Steer Clear: Anatomic Evaluation of Techniques to Improve Safety with Retropubic Sling

Objectives: The aim of this video is to evaluate different surgical techniques intended to improve safety and decrease complications during insertion of a retropubic sling, with specific focus on suprapubic injection and urethral deviation.

Methods: This is a descriptive, anatomic evaluation using a female cadaver. First, we filled the bladder with contrast and obtained fluoroscopic images after injecting various amounts of fluid in the suprapubic space. Our images demonstrate that even with just 20 mL of fluid, the bladder was displaced away from the pubic bone.



Next, we evaluated different tools for urethral deviation, including a catheter guide, a metal catheter, and a Foley catheter alone. We collected measurements using a dissected cadaver with the retropubic space exposed. Additionally, we acquired fluoroscopic images using different tools for urethral deviation. Our measurements suggest that the metal catheter achieves a similar level of deviation as the catheter guide. However, external manipulation of the Foley catheter alone did not result in any lateral deviation. Instead, tension applied on the catheter moved the bladder neck distally. This suggests that a catheter alone does not achieve the same level of deviation as a catheter guide or metal catheter.

Clinical Relevance: This evaluation supports the value of suprapubic injection, as even the minimum amount injected displaced the bladder away from the pubic bone, thus likely minimizing the risk of bladder perforation. Our evaluation of different deviation tools suggests similar results when using either a catheter guide or a metal catheter. Similar deviation was not achieved with a catheter alone. This suggests that using a metal catheter is an appropriate alternative to the originally described method of a catheter guide. This technique may aid with surgical efficiency by decreasing operative time and avoiding the need for specialized equipment.