The sling plus: a new concept for minimally invasive treatment of female urinary stress incontinence

v22

v21 ENDO-LAPAROSCOPIC

THE SLING PLUS: A NEW CONCEPT FOR MINIMALLY INVASIVE TREATMENT OF FEMALE URINARY STRESS INCONTINENCE Palma Pau10~. Riccetto Cassio’, Herrmann Viviane’.

Dambros Miriam’,

Marcelo’.Paz Lucero’, Netto Jr. Nelson’ ‘Urology.

University

of Campinas.

IN THE

Brwil,

‘Urology.

OF INCRUSTED

IUD MIGRATED

BLADDER

Thiel Kociancic E.‘. Maffezzini

Campinaa.

REMOVAL

University of

M.‘. Fumagalli

U.‘, Martinengo

C.‘, Minocci

D.‘.

Monesi G.‘, Sala M.‘, Frea B.’

Campinas, Americana. Brazil

INTRODUCTION & OBJECTIVES: This video tape is a comprehensive approach to the Sling Plus, a new technique to create a support to midurethra. in order to restore the continence in women with urinary stress incontinence (USI). The Sling Plus is built of high purified silicon polimer and its design allows minimum surgical damage of pelvic floor natural support structures. such as pubourethral and urethropelvic ligaments. The area that the will be kept in contact to the urethra has a rectangular 3 cm per I cm shape. It’s self-fixation is provided by adjustable serial 0.3 diameter bulges in both sling branches. A specially designed insertion needle permits both suprapubic or transvaginal approach, according to the surgeon best skills, by changing the needle holder between it’s extremities.

SURGICALTECHNIQUE:

The technique may be performed under local anesthesia and intravenous sedation or under spinal blockage. Two 0.5 cm transverse incisions are made close to the superior aspect of the pubic bone 5 cm apart. A longitudinal vaginal incision, I .Scmlong is made. starting 0.5 cm from the urethral meatus. Notice that this incision is not allowed to encroach on the bladder neck. Dissection is done to create a I cm tunnel lateral to the urethra for the introduction of the Sling Plus insertion needle. A straight I4 Fr inserter is introduced in the urethra and brought to the same side of the needle to avoid bladder perforation. First, the needle is advanced through the vaginal tunnel until the perforation of pelvic floor at the level of the midurethra.Than, it is redirected agamst the inner surface of pubic bone and advanced continuously to the benchmarks in the auprapubic area. Cystoscopy is performed to rule out bladder perforation. After the removal of the holder, the Shng Plus is attached to the needle and pulled out to the suprapubic area. The same manoeuvres are repeated on the other side. The proper tension of the sling is adjusted by a cough-test performed with 300 ml of saline in the bladder always maintaining a Metzenbaum scissors between the urethra and the sling. to prevent undue tension. After this manoeuvre, the extremities of the sling were cut and the Metzembaum scissors were removed. No further fixation is needed and the incisions arc closed in the usual manner. An indwelling catheter is maintained over night. When the proper technique is used, few complications may occur. If bladder perforation occurs, the surgeon simply pulls the needle back and makes another introduction. In these cases, a Foley catheter is left in place for 48 hours.

‘Ospedaliera “Maggiore Humanitas. Milano, Italy

della

Caritl”,

Novara,

Italy,

‘Istituto

Clinic0

Utilisation of the intrauterine contraceptive device (IUD) has led to a number of complications, the most important being infection, perforation and bleeding. A case of a 55 years old woman with irritative symptoms like urgency/frequency and recurrent urinary tract infection lasting more than 5 years is presented. The bladder ultrasound reveals a presence of a bladder stone locate at the bladder’s roof. The plain film of the pelvis shows that the bladder stone was incrusted around one of the branches of a IUD placed more than 20 years ago and disregarded. At the CT scan the IUD appeared completely migrated from the uterine wall into the abdominal cavity with one branch penetrating the roof of the bladder and the two others covered with omentum. A minimal invasive solution was chosen with endoscopic treatment of the bladder stone and a laparoscopic removal of the migrated IUD.

CONCLUSIONS: This technique is accordin,~1 the modem concepts of female continence mechanism and adds the advantages of a simple, safe and coat-effective micro-invasive procedure, that may be performed under local anesthesia, on an outpatient basis. It can became an alternatlve for restoriq the urethral wpport. if the excellent short-term results proved to he long lasting.

