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

2. 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

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

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

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

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

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

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

15. 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

16. 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

17. Solyx Sling

18. Ajust Sling

19. 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

20. 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

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

22. Cadaver shoot 22

25. Cadaver TVT 25

27. Gunkel 27

28. AMS Miniarc 28

29. Clip 1 29

30. Clip 2 30