Transobturator methods for installing sling to treat incontinence, and related devices
Described are methods of treating urinary incontinence using a urinary sling and a tissue path that passes through the obturator foramen, along with related surgical implants, devices, systems, and kits.
1. A method of treating incontinence comprising the steps of:
providing an elongate implantable sling comprising a central support portion and elongate end portions sized and shaped to extend between an incision substantially adjacent to a patient's obturator foramen, through the obturator foramen, and to a location below the urethra,
creating a pair of lateral incisions substantially adjacent a patient's left and right obturator foramen,
creating a medial incision at the perineum,
exposing bulbospongiosus muscle,
dissecting bulbospongiosus muscle to expose corpus spongiosum,
placing the central support portion to contact the corpus spongiosum, and
extending the end portions internally through the obturator foramen to the lateral incisions substantially adjacent to the obturator foramen.
2. The method of claim 1 , comprising
providing a left-hand surgical tool comprising a needle portion extending from a handle, the needle portion comprising a three-dimensional portion having structure in three dimensions and sized and shaped to extend between a patient's right-side lateral incision, through the obturator foramen, and to the medial incision,
inserting a distal end of the left-hand tool through the right-side lateral incision, through a patient's right-side obturator foramen, and to the medial incision,
associating an end of the sling with the distal end of the left-hand tool at the medial incision,
drawing the end of the sling through the right-side obturator foramen to the right-side lateral incision,
providing a right-hand surgical tool comprising a needle portion extending from a handle, the needle portion comprising a three-dimensional portion having structure in three dimensions and sized and shaped to extend between a patient's left-side lateral incision, through the obturator foramen, and to the medial incision,
inserting a distal end of the right-hand tool through the left-side lateral incision, through a patient's left-side obturator foramen, and to the medial incision,
associating an end of the sling with the distal end of the right-hand tool at the medial incision,
drawing the end of the sling through the left-side obturator foramen to the left-side lateral incision.
3. The method of claim 1 , comprising placing tension on the end portions of the sling to approximate pelvic tissue.
4. The method of claim 3 , comprising approximating the urethra in a proximal direction.
5. The method of claim 3 , comprising approximating the urethra in a proximal direction by a distance in the range from 1 to 5 centimeters.
6. The method of claim 1 , comprising
creating tissue paths between each lateral incision and the medial incision, exiting in the perineal region between the corpus cavernosum and the corpus spongiosus,
placing the central support portion in contact with the corpus spongiosum at a location from 0.5 to 1.5 centimeters distal to a line created between needle passages on both sides of the corpus spongiosum, and
placing tension on the end portions of the sling to approximate the corpus spongiosum.
7. The method of claim 1 , wherein the patient is affected by a condition of perineal descent.
8. The method of claim 1 , wherein the patient has experienced radical prostatectomy, a TURP (trans-urethral resection of the prostate), or a cystectomy.
9. The method of claim 1 , wherein the approximating step repositions pelvic tissue to place a urethra to a more physiologically correct position to improve coaptation of the urethra by the rhabdosphincter.
10. The method of claim 1 , wherein prior to the surgical procedure the patient exhibits residual sphincter function.
11. The method of claim 1 , comprising
contacting the central support portion to the corpus spongiosum, and
after placement of the central support portion and the end portions, placing tension on the end portions of the sling to approximate tissue selected from the rhabdosphincter, the urethra, and a combination of these.
12. The method of claim 1 , wherein the implant comprises a widened central support portion, and the method comprises placing the widened central support portion below the corpus spongiosum.
13. The method of claim 12 , comprising securing the widened central support portion to the corpus spongiosum.
14. The method of claim 13 , comprising securing the widened central support portion to the corpus spongiosum by use of a suture.
15. The method of claim 1 comprising treating incontinence in a male patient.
16. The method of claim 1 comprising approximating the urethra without placing compressive forces on the urethra.
17. The method of claim 1 comprising placing the central support portion in contact with the corpus spongiosum at a location below a membranous urethra.
18. The method of claim 1 comprising approximating pelvic tissue to improve coaptation of the urethra without requiring a compressive effect on the urethra.
19. The method of claim 1 comprising
treating incontinence in a male patient,
approximating pelvic tissue without requiring a compressive effect on the urethra, and
placing the central support portion in contact with the corpus spongiosum at a location below a membranous urethra.
20. The method of claim 1 comprising associating an end portion of the implant with a needle and passing the needle between the medial incision and a lateral incision by inserting the needle at the medial incision, passing the needle through an obturator foramen, and then passing the needle through the lateral incision.
21. The method of claim 1 comprising associating a first end portion of the implant with a first needle and passing the first needle between the medial incision and a right-side lateral incision by inserting the first needle at the medial incision, passing the first needle through the right-side obturator foramen, and then passing the first needle through the right-side lateral incision, and
associating a second end portion of the implant with a second needle and passing the second needle between the medial incision and a left-side lateral incision by inserting the second needle at the medial incision, passing the second needle through the left-side obturator foramen, and then passing the second needle through the left-side lateral incision.
22. The method of claim 1 comprising using a finger passed between the bulbocavernous muscle and the corpus spongiosum, to identify the intersection of the corpus spongiosum and the perineal membrane.
23. The method of claim 1 comprising passing a needle tip through a pernineal membrane of the patient, lateral to the corpus spongiosum.
24. A method of treating incontinence in a male patient, the method comprising
providing an elongate implantable sling comprising a central support portion and elongate end portions,
creating an incision at the perineum of the male patient,
exposing bulbospongiosus muscle,
dissecting the bulbospongiosus muscle to expose corpus spongiosum,
inserting the implant through the perineal incision,
installing the central support portion below the bulbous urethra to contact the corpus spongiosum, and
attaching an end portion to an obturator membrane without making a lateral incision substantially adjacent the patient's obturator foramen.
25. The method of claim 24 , comprising placing tension on the sling to approximate pelvic tissue including the urethra, to improve sphincter function and coaptation of the urethra.
26. The method of claim 24 wherein the implant comprises a widened central support portion, and the method comprises placing the widened central support portion below the corpus spongiosum.
27. The method of claim 24 comprising approximating the urethra without placing compressive forces on the urethra.
28. The method of claim 24 comprising placing the central support portion at a location below a membranous urethra.
29. The method of claim 24 comprising approximating pelvic tissue to improve coaptation of the urethra without requiring a compressive effect on the urethra.
30. The method of claim 24 comprising
treating incontinence in a male patient,
approximating pelvic tissue without requiring a compressive effect on the urethra, and
placing the central support portion at a location below a membranous urethra.
31. The method of claim 24 wherein the implant comprises an anchor and the anchor attaches to the obturator membrane.