This video will show a retropubic midurethral sling placement, the steps, relevant anatomy, and potential complications. We will first review the steps of a retropubic sling placement. The patient is typically positioned in Allen stirrups. The bladder is then drained with an 18 French catheter. The suprapubic sites are marked approximately 2 to 3 centimeters lateral to the midline. These sites are selected to be medial to the pubic tubercle. This represents the lateral boundaries for safe perforations of the abdominal wall, as a more lateral sling placement will increase the risk of neurovascular injury. A 1 to 2 centimeter incision is made under the midurethra. A 2 centimeter tunnel is then made with Betzenbob scissors at a 45 degree angle towards the ipsilateral shoulder. Prior to placement of the chokar, a urethral guide can be placed but is not necessary. The bladder is then deviated away from the site on which the surgeon is working with the catheter guide to minimize the risk of bladder injury. The insertion of the sling will also be shown in a cadaveric model and appear in the top left hand corner. In this cadaveric model, moving from inferiorly to superiorly, you will see the rectum, vagina, and bladder are labeled for reference. The insertion chokar is placed through the vaginal incision under the vaginal wall. The insertion chokar is then guided to perforate into the retropubic space immediately along the bone, entering the space of retsias at the junction of the descending pubic ramus and pubic bone. The chokar is then guided along the pubic bone, staying medial to the pubic tubercle, and perforating the abdominal wall within two centimeters of the midline. The chokar is then pulled through the abdominal wall. We will now show the procedure being performed from a laparoscopic view in the top left hand corner in addition to the sling placement on the contralateral side from the vaginal viewpoint. For orientation, the space of retsias, bladder, and catheter guide are labeled. The catheter guide can be seen on the patient's right in the laparoscopic view. The bladder will be deviated to the patient's left, and the chokar will be passing through on the patient's right. On the outside, the assistant is moving her hands to the patient's right, but it is to deviate the bladder and the tip of the catheter guide to the patient's left. The chokar, highlighted by the red arrow, is then seen passing just superiorly to the peritoneum in the space of retsias. The path of the chokar, its proximity to the surrounding anatomical structures in the peritoneum, can be easily appreciated from this viewpoint. A cystoscopy is also performed after each pass, or alternatively, after both passes have been made. If there is no bladder perforation, the needles are advanced and pulled completely through the abdominal wall. The sling is then left tension-free underneath the mid urethra, and the needles are detached from the sling devices. The plastic sheaths are pulled free from the mesh, and the excess sling material is cut flush to the skin surface. The vaginal and skin incisions are also closed. The bladder is then drained, and a voiding trial is performed prior to discharge home. We will now review the pertinent anatomy related to the retropubic sling procedure. As you can see, several vascular structures traverse closely to the path of the chokar. The numbers represent the mean distance from the lateral aspect of the chokar to the medial edge of the vessels. The obturator artery and main travel approximately 3.2 cm laterally to the path of the chokar, while the inferior epigastric vessels travel approximately 3.9 cm laterally. The external iliac artery also travels approximately 4.9 cm laterally from the path. In this cadaver, we can clearly see the inferior epigastric artery highlighted by the yellow wire. You can see the close proximity of the inferior epigastric artery to the path of the chokar, as demonstrated by the previous figure. You can also appreciate the proximity of the external iliac artery and vein to the chokar. Here we see the location and relationship between the pubic symphysis, bladder, and obturator neurovascular bundle. If the TVT needle is intentionally continued in a cephalad lateral direction, one can see how it can easily come into contact with the obturator neurovascular bundle in the retropubic space. In order to have a full understanding of the procedure, it is critical to understand the key anatomical landmarks of the space of Retzius otherwise known as the retropubic space. Here is a view of this space in a cadaveric model. Labeled are the inferior epigastric artery and vein, Cooper's ligament, and the external iliac vessels as they exit the pelvis under the inguinal ligament. Again, you can appreciate the proximity of the vascular structures in relation to the chokar. The insertion of the chokar is guided to perforate into the retropubic space immediately along the bone, entering the space of Retzius at the junction of the descending pubic ramus and pubic bone. If the chokar perforates at this location, the chokar will be lateral to the retropubic branches of the internal pudendal vessels and medial to the inferior epigastric, obturator, and accessory obturator vessels. If the chokar is directed away from the surface of the bone, a bladder perforation is more likely as is injury to the branches of the perivesical venous plexus and vesicle vessels. Now we will address the two main complications that can arise during the retropubic sling procedure, bladder perforations and vascular injuries. Bladder perforation occurs in 2-4% of cases. Cephalon migration of the chokar away from the back of the pubic bone is the most common cause of bladder perforation. A surgeon may purposely direct the chokar laterally to avoid this injury. However, the chokar can assume a lateral course if the patient moves while under local anesthesia. Once identified, it is usually managed by withdrawal and reinsertion of the chokar. Major vascular injuries have occurred with the retropubic sling procedure. External rotation of the handle will initially result in penetration of the obturator and ternus muscle by the needle tip, with the potential to injure aberrant vessels along the lateral pelvic side wall. Continued external rotation of the handle with cephalon migration of the needle may result in injury to the obturator neurovascular bundle or the external iliac vessels. As you can see in this video, the surgeon has his hand incorrectly pronated and the chokar handle is incorrectly externally rotated. He will then move his hand back into the correct position for sling placement. Again, the hand should be supinated and avoid pronating during the chokar placement. We will revisit the obturator neurovascular bundle again. You can see the chokar traversing along the retropubic space in the direction of the obturator neurovascular bundle due to incorrect pronation of the hand. The obturator neurovascular bundle, pictured here, is now in danger of injury from incorrect chokar placement. The inferior epigastric artery, outlined by the yellow wire, is also in danger of injury with lateral placement of the chokar. Thank you for watching this video as it demonstrates the steps, relevant anatomy, and potential complications that can arise from the retropubic midurethral sling procedure.

retropubic midurethral sling placement

anatomy

complications

abdominal wall perforation

bladder perforation