Instrumentation for Native Tissue Repair Reconstructive Procedures

Fig. 2.1

Male versus female cystourethroscope tip comparison. The female tip prevents escape of irrigant and allows better urethral lumen distension

Fig. 2.2

Female urethrocystoscope

Fig. 2.3

Better view: Pathology such as sling mesh erosion in the female urethra can be missed without the superior distention allowed by the female urethrocystoscope

Several female urethro-cystoscopes exist. The smallest one made by Wolff is a 17.5 Fr scope (Fig. 2.2). There are larger ones, such as a 21 Fr intended for injection of bulking agents. They all have an obturator sheath in case the meatus is too tight for introduction and the tip gets caught at the meatal lip. These cystoscope sheaths can accommodate a 30° lens as well as a 70° lens to carefully inspect the anterior bladder wall and dome.

A flexible scope can also be used to inspect the urethra. This is generally employed more for diagnostic purposes in the clinic setting. However, both flexible and rigid scopes can be used to detect small areas of exposed mesh in the vagina and provide documentation of such. This procedure, called vaginoscopy, can also be useful in some very elongated vaginas after open or laparoscopic/robotic mesh sacrocolpopexy when it is difficult to reach the upper vagina to locate the site of extrusion. The vagina may be manually pinched or plugged to allow for distension. The flexible scope can also help in visualizing sutures or mesh exposed along the anterior bladder wall or bladder neck by using its retroflexion feature, or to identify the site of a small fistula and its relationship to the trigone and ureteric orifices.

Equipment for Vaginal Reconstruction

(Figs. 2.5, 2.6, 2.7, 2.8, 2.9, 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18, 2.19, and 2.20). The following equipment should be familiar and available to the vaginal surgeon. The list is not an absolute, but some version of each function will be necessary at one point or another during vaginal dissection and reconstruction.

Fig. 2.4

General cystoscopic equipment: Male 22 French cystoscopy set including obturators, graspers and endoscopic scissors. The flexible graspers can be used, for example, next to the cystoscope to place traction on eroded mesh during endoscopic laser removal

Fig. 2.5

Pediatric tonsil suction tip: small and angled so as to be unobtrusive in a small field. It does obstruct periodically so it is recommended to have an extra available separate from the set

Fig. 2.6

Scissors in order near to far: (1) The “Church” vaginal scissors are sharp and flat with a blunt leading edge, useful for the majority of sharp dissection. They are the dissection tool of choice for one of the authors. (2) Metzenbaum, more blunt-tipped than Church. (3) Curved Metzenbaum, useful in fistula. (4) Curved Mayo, which can be used for deep dense scar, rarely used. (5) Demartel acutely angled, useful for the initial edge in fistula, rarely used, can create a hole in dissection

Fig. 2.7

Bovie tips. Useful in keeping bleeding under control throughout the dissection, a protected bovie tip can be extremely handy. Bovie is the dissection tool of choice for one of the authors. One can switch from cutting to coagulating with no time loss. The cutting/coagulation levels can be adjusted from 20 to 30 depending on the situation and the proximity of vital structures. The bovie tip comes in short, medium or long sizes. The medium size is suitable for mesh sling removal for example (Refer to Video 19.2, Vaginal removal of suburethral sling, Chap. 19) as the hand of the operator is away from the field, allowing the assistant to follow the dissection well. When working close to the undersurface of the urethra, the coagulation is lowered to the 20s. A longer bovie tip can be useful in freeing prolapse kit mesh arms extending deep laterally into the pelvic sidewalls. The “gritty” texture of the mesh is easily recognizable from the surrounding scar tissue with both bovie and scissors, comparable to running one’s fingers along a screen door

Fig. 2.8

Grasping Forceps in order near to far: (1) and (2) Allis Tissue Forceps 5 × 6 teeth – 6″ and 7.5″, used throughout dissection to grasp mucosal edge. They can also be hooked to Scott retractor (see also Fig. 2.16). (3) and (4) Gerald Forceps with 1 × 2 teeth. These hold tissue and needles well, due to the flat raised distal edge abutting the tips. Avoid grasping the bladder, urethra, bowel, and ureter with toothed Geralds due to teeth. (Smooth Geralds are useful for fine work such as a Monti or ureteric anastomosis). (5) and (6) Debakey Forceps Heavy tips – 7 ¾ inch. Used to grasp more delicate structures and to provide tension during dissection of tissue planes. Good at manipulating the needle during suturing

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