| Purpose: To study the novel surgical technique for female stress urinaryincontinence, that is the transobturator vaginal tape inside out, whether is highly accurate, reproducible and safe by cadaver dissection. Herein we report the results of cadaver dissection performed to determine the anatomical trajectory of the tape and its relationships with neighboring neurovascular structures and organs.Materials and Methods:1. Materials:1.1 Tape material: TVT-O instrument is produced by Johnson medical limited company, comprising a pair of helical passers and a Winged Guide, and a piece of polypropylene mesh tape with barbs.1.2 Cadavers: These fifteen freshly frozen female cadavers are provided by Anatomical Department ,with simple antiseptic treatment. All female cadavers were 40～75 years old with no history of pelvic or perineal intervention. 2. Methods:2.1 TVT-O operation:These forteen cadavers are divided in two groups and operated according to the standard procedure by different surgeons. Place the cadavers in the dorsal lithotomy position with the hips hyperflexed over the abdomen. Make a 1.5cm midline anteroposterior axes incision in the vaginal mucosa starting 1cm proximal to urethral meatus. Make a 0.5cm incision 2cm lateral to the folds of the thigh and 2cm above the horizontal line at the level of the urethral meatus. Using Allis clamps for traction vaginal mucosa incision, using a "push-spread technique",begin blunt dissection the vaginal mucosa with curved scissors.The path of the lateral dissection should be oriented at a 45°angle from the midline,with the scissors oriented either on the horizontal plane or with tips pointed slightly upward. Continue dissection toward the "junction" between the body of the pubic bone and the inferior pubic ramus.When the "junction" between the body of the pubic bone and the inferior pubic ramus is reached, perforate the obturator membrance.Insert the Winged Guide into the dissected tract until it passes the inferior pubic ramus. Insert the helical passer into the dissected tract following the channel of the Winged Guide, slightly push the device inward, traversing and passing the obturator membrance. Remove the Winged Guide and exit the helical passer from the skin incision at the folds of the thigh.Remove the helical passer. Pull the plastic tube until the tape appears. Repeat the technique on the cadaver's other side.2.2 Dissection methods: One of the 15 cadavers were dissected prior to tape insertion to identify specifically the anterior branch of the obturator artery, of which the location may have been modified by tape passage. Dissection was started at the level of Scarpa's femoral triangle,then the thigh, obturator, perineal and pelvic regions were dissected and tape trajectory was recorded.Results: The tape was inserted according to a certain consistent path, that is penetration from the suburethral space into a strictly perineal region limited medial and cranial by the levator ani muscle, caudal by the perineal membrane and lateral by the obturator interims muscle. This region corresponded to the most anterior recess of the ischiorectal fossa. The tape then perforated the obturator membrane and muscles, and exited through the skin after traversing adductor muscles and subcutaneous tissue. The tape was coursed away from 1) the dorsal nerve to the clitoris located more superficially below the perineal membrane, 2) the obturator nerve and vessels, and 3) the saphenous and femoral vessels.Conclusions: These findings strongly suggest that trans-obturator tape inside-out technique for female stress urinary incontinence is highly accurate, reproducible and safe, and it does not require perioperative cystoscopy.
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