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New transobturator sling reduces risk of injury

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By placing the tension-free sling between the 2 obturator foramens using a perineal approach, surgeons can eliminate complications that stem from passing needle carriers through the retropubic space. Here, 2 experts delineate this easily learned technique.



  • The route of the transobturator sling is strictly perineal, with a very short, blind passage through the crural region. This pathway ensures that the retropubic space is not entered and that the anatomic structures crossed by the needle passer and mesh are either muscle or fascia.
  • The transobturator approach eliminates the need for routine cystoscopy in most patients.
  • Short-term efficacy of the transobturator sling is similar to that of other suburethral tension-free slings.
  • In our experience, the transobturator approach reduces average operating time to 17 minutes.

Potential complications associated with passing needle carriers through the retropubic space are eliminated, and cystoscopy is not routinely required with the use of a transobturator sling.

Although it is effective and easy to perform,1-6 retropubic placement of suburethral tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence has been associated with a number of bowel, vascular, nerve, and bladder injuries (TABLE).7-13

Such complications appear to be related to the unique upward vaginal passage of the metallic sling trocars through the retropubic space. Newer slings eliminate the upward approach, but still require routine cystoscopy to confirm an intact bladder and urethra.

A new tension-free suburethral sling addresses these shortcomings using an innovative transobturator route.14 In the new procedure, the surgeon uses needle passers to run the sling from one obturator foramen to the other. The perineal approach reproduces the natural suspension of the urethral fascia while preserving an intact retropubic space (FIGURE 1).


Advantages of the transobturator sling

  • Offers short-term efficacy (1 year) similar to SPARC and tension-free vaginal tape systems
  • Reproduces natural suspension mechanism of pubocervical fascia and pubourethral ligaments, which may pose less risk for overcorrection and dysuria
  • Offers safe needle passage by avoiding the retropubic space
    • May eliminate vascular, bladder, and bowel injuries
    • Eliminates the need for cystoscopy in most patients
    • Avoids retropubic scarring
    • May prove useful in cases with scar tissue impedance
    • May prove useful in obese patients
    • May prove useful in treatment failures
  • Offers shortened procedure time
  • Increases surgeon comfort by minimizing blind perineal needle passage
  • Is easy to learn and teach

FIGURE 1 Suburethral slings: Retropubic and transobturator pathways

Traditional suburethral tension-free slings require the needle passers and sling to be placed through the retropubic space.

The newer transobturator sling uses a perineal approach. The needle passer and sling are passed from one obturator foramen to the other, preserving an intact retropubic space.

What does ‘tension-free’ mean?

Tension-free slings are used to treat stress urinary incontinence caused by urethral hypermobility and intrinsic sphincter deficiency. In this approach, a synthetic transvaginal suburethral sling is placed through the retropubic space without using suspension sutures. The sling is held in place by the friction between the mesh and the tissue canals created by the metallic needle passers. Scar tissue later fixes the mesh, preventing migration.

Short-term efficacy of the Monarc transobturator sling is similar to that of the SPARC and tension-free vaginal slings.

Because the sling is not anchored to the pubic bone, ligaments, or rectus fascia, it is considered “free of tension.” The result is a midcomplex urethral support that limits urethral descent, improves the stabilization mechanism generated by pubourethral ligaments and levator ani muscles, and reinforces support of the backboard vaginal hammock.

A tension-free sling designed to reduce injury

Since its introduction in the mid 1990s, retropubic placement of suburethral tension-free tape has continued to gain in popularity.15-22 The technique has several advantages: It is simple to perform under local, regional, or general anesthesia, and has proved to be a safe treatment for stress urinary incontinence, with minimal complications in experienced hands. Still, injuries have occurred7-13 —likely due to the blind passing of metal trocars from the vagina upward through the retropubic space.9,23

Downward placement introduced. In an effort to reduce these complications, tension-free sling systems that rely on suprapubic, downward needle-carrier placement through the retropubic space were developed, such as the SPARC Female Sling System (American Medical Systems, Minnetonka, Minn), introduced in 2001.24 The manufacturer of the traditional TVT (Gynecare, a division of Ethicon, Somerville, NJ) also recently introduced suprapubic needle passers. However, because these slings still require passage through the retropubic space, their use may lead to vascular, bowel, and bladder injury. Routine cystoscopy is therefore required.

The transobturator sling. In the Netherlands in 1998, Nickel et al25 reported a successful sling procedure using a polyester ribbon passed through the obturator foramen and around the urethra for treatment of refractory urethral sphincter incompetence in female dogs. In France in 2001, Delorme14 introduced the transobturator sling procedure in humans. Dargent et al26 then performed the operation in 71 patients using a technique inspired by Delorme, and found the shortterm results similar to those of the TVT.

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