THE SURGERY
“Tape rescue surgery”. The operation needs to be performed
under spinal anesthesia, as it permits testing for continence during the
procedure. With a No18 Foley catheter in place, a vertical incision is
made in the vagina from midurethra to within 0.5cm of external meatus,
so the external urethral ligament can be accessed for the vaginal part
of the procedure, see VIDEO2. The tape is identified. After preliminary
dissection, the suburethral loop of the tape is grasped with two fine
mosquito forceps and, under tension, divided in the midline. This
facilitates further dissection of each side of the tape from its lateral
attachments to the urethra. The bladder is filled with 300ml of saline
and the patient is asked to cough. The forceps are moved to each edge of
the cut tape. They are approximated while the patient is coughing until
there is no urine loss, or preferably, a few small drops which are more
indicative of the correct tension. Interrupted non-absorbable sutures
are placed into both cut edges, but not immediately tied. The catheter
is re-inserted and the sutures are tied over the catheter, taking care
to avoid excessive tightness. It needs to be remembered that the urethra
is elastic and easily compressed*[7,8]. The 18gauge Foley catheter
acts as an obturator and prevents over-tightening. The catheter is
removed and the patient is re-tested.