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• W2021770735 abstract "OBJECTIVE: To describe the 3-D anatomy of the external obturator space and surgical relationships of the TVT-O procedure. METHODS: Twenty fresh cadaver dissections were performed to examine the external obturator space, the surrounding regional anatomy related to the technical aspects of the inside-out transobturator midurethral sling (TVT-O). Measurements were taken in 14 of the specimens to determine the spatial relationships of vital structures with respect to the surgical events. RESULTS: The obturator foramen is bounded by the superior pubic ramus, the body of the pubis, the inferior pubic ramus, the ischium (fusing with the inferior ilium) and spanned by the fibrous obturator membrane. The surgical path begins with a mid-urethral vaginal incision, then courses laterally at a 45° angle toward the superior medial edge of the obturator foramen, beneath the origin of pubococcygeus and puborectalis muscles and below the arcus tendineus levator ani and arcus tendineus fascia pelvis through the anterior recess of the ischioanal fossa. No entry is made into the space of Retzius. Dissections revealed the mean distance from the vaginal incision to the obturator membrane to be 4.5 cm (range 3.5–5.8 cm), and from vaginal incision to the obturator neurovascular bundle, 6.9 cm (range 6.5–8.5 cm). The tract then curves laterally along the bony inferior pubic ramus near the attachment of the obturator internus muscle, and passes through the obturator membrane. At its closest point, traversing the obturator membrane the passer was observed to be a mean distance of 2.5 cm (range 1.5–3 cm) from the obturator neurovascular bundle and as a function of its curvature, is directed away from these structures when advanced. Once through the membrane, the tract passes through the obturator externus, superior aspect of the adductor magnus, the adductor brevis, upper edge of the gracilis muscle, fascia lata, subcutaneous tissue and skin exiting 2 cm above the level of the external urethral meatus and 2 cm lateral to the thigh crease. In 14 out of the 20 cadavers (70%) an anterior branch of the obturator artery was found coursing medially along the exterior edge of the obturator foramen. This artery is effectively shielded by the exterior bony rim of the obturator foramen during an “inside-out” passage. The femoral neurovascular structures are well away at a mean distance of 11.4 cm (range 8–13 cm). CONCLUSION: The “inside-to-out” placement of the TVT-O procedure appears to offer additional safety during transobturator passage being directed away from the urethra and bladder and when present, unable to jeopardize the anterior branch of the obturator artery. The radius of the helical passer assures that as it traverses the obturator foramen it is directed away from the obturator neurovascular bundle into the surgically safe environment of the external obturator space to exit the skin lateral to the groin fold." @default.
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• W2021770735 date "2005-01-01" @default.
• W2021770735 modified "2023-09-26" @default.
• W2021770735 title "Paper 26: Anatomic Considerations for the TVT-Obturator Approach for the Correction of Female Stress Urinary Incontinence" @default.
• W2021770735 doi "https://doi.org/10.1097/01.spv.0000176100.26520.ec" @default.
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