operator, is pushed in the pre-formed dissection pathway until it reaches and perforates the obturator membrane. European Urology 2003 44, 724-730DOI: (10.1016/j.eururo.2003.09.003)

Fig. 4 (A) After the surgical device has been assembled by mounting the distal end of the tube onto the spiral segment of the “passer”, it is slipped along the gutter of the introducer so as to pass through the obturator foramen. (B) After removal of the introducer, the passer’s handle is aligned in a parallel manner with the sagittal axis of the vulvar slit. (C and D) The passer is rotated inside-out with the tip of the tube directed towards the skin exit points at the thigh folds. (E) The pointed tip of the tube appears at the previously incised skin exit points at the level of the thigh folds. (F) The tube is pulled from the supporting passer, which is removed by a backwards-rotational movement. European Urology 2003 44, 724-730DOI: (10.1016/j.eururo.2003.09.003)

Fig. 5 (A) Alignment and adjustment of the tension of the tape under the junction between the mid and distal urethra by grasping the tape at its middle with Babcock forceps so as to create a small tape loop. (B) After traction has been exerted on the distal ends of the tape, which brings the Babcock forceps grasps in contact with the ventral aspect of the urethra, plastic sheaths are simultaneously removed at either end of the tape. European Urology 2003 44, 724-730DOI: (10.1016/j.eururo.2003.09.003)