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One of the advantages of using the TVT sling device is that the tvt sling procedure can be performed under a local anesthesia in a rather expeditious sequence with successful results. Under local anesthesia the patient will be semi-awake, but will not feel the surgery. It is performed in this way so the patient can participate in the surgery, which allows the surgeon to confirm that the patient no longer leaks urine and that the TVT sling is set correctly. During the procedure, once the tape is in the correct position, the patient is awakened enough to produce a cough. When the patient loses urine, the tape is elevated until leaking stops. The TVT sling and the conscious sedation allow the surgeon and the patient to work together to achieve the ultimate surgical cure rate. If the patient leaks urine the tape can be gently adjusted to increase support thus decrease leakage. The cough test allows the surgeon to give the patient the "Designer Sling" she needs. The tvt sling is adjusted on an individual basis to meet the need of each individual patient. The cough test prior to the completion of the tvt sling surgery is not normally performed with traditional sling procedures. Patients report minimal discomfort following surgery with the TVT for incontinence. In fact approximately 60% of Dr. Miklos' patients will not use any pain medication after being discharged from the hospital. Regional or General AnesthesiaSince a cough test, which requires patient participation is to be conducted, it is recommended that the procedure be performed under local anesthesia with intravenous (IV) sedation. However, regional or general anesthesia can also be used. The decision to select regional anesthesia should be made with the understanding that the patient will need to cough during the procedure. It is recommended that the surgeon work closely with the anesthesiologist to choose a regional block that will allow the patient to cough normally. Only surgeons experienced with the TVT sling should consider general anesthesia, the surgeon should be comfortable with the tension-free application of the mesh. Due to the inability to perform the cough test during the procedure under general anesthesia, the surgeon must be comfortable leaving the mesh placed loosely under the mid-urethra. The only tape setting end point measurement will be spacing with a blunt instrument. Occasionally the anesthesiologist can provoke a patient cough under general anesthesia by lightening up the sedation and simulating the cough or gag reflex. However this technique has not been proven to be as effective as a self initiated cough.
Surgical TechniqueRecommended Local AnesthesiaRecommended local anesthesia with intravenous sedation agents include a .25% Marcaine with epinephrine diluted 1:1 with injectable saline (60 cc Marcaine and 60 cc NS = 120 cc working volume). Abdominal AnesthesiaInitially, the bladder is emptied with an 18 French Foley catheter. The catheter balloon will help the surgeon identify the bladder neck to help direct the local anesthesia injections. The local anesthesia should be injected bilaterally via a long spinal needle in the skin and abdominal wall just above the pubic symphysis, downward posterior to the pubic bone through the space of Retzius. The anesthesia should be injected along the intended course of the needle. 
Vaginal Anesthesia
Anterior Vaginal Wall Mid-Suburethral--the vaginal speculum should be inserted to expose the anterior vaginal wall. The local anesthesia is injected sub-urethral, starting approximately 1.0 cm from the external urethral meatus and moving proximally. The local anesthesia is injected on each side of the urethra toward the bladder neck in to the retropubic space. The surgeon should then wait three to four minutes for the anesthesia to take effect. Abdominal/Suprapubic Incisions & Single Vaginal IncisionA vaginal incision with blunt dissection produces a space lateral to the urethra, which becomes the starting position for each of the TVT sling needles. Two abdominal incisions are performed first at the intended exit points with the needles just superior to the pubic symphysis. The key steps for this pat of the procedure are:
Abdominal/Suprapubic Incision
Single Vaginal IncisionThe anterior vaginal wall overlaying the midurethra is elevated with Allis clamps and incised vertically in the midline. The incision should begin approximately 1 cm from the external urethra meatus and extend proximally for 1.5 cm. The incision should be long enough to accommodate the width of the TVT sling. 
Metzenbaum scissors are used to mobilize a flap of the vaginal mucosa (1 cm) on each side of the urethra. The dissection should be limited to the vaginal mucosa by only moving laterally. Care should be taken not to puncture the pubocervical fascia or the urethra. Minimal dissection is required so that only the tips of the needle pass on each side.
