Anatomical premises for the variability of the results of transobturator mid-urethral sling

Introduction. The implantation of a synthetic sub-urethral sling is the main method of surgical correction of stress urinary incontinence (SUI). However, the investigation results of long-term effectiveness indicate the ambiguity of the surgery outcomes. In addition, the problem of pain in the perineum remains relevant for everyday practice. One of the important aspects in this matter may be a variant technique for installing a suburethral sling, including based on the anatomical variability of the small pelvis.Purpose of the study. To identify key anatomical factors that can negatively affect the effectiveness and safety of the environment of suburethral sling surgery for urinary incontinence in women.Materials and methods. The study consisted of 2 parts - anatomical and clinical. In the anatomical part of the study, a suburethral sling was implanted on 20 preparations of a female pelvis with a lower limb and preserved soft tissues. The clinical part of the study involved 50 patients with stress urinary incontinence. These patients underwent installation of a transobturator suburethral sling in two ways using the “inside-out” technique: using the standard “external landmarks” technique and using the proposed anatomical technique developed in the first part of the study. After visualization of the suburethral sling using the original method, the outcomes of the operations were assessed depending on the location of the sling in the patient's tissues.Results. In the anatomical part of the study, the most atraumatic method of suburethral sling implantation was determined by rotating the tool around the lower branch of the pubic bone. In the clinical part of the study, this method demonstrated a higher efficiency of the operation at a follow-up of 1 year, presumably due to the U-shaped angle of the «hammock» for the urethra, which is characteristic of the retropubic sling.Conclusion. Outcomes of operations for SUI depend, among other things, on the method of the suburethral sling implantation.

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Anatomical Reasoning for Atraumatic Trocar Placement during Implantation of a Transobturator Suburethral Sling

Journal of Anatomy and Histopathology ◽

10.18499/2225-7357-2021-10-2-23-29 ◽

2021 ◽

Vol 10 (2) ◽

pp. 23-29

Author(s):

I. V. Gaivoronskii ◽

G. V. Kovalev ◽

D. D. Shkarupa ◽

G. I. Nichiporuk

Keyword(s):

Risk Factor ◽

Urinary Incontinence ◽

Stress Urinary Incontinence ◽

Soft Tissues ◽

Obturator Nerve ◽

Suburethral Sling ◽

Pubic Bone ◽

Trocar Placement ◽

The University ◽

Variant Anatomy

The aimof this research was to study the variant anatomy of the obturator complex in terms of surgical treatment of stress urinary incontinence, as well as to determine the most atraumatic technique for conducting a surgical trocar for a transobturator suburethral sling.Material and methods.A suburethral sling was implanted on 40 sagittally dissected samples of the female pelvis with preserved soft tissues using two techniques: the conventional one based on the use of external landmarks and the technique of the trocar rotation around the lower branch of the pubic bone developed at the University Clinic of St. Petersburg. After implantation of a transobturator suburethral sling, the probability of injury to the branches of the obturator nerve was assessed by precision preparation for each of the presented techniques using 40 samples. It was also suggested to develop a protocol for atraumatic placement ofa sling for stress urinary incontinence.Results. Based on the results obtained and study of the topographic relationships of the trocar and branches of the obturator nerve, it is concluded that the obturator complex has significant anatomical variability. This relates to both the muscular component –the internal and external obturator muscles, and neurovascular structures. The obturator nerve has two types of branching: joint and separate. The latter is a risk factor for intraoperative nerve injury. The technique of suburethral sling implantation by rotating the surgical trocar around the inferior branch of the pubic bone is atraumatic and safe.Conclusions.Variant anatomy of the obturator complex influences the probability of trauma in a transobturator suburethral sling implantation. In particular, the separate branching of the obturator nerve is a risk factor for its intraoperative injury. Further clinical studies are required to assess the outcomes of surgical t reatment of stress urinary incontinence taking into account the variant anatomy of the true pelvis.

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