PROMEDON S.A. requires that all surgeons inform the Company or the
Distributor of any complication observed with the use of Steema.
SURGICAL PROCEDURE
INSIDE-OUT APPROACH
The sling is implanted by a transobturator approach, following the currently
accepted surgical technique, under regional, local or general anesthesia. The
administration of prophylactic therapy with antibiotics should be considered,
according to the procedure approved by the hospital.
The inside-out transobturator technique is summarized in the following steps:
1. Make a punctiform incision where a horizontal line passing at the level of
the clitoris meets the genitofemoral folds.
2. Midline Colpotomy: Perform a sagittal incision, 1.5 cm long, starting about
1 cm from the lower edge of the urethral meatus.
3. Paraurethral Dissection: From the incision, perform a dissection at a
45° angle from the urethral axis, towards the obturator foramen in the
paraurethral space. Take care not to injure the vaginal mucosa. Perform a
minimal vaginal dissection in order to form a tunnel that will allow the passage
of the transobturator needle. Repeat the process in both sides.
4. Thread the end of suture loop into the needle eyelet (see Figure 1).
Figure 1
5. Insert the urethral protector in the dissected area.
6. Enter the needle tip into the dissected area, following the urethral protector
channel. Push the needle forward, slightly passing through and penetrating
the obturator membrane.
7. Once in this position, remove the urethral protector and keep it sterile for
later use in the same patient on the other side.
8. Rotate the instrument on the ischiopubic branch until the needle appears at
the incision previously performed in the skin.
9. When the tip of the needle and the suture loop appear at the opening of
the skin, unthread the loop, clamp it with forceps and remove the needle,
rotating the handle in the opposite direction.
10. Pull the suture loop until it completely passes through the skin, and the
sling with its protective cover appears.
11. Repeat the process in the other side of the patient (step 4 to 10). Make
sure the positioning tab is located under the urethra and the sling is in
horizontal position.
12. Cut the sling and its protective sheaths under the dilator arms. Locate
the sling without tension under the mid-urethra by placing a Metzenbaum
scissors between the sling and the urethra to make tension regulation easier
and prevent the sling from bending. Pull the ends of the mesh until it makes
contact with the scissors.
When the sling is located without any tension under the urethra, remove the
protective sheaths of the sling, without removing the Metzenbaum scissors.
13. Remove the Metzembaum scissors.
14. Remove the positioning tab from the sling by cutting the thread located in
the front. Make sure to take out the positioning tab and the thread from the
vaginal channel.
15. Finally, cut the mesh excess and suture the incisions.
OUTSIDE-IN APPROACH
The sling is implanted by a transobturator approach, following the currently
accepted surgical technique, under regional, local or general anesthesia. The
administration of prophylactic therapy with antibiotics should be considered,
according to the procedure approved by the hospital.
The transobturator technique is summarized in the following steps:
1. Make a punctiform incision where a horizontal line passing at the level of
the clitoris meets the genitofemoral folds.
2. Midline Colpotomy: Perform a sagittal incision, 1.5 cm long, starting about
1 cm from the lower edge of the urethral meatus.
3. Paraurethral dissection: From the incision, perform a dissection at a
45° angle from the urethral axis, towards the obturator foramen in the
paraurethral space. Take care not to injure the vaginal mucosa. Perform a
minimal vaginal dissection in order to form a tunnel that will allow the passage
of the transobturator needle. Repeat the process in both sides.