Bladder Positioning
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 TVT Sling Fig: 15 |
TVT Sling and Device Placement
During this step, the surgeon insert the TVT needle into the vaginal incision, through the periurethral fascia, into the retropubic space (Space of Retzius) and upward until the needle comes through the abdominal incisions. Correct placement, positioning and movement of the introducer needle during the procedure are critical.
Key points and steps:
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Vaginal finger guidance |
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Initial alignment of the needle tip toward the ipsilateral shoulder until the endopelvic fascia has been perforated |
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Immediate upward deflection of the tip of the needle upon piercing of the pelvic fascia, passing behind the inferior ramus staying close to the posterior aspect of the symphysis |
The surgeon should:
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Be aware of the pace and direction of each movement |
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Review the angle of the introducer handle for orientation |
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Focus on the role of each hand throughout the procedure |
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Try to maintain a visual mental image of the needle tip as it guides through the female pelvis |
Two hands are required to pass the needle. The surgeon should concentrate on the role of each hand. Position the needle tip through the vaginal incision directed lateral to the urethra. When passing the needle, the vaginal mucosa is between the surgeon's finger and the tip of the needle.
TVT Sling Fig: 16 |
TVT Sling Fig: 17 |
TVT Sling Fig: 18 |
 TVT Sling Fig: 19 |
Palpate the inferior ramus laterally and the urethra medially with the straight catheter guide inside. Once the endopelvic fascia has been penetrated beneath the inferior ramus, the handle of the needle is directed downward and pressure is applied upward by the hand in the vagina. The force advancing the needle actually comes form the palm or the thumb of the vaginal hand and the vaginal finger guiding it. The second hand is used to direct the back end of the handle. It determines the angle and steers the needle. The second hand does not torque or advance the needle.
TVT Sling Fig: 20 |
TVT Sling Fig: 21 |
Once the needle tip has been passed through the abdominal incision the handle can be disconnected. The needle should not be pulled completely though to the abdomen until cystoscopy has verified its position.
TVT Sling Fig: 22 |
TVT Sling Fig: 23 |
Laparoscopic View of TVT needles
TVT Sling Fig: 24 |
The next two pictures shows a "birds eye view" of what is going on inside the pelvis. During Dr. Miklos' first case in 1998 he was able to capture these pictures using a laparoscope. This patient had a laparoscopic paravaginal repair and then the TVT sling was inserted under laparoscopic guidance. Though these pictures add to our knowledge as to where the needles pass behind the pubic bone, it is not necessary or recommended to use a laparoscope to perform this operation. This patient's scenario was unique; she had both stress urine incontinence and a symptomatic cystocele due to paravaginal defects. Dr. Miklos repaired the paravaginal defects first and then performed a TVT sling.
TVT Sling Fig: 25 |
TVT Sling Fig: 26 |
Cystoscopic Evaluation
After each pass of needle, cystoscopy is performed with needle in place extending from the vagina to the abdomen. In the event of a perforation, the needle will be easy to identify so it can be removed and re-introduced The surgeon must have cystoscopy privileges to perform this critical step of the procedure. During cystoscopy, the bladder should be distended to at least 250-300 cc of fluid. Using a 70-degree lens, the cystoscope is rotated and the bladder is inspected for perforations, which often occur at the one o'clock and 11 o'clock positions on the anterior wall of the bladder. The bladder neck should also be inspected.
After bladder integrity has been confirmed the TVT needles are pulled through the tissues and placed on the abdomen.
Bladder Perforation
When reinserting the needle for a second attempt after a peroration, stay close to the pubic symphysis and direct the needle slightly more lateral than the first attempt. Avoid directly scraping the bone because of the potential for bleeding. Also consider the position of the patient. The degree of the Trendelenburg position affects the angulations of the pelvis. A patient with abnormal anatomy or previous abdominal surgeries may make needle passage difficult. After two or three unsuccessful needle passes with bladder perforations it may be necessary to consider other surgical options.
