TECHNIQUES FOR RETROPUBIC, TRANSOBTURATOR, & SINGLE INCISION SLINGS MICKEY KARRAM MD DIRECTOR OF UROGYNECOLOGY THE CHRIST HOSPITAL PROFESSOR OF OB/GYN & UROLOGY UNIVERSITY OF CINCINNATI

CURRENTLY AVAILABLE SYNTHETIC SLINGS RETROPUBIC; below to above vs above to below PREPUBIC TRANSOBTURATOR; outside in vs inside out MINI-SLING; urogenital diaphragm vs obturator internus HOMEMADE SYNTHETIC SLINGS

GENUINE STRESS INCONTINENCE Suspend or Support Obstruct ANATOMIC ISD SPECTRUM OF DISEASE

BACKGROUND OF TVT ULMSTEN & PETROS INVENTOR OF PROCEDURE PROPOSED INTEGRAL THEORY CHALLENGED CURRENT THEORIES

Obturator Canal Obturator Foramen Ilium Obturator Foramen Ischiopubic Ramus Pubic symphysis Ischium

Transobturator Landmarks Adductor longus Urethra Obturator canal SAFE ENTRY ZONE of NEEDLE

Reiffenstuhl ,Platzer & Knapstein Mesh Position TVT Reiffenstuhl ,Platzer & Knapstein

Synthetic Midurethral Slings Third Generation MINI-SLING Sling is much shorter Requires only a small vaginal incision No exit points

GYNECARE TVT SECUR System Mesh Implant Laser cutting fuses the dual strand ends to prevent fraying. Studies have demonstrated that within a predetermined physiological range the elongation of laser-cut mesh is equivalent to the mechanical cut mesh, in addition to the average particle loss being less. The same proprietary PROLENE* polypropylene Mesh used for other GYNECARE TVT family of products 7 years of clinical data on the mesh Consists of a 1.1 cm x 8 cm PROLENE Mesh Laser cut instead of mechanically cut with a knife or blade

MiniArc™ Single-Incision Sling System MiniArc is a new procedure for SUI that is: Less Invasive Requires only one incision, resulting in less dissection Not necessary to perforate obturator membrane Designed for Efficacy Same materials and similar sling trajectory as Monarc® Sling delivery tool that maximizes safety and consistency of support Easy to Perform Unique, simple design that is intuitive to use

Solyx Sling

Ajust Sling

Single Incision Minislings PERCEIVED ADVANTAGES Minimal post-operative retention or voiding dysfunction requiring intervention No bladder or urethral injury No vascular injury No nerve injuries No erosions or excrusions Can be done under local anasthesia or with very minimal sedation Allows more objective utilization of cough stress test

Single Incision Minislings PERCEIVED ADVATAGES (cont) Minimal to no postoperative pain HAS BEEN SUCCESSFUL IN SEVERE ISD PATIENTS WILL BECOME VERY POPULAR IF REIMBURSEMENT CODES FOR OFFICE PLACEMENT ARE CREATED

Technical Points Unique to the Synthetic Midurethral Slings Vaginal Incision Direction of Insertion Device Depth of Insertion Tensioning of Sling

Cadaver shoot 22

Cadaver TVT 25

Gunkel 27

AMS Miniarc 28

Clip 1 29

Clip 2 30