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This procedure is done with the patient in lythotomy position and may be done with local anesthesia. So, previous sedation is recommended using intravenous midazolam, in a dosage of 1mg, up to 5mg may be used.
At the beguinning of the procedure 0,05 mg of intravenous fentanyl is used, this same doses is repeated before passing the needles for the setting of the sling.
Our preference is to use 20 ml of bupivacaine at 1% with adrenaline, diluted in 40ml of physiologic serum, resulting in a volume of 60ml used for injecting.
Initially, 5ml of anesthetic is injected in the skin and subcutaneously at each side next to the upper border of the pubis. Following with a needle 22G of the spinal anesthesia is introduced near the pubis in the space of Retzius, injecting 15ml of the solution.
Two small transversal incisions are made of 1cm, next to the upper border of the pubis at each side.
The vaginal anesthesia is made injecting 20ml of the anesthetic solution on the vaginal wall sub and paraurethral, 1cm from the meatus urethral, as well as the vaginae pillars.
A medium vaginal incision is made of approximately 1.5cm, 1cm from the meatus urethral in proximal direction, but avoiding that this incision hits the bladder neck. Next, with the help of a Matzenbaum scissors, it is dissected in rhombus way laterally on both sides below the vaginal wall, creating a tunnel of 1cm, enough to introduce the end of the TVT needle, which set is formed by a prolene tape wrapped in a plastic sheath, showing a curved needle on each extremity, a mechanic gauntlet to orient the introduction of the needle and a straight metallic mandrill to introduce the Foley catheter 18 or 20 F (Fig 1).
This done we introduce urethra way a Foley catheter 20F, empty the bladder and in sequence introduce a straight metallic mandrill inside the Foley. This time has as an objective not only to facilitate identification of the urethra, but also to separate it, together with the bladder at the moment of the introduction of the needles. The sling which has a 5mm needle in diameter at each extremity is then prepared introducing one of these needles in the mechanic gauntlet which will guide its passage. Previously to the introduction off the needle, the Foley catheter with the mandrill are lateralized to which the needle will be introduced, to separate the urethra as well as the bladder from the passage of the TVT needle.
The introduction of the needle is made placing an extremity in the tunnel, previously dissected, in direction of the homolateral shoulder of the patient doing two movements.
In the first the needle is advanced horizontally till it perforates the urogenital diaphragm, which is easily seen by the surgeon. The second movement consists in an angular movement which will make the extremity of the needle advance through the space of Retzius, scraping the periosteum of the pubis till it hits the retropubic region, perforating the abdominal rectal muscle and its fascia, being exteriorized by the previous incision made.
The Foley is removed and a cystoscopy is done to verify if there was no vesicle perforation
(Fig 2). In case a vesicle perforation occurs, simply remove the needle and introduce it again.
Not having a perforation, the gauntlet is removed and the needle is pulled, bringing it to the retropubic region (Fig 3). In this phase the sling is covered by a plastic envelope which allows its sliding.
The same maneouvres are repeated on the other side, getting a U shape of the pubovaginal
Sling.(Fig.4),on the mid urethra. The needles are removed cutting the extremities of the sling and next the tension is adjusted before removing the plastic envelopes that are superposed in the mid region. These envelopes posses two functions, to avoid contamination of the sling during its introduction and to allow its sliding without any tissue trauma.
Next, with about 300 ml of physiological serum in the bladder the patient is told to cough vigorously and in case of urinary loss, the extremities of the sling are lightly tractioned, until we obtain continence. During this maneouver, the extremity of the scissors should be maintained between the urethra and the sling, to avoid tension at this level.
Notice that the sling was placed at the level of the mid urethra, where the pubourethral ligaments make their functional insertions and not at the level of the bladder neck.
This done and keeping the scissors between the urethra and the sling, both plastic envelopes are removed, which will make that it stays adhered to the tissues by friction. The extremities of the TVT are cut close to the skin and next the retropubic region and vaginal incisions are closed in a conventional manner.
The bladder is emptied, not being necessary a indwelling catheter unless there has been a vesical perforation, then it is recommended to do a 24 hour vesicle drainage. After the anesthesia recovery, spontaneous urination and an evaluation of the post-urination residue, which generally is inferior to 50 ml, the patient receives hospital discharge.
Antibiotic prophylactic therapy is recommended for 3 days.