Placement on the Contralateral Side
When passing the second needle, the Foley catheter should be reinserted into the bladder to Dr.ain the fluid. Insert the catheter guide and again move the handle to the side through which the needle will pass. As the needle tip is placed in the starting position, care should be taken to ensure the tape is not twisted.
After the second needle passage is completed in the same manner as the first, conduct a second cystoscopy to look for perforations. After bladder integrity is confirmed, pull the second needle through to the abdomen. Here we see the completed placement of the TVT sling both from a side view, as illustrated below as well as the "birds eye view" as seen with a laparoscope.
TVT Sling Fig: 27 |
TVT Sling Fig: 28 |
Adjust Placement and Remove Needles
After placement of the TVT sling, and prior to removal of the protective plastic sheath covering the Prolene mesh sling, the surgeon has the patient cough to test the positioning of the tape. The final adjustment of the tape is critical to the success of the tvt sling procedure. The goal is to position the tape so that during the cough test only one or two drops of urine leak.
 TVT Sling Fig: 29 |
Before performing the cough test, all instruments should be removed. There should be no pressure on the vaginal walls. The cough test should be conducted with a full bladder (250cc or saline). The surgeon should coordinate the procedure with the anesthesiologist so the patient is awake to cooperate during the tension test. Tilting the patient out of a supine position and into a reverse Tendelenburg position may help demonstrate leakage.
To prevent over-correction, a blunt instrument in placed between the tape and the urethra (forming a loop of tape). Before pulling on the tape, the instrument is placed in the loop to provide counter traction, allowing the slack to be removed while preserving the loop. The abdominal end of the tape is pulled until there is slight contact between the tape and the instrument. When placing an instrument between the tape and the urethra, remember "looser is better than tighter." The instrument that is used should be consistent, easy to handle and stable. Consider curved Mayo scissors.
TVT Sling Fig: 30 |
TVT Sling Fig: 31 |
TVT Sling Fig: 32 |
TVT Sling Fig: 33 |
After the first cough, if the patients leaks, the tape should be pulled upward slightly from the abdominal ends. The patient is asked to cough, if the patient leaks, the tape should be pulled upwards slightly from the abdominal ends. The patient is asked to cough again and the tape is adjusted until only one or two drops of urine leak. The test should be completed by ensuring that a Hagar dilator, number 7-8, passes through the urethra smoothly. There should be no resistance when the Hagar is inserted through the urethra.
Conceptually, the loop of tape functions as a blackboard. Descent of the urethra is prevented. The surgeon is adjusting the tape to act as a stopping point by limiting the range of motion of the urethra. The goal is to provide support but avoid angulations and obstruction. The most important support is provided by the mesh laterally rather than immediately beneath the urethra. This concept is further demonstrated by the division of the mesh beneath the urethra in patients with post-operative voiding obstruction that have normal voiding restored and also remain continent.
 TVT Sling Fig: 34 |
Remove Plastic Sheath and Cut Excess Abdominal Tape
The sheath performs two major tasks: it protects the tape during insertion and provides smooth movement of the mesh through the tissue.
After the needles are cut off, the plastic sheath is grasped with the hemostats at the abdominal ends. An instrument, either scissors or forceps, is placed between the urethra and the tape and stabilized. Holding the tape in place, the plastic sheath is removed by pulling upward with equal force. The mesh is now in place, without tension, underneath the mid-urethra. The abdominal ends of the tape are cut just below the surface of the skin.
TVT Sling Fig: 35 |
TVT Sling Fig: 36 |
TVT Sling Fig: 37 |
There is no need to suture or anchor the abdominal ends of the TVT sling. The friction of the 1.1cm wide tape coming through a hole produced by a .5 cm needle is enough to maintain the tape in place at both the pubocervical fascia and anterior abdominal wall fascia and muscle. The skin and vaginal epithelium are closed. The bladder is emptied and the catheter is removed.
TVT Sling Fig: 38 |
TVT Sling Fig: 39 |
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