Anatomical Reasoning for Atraumatic Trocar Placement during Implantation of a Transobturator Suburethral Sling

The aimof  this research was to study the variant anatomy of the obturator complex in terms of surgical treatment of stress urinary incontinence, as well as to determine the most atraumatic technique for conducting a surgical trocar for a transobturator suburethral sling.

Material and methods.A suburethral sling was implanted on 40 sagittally dissected samples of the female pelvis with preserved soft tissues using two techniques: the conventional one based on the use of external landmarks and the technique of the trocar rotation around the lower branch of the pubic bone developed at the University  Clinic  of  St.  Petersburg.  After  implantation  of  a  transobturator  suburethral  sling,  the  probability  of injury  to  the  branches  of  the  obturator  nerve  was  assessed  by  precision  preparation  for  each  of  the  presented techniques using 40 samples. It was also suggested to develop a protocol for atraumatic placement ofa sling for stress urinary incontinence.

Results. Based  on  the  results  obtained  and  study  of  the  topographic  relationships  of  the  trocar  and branches of the obturator nerve, it is concluded that the obturator complex has significant anatomical variability. This relates to both the muscular component  –the internal and external obturator muscles, and neurovascular structures. The obturator nerve has two types of branching: joint and separate. The latter is a risk factor for intraoperative nerve injury. The technique of suburethral sling implantation by rotating the surgical trocar around the inferior branch of the pubic bone is atraumatic and safe.

Conclusions.Variant anatomy of the obturator complex influences the probability of trauma in a transobturator suburethral sling implantation. In particular, the separate branching of the obturator nerve is a risk factor for its intraoperative injury. Further clinical studies are required to assess the outcomes of surgical t reatment of stress urinary incontinence taking into account the variant anatomy of the true pelvis.

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