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					                               CHAPTER 28
                              “Classical” slings

28.1 Summary sketch.

1. Incision 1-cm opposite the middle third of the urethra. 2. Lateral dissection. 3. Passage of
            the needles. 4. Adjusting the tension.

Guide to the reader
1. Describe the different variations of existing slings and their general principles.
2. List the respective advantages and disadvantages of these procedures.
3. Detail the different operational stages, particularly the passage technique through
   the Retzius space.
Based on the principle of directly suspending the uterovesical junction, the efficiency
of these techniques is in part due to the obstructive effect resulting from the tension
applied. This obstructive effect is the reason for preferring the use of such techniques
e.g. in the case of a sphincter insufficiency. However, the same effect is also the cause
of a prolonged urinary retention, as well as of debilitating secondary dysuria. The
slings that are nowadays referred to as “classical slings”, together with the
colposuspensions according to Burch, represent the main reference techniques for
treatment of urinary incontinence occurring under stress…in the pre“TVT” world.
Since then, the new religion has, in the view of many surgeons, turned these
procedures into peripheral surgical techniques. Without doubt, the progressive
evaluation of secondary complications associated with suburethral slings, as well as
of their failures, will do justice to these earlier techniques that are easy to perform
while providing favourable long-term results. However, some technical modifications
and complementary evaluations might have to be performed.
   The results published for theses techniques are comparable to those achieved with
colposuspension techniques, and it is merely the absence of randomised studies that
has prevented them from obtaining their precise place among urinary incontinence
Numerous techniques for different types of slings have been described, varying in the
material used (synthetic or autologous), the technique for adjusting the tension, and in
the access route used in order to put the sling into place.
  We will not describe the classical Goebell-Stoeckel operations with application of a
musculo-aponeurotic strip: we do not have any experience with this technique and
their post-operative morbidity has progressively reduced the scope of their indications,
even though they produce encouraging results concerning urinary continence.
                         Variations in the use of materials
Variations are found in the material used for the sling itself, which can be autologous,
removed from the aponeurosis or from the patient’s thigh (fascia lata), or originating
from the cadaver (fascia lata, dura mater), with all the legitimate reservations this
requires in terms of virological security. One can use vaginal tissue, as described in
chapter 26 “Vaginal slings”, with reservations concerning long-term efficiency for the
treatment of isolated incontinence.
              Variations in the passage through the Retzius space
Most of the sling techniques commence with a vaginal incision that is directly
followed by a dissection and breaching of the Retzius space via the vaginal route
using a finger. Some surgeons prefer to then glide a forceps via the vaginal access
along their finger, protecting the bladder. Others will rather perforate the abdominal
aponeurosis with a needle, such as a Stamey needle, directly on the surgeon’s finger,
which will then guide it all the way to the vaginal incision. These do not represent
individual techniques, but rather personal preferences.
   We lastly consider the techniques for regulating the slings’s tension, a major part of
the procedure. Ideally, this adjustment should be performed under loco-regional
anaesthesia. It should be adapted to the correct exactly of any urinary leakage of the
coughing patient with the bladder filled. Blind adjustment of the tension must be
avoided, leading to the risk of over-adjusteing that could result in prolonged urinary
retention. If adjustment is performed under general anaesthesia, one must resist the
temptation of “good intentions” and not apply tension. Ideally, the knot will be left
free, so that it can be lifted 1 to 2 cm above the aponeurosis after having been pulled
28.2 Vaginal sling procedure using sub-cervical strips suspended to the anterior abdominal
          wall by a mixed approach.

The classical slings are indicated for:
  – a urinary incontinence during stress;
  – one that has been confirmed by examination, with a padtest and during the
urodynamic evaluation;
  – debilitating urinary incontinences or those hidden by a cystocele;
  – patients of all ages.

The technique described here is a treatment for isolated urinary incontinence (figure
Identifying the urethro-vesical junction and positioning the Kocher forceps
The urethro-vesical junction is identified by the bulge of the vesical probe that has
been filled and pulled downward, so that it can serve to identify the junction by
palpation. Ideally, the functional, as opposed to the anatomical, junction has
previously been identified by vaginal ultrasound including an exact measurement of
the distance from the junction to the urethral orifice. The Kocher forceps mark off the
vaginal incision and are positioned on either side of the vaginal incision, transversally
about 5 cm from each other.
                                  Vaginal infiltration
The infiltration is performed below the incision and laterally along the dissection path
towards the Retzius space. This infiltration must allow for a dissection that is
sufficient to allow passage of a finger. The infiltration can be extended into the
Retzius space.
                       Incision and dissection of the junction
The vaginal incision is followed by positioning the Allis’ forceps, two on the upper
edge and two on the lower edge. Traction exerted on the Allis’ forceps displays the
dissection spaces, allowing the liberation of 1 cm below the upper edge and 1 to 2 cm
above the lower edge.
                              Vesicovaginal dissection
The dissection is now extended laterally to the bladder’s sides, towards the branches
of the pubic symphysis. It is unnecessary to dissect more than required to allow
passage of the surgeon’s finger.
                            Access to the Retzius space
Having reached the point opposite to the branches of the pubic symphysis, one
proceeds by opening the paravesical fossae, perforating them with scissors (cf.
chapter 27, Bologna). The strip is taken hold of with two non-resorbable threads.
      Passage of the non-resorbable threads through the Retzius space
The threads are gripped with a Bengolea forceps, which is -brought into contact with
the abdominal aponeurosis, all the while moving along the surgeon’s finger, thus
protecting the bladder. A cutaneous incision as well as an incision of the aponeurosis
is carried out opposite each of the forceps, and the threads are brought to the skin. The
threads coming from the vaginal strips are brought together at the midline and tied,
adjusting the tension as previously described for the sub-urethral strips.
       Putting the strip into place and attaching opposite the junction
In order to avoid a secondary mobilisation of the strip below the urethra, one can
easily fix the strip to the para-urethral tissues with two stitches using resorbable
                Adjusting the strip tension and vaginal closure
The tension is adjusted as described in the chapter that is devoted to the Bologna
intervention (cf. chapter 27). One then proceeds with the vaginal closure.
   The intervention is completed with a verification of haemostasis and a count of

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