V23 RADICAL

CYSTECTOMY

WOMEN:

RATIONALE

AND

ORTHOTOPIC

AND NERVE-SPARING

NEOBLADDER TECHNIQUE

Martorana

Giuseope, Concetti Sergio, Vece Emmanuele,

University

of Bologna, Bologna,

Orthotopic because radicality

of the procedure.

to maintain continence

alone was unable to maintain have clarified addition

somatic innervation nerve,

anterolateral

results

(continence)

autonomic

and pudendal

similarly

observations

innervation,

from the same roots a\ the

to the autonomic

nerves,

of the urethral sphincter maintaining

along

the

is responsible continence

after

cystectomy. and the sub-cervical

perform

a continent

with Ghoncim’s one dissects

urethra

orthotopic

by usin g a nerve-sparing

urinary

diversion

urethral reimplantation).

the vagina

immediately

in women saving the

(Hautmann’s

then tied carefully

under the fomix.

to save the anterolateral

level of the medio-proximal in which

respectively.

we performed

bundles

of urinary fistulas.

are present

an omentoplasty

plane in order to improve the positioning formation

pamvaginal

to

ileoneobladder

peeling

technique the anterior

peduncles

Vallancien

INTRODUCTION & OBJECTIVES: Substitution cystoplasty is occasionally indicated to enlarge the capacity of a small contracted bladder when conservative forms of management have been unsuccessful. For these patients, open enterocystoplasty remains the most widely accepted technique. We report one case with laparoscopic supratrigonal cystectomy and ileocystoplasty in management of instertitial cystitis. MATERIAL

& METHODS:

We present a 47 years old woman with irritative

voiding symptoms and suprapubic pain related to bladder filling. Surgical treatment was indicated for the severely of symptoms and unsuccessfully medical therapies. The patient is installed supine position. 5 trocarts are used. The first surgical step was the detachment of the bladder from the uterus and dissection of the Retzius space. It is followed by the transsection of bladder wall.

at 4 and

8 o’clock

of the pelvico-perineal

of the neobladder

pedicles is performed after meticulous dissection of both ureters until the limit of the urethral meatus in the trigone. After an minimal infraumbilical incision (5 cm) an ileal segment was detubularised in a Z-shaped fashion. The bowel was returned to the abdominal cavity and the incision closed around the reinserted 10 mm trocart. The substitution cystoplasty was anastomosed to the supratrigonal bladder by 3 running sutures.

are

tissues and also at the

urethra one has to save the lateral pamurethral

nemovascular

Finally

technique

To follow the newe-sparing

vaginal wall from the hase of the bladder: the bladder vascular

tissues

Rosa Juliana,

WITH

and incision of the bladder trigone. The transsection of the bilateral bladder

In this video we present a procedure of anterior pelvectomy vagina

CYSTECTOMY

In

an intrapelvic

walls of the vagina, reaching the middle urethra.Thir

for the residual contraction

of the

of the female urethral sphincter.

has been identified: it originates but tuns.

and

and that the distal sphincter

it. Recently, clinical and anatomical

the role and the innewation

to the known

pudendal

the functional

In fact, it was thought that the preservation

bladder neck was necessary

SUPRATRIGONAL BLADDER ILEOPLASTY

Urology, Institute Mutualiste Montsouris, Paris, France

in women has been avoided for a long time

regarding

V24 LAPAROSCOPIC SUBSTITUTE

Bermudea Hugo, Gerard Cvril, Rey Denis, Adorn0 Guy, Guillonneau Bertrand

Bertaccini Alessandro

Italy

bladder after cystectomy of uncertainties

IN

and to prevent the

RESULTS:

The operating time was IS0 minutes and the blood loss was 100 cc.

The Foley catheter was removed on 5 days with excellent functional results. The hospital stay was prolonged on I2 days by an asymptomatic bacteriuria.

CONCLUSIONS: Laparoscopic supra trigonal cystectomy is feasible, safe and efficacious and appears to be an alternative to open approach in the management of severe refractory bladder contracture.

European

Urology

Supplements

1 (2002) No. 1, pp. 191