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FASCIA PUBOVAGINAL SLING

After a rigorous clinical evaluation, adequate diagnosis and appropriate surgical indications, many urologists in Brazil prefer to use the abdominal rectal fascia to do the sling. This surgical option is based in the simplicity of taking away the fascia tape and in the almost absence of complication of a strange object, such as, infection and erosion. The pubovaginal sling offers a lateral and posterior support to the proximal urethra, enlarging the resistance against the urinary lookl at the moment of increase of intra-abdominal pressure (coughing, sneezing and effort).

SURGICAL TECHNIQUE STEPS

1) Patient in position of lythotomy, after placing the catheter of Foley 18 Fr., an incision type Pfannenstiel is made with about 8-10 cm. A rectangular tape is removed of fascia of the abdominal rectum of about 8 cm in length and 2 cm in width (Fig.1)

2) Extremity reinforcement of the sling with a suture continues with prolene -1, leaving the tips of the strings for a later transference to the retropubic region.

3) A vaginal incision is made (longitudinal, transversal, and in an inverted U or 2 parallel incisions).

4) A dissection at the mid level of the urethra, together to the vaginal epithelium, in direction of the homolateral shoulder of the patient.

5) The endopelvic fascia must be perforated and the urethra must be digitally liberated up to the pubic region, you must be careful not to dissect too closely to the urethra or next to the bladder neck. In patients with former surgeries this maneuver might be difficult in virtue of intense fibrosis, you must dissect with the scissors.

6) Passage of a needle ( any kind used for endoscopic suspension) from the retropubic region to the vaginal incision, guided digitally, to avoid vesical perforation. The extremities of the thread will be taken to the retropubic region.

7) The sling is placed in position in the mid region of the urethra, loosely, you may place 2 stitches of absorbable thread next to the peri urethral tissue, so the sling does not roll over itself. The same procedure we described before is done for the passage of the counter lateral threads.

8) A cystoscopy is done to exclude a urethral or vesical lesion and to verify the correct position of the sling under the urethra.

9) Tying the threads in the retropubic region, taking extreme care not to compress the urethra. For this, you may place tweezers between the urethra and the sling (Fig. 2) or tie the threads on tweezers placed longitudinally in the abdominal incision.

10) Suture of the abdominal rectum fascia; closing of the retropubic incision and closing of the vaginal incision with a polyiglyicolic acid, 4-0 placing a vaginal compress in 24 hours.