Founded in 1951, the American College of Obstetricians and Gynecologists is the specialty's premier professional membership organization dedicated to the improvement of women’s health. With more than 58,000 members, the College is a 501(c)(6) organization and its activities include producing the College's practice guidelines and other educational material.

Fellows of ACOG are board certified ob-gyns whose professional activities are devoted to the practice of obstetrics and/or gynecology, who possess unrestricted licenses to practice medicine, and have attained high ethical and professional standing. Fellows of ACOG can be recognized by the designation of FACOG (Fellow, American College of Obstetricians and Gynecologists) after the physician’s name. There are also several other categories of membership.

Learn more about Fellows of ACOG or other categories of membership.

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Contact Information

South Carolina Section Chair

Judith Burgis, MD

Email: judy.burgis@uscmed.sc.edu

To learn more about what is happening in your region, visit the District IV website.

• Treasurer: Ted L. Anderson, MD,; Nashville, TN
• Secretary: J. Martin Tucker, MD; Flowood, MS
• Assistant Secretary: Laura A. Dean, MD; Stillwater, MN
• Executive Vice President and CEO: Hal C. Lawrence, III, MD; Washington, DC
• Chair, District I: Markus C. Martin, MD; Quebec, Canada
• Chair, District II: Iffath A. Hoskins, MD; New York, NY
• Chair, District III: Ann L. Honebrink, MD; Ardmore, PA
• Chair, District IV: Wade A. Neiman, MD; Lynchburg, VA
• Chair, District V: Jeffrey M. Rothenberg, MD, MS; Indianapolis, IN
• Chair, District VI: Denise M. Elser, MD; Oak Lawn, IL
• Chair, District VII: Verda J. Hicks, MD; Leawood, KS
• Chair, District VIII: Clayton "Tersh" McCracken, III, MD; Billings, MT
• Chair, District IX: Laura L. Sirott, MD; Pasadena, CA
• Chair, Armed Forces District: John D. O’Boyle, CAPT, MC USN; Bethesda, MD
• Chair, District XI: Carl A. (Tony) Dunn, MD; Waco, TX
• Chair, District XII: Karen E. Harris, MD, MPH; Gainesville, FL
• Fellow-at-Large: John P. Keats, MD; Timonium, MD
• Fellow-at-Large: Wanda K. Nicholson, MD, MBA, MPH; Chapel Hill, NC
• Young Physician-at-Large: Tamara G. Helfer, MD, MBA; Champaign, IL
• Young Physician-at-Large: Erin A Keyser, MD; San Antonio, TX
• Young Physician-at-Large: Hartaj K. Powell, MD, MPH; Reston, VA
• Chair, Junior Fellow College Advisory Council: Ryan D. Cuff, MD; Johns Island, SC
• Vice Chair, Junior Fellow College Advisory Council: Katherine W. McHugh, MD; Indianapolis, IN
• Representative, American Board of Obstetrics and Gynecology, Inc: George D. Wendel, MD; Dallas, TX
• Subspecialty Representative, American Urogynecologic Society: Amy E. Rosenman, MD; Santa Monica, CA
• Subspecialty Representative, Society for Maternal-Fetal Medicine: Mary E. Norton, MD; San Francisco, CA
• Subspecialty Representative, Society for Reproductive Endocrinology and Infertility: Thomas M. Price, MD; Hillsborough, NC
• Subspecialty Representative, Society of Gynecologic Oncology: Eva Chalas, MD; Mineola, NY
• Public Member: Jamie H. Bardwell, MPP; Jackson, MS

Fellow Requirements

An ACOG Fellow is a board certified ob-gyn whose professional activity is devoted to the practice of obstetrics and/or gynecology. To be a Fellow, you must have:

Certification and maintenance of certification in obstetrics-gynecology by one of the following boards:

• American Board of Obstetrics and Gynecology: Parts I and II
• Royal College of Obstetricians and Gynaecologists
• Royal College of Physicians and Surgeons of Canada or College des medecins du Quebec
• Consejo Mexicana de Ginecologia & Obstetricia
• The Univ of the West Indies Postgraduate Doctorate of Medicine

• Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG)
• Federacion Centroamericana de Sociedades de Obstetricia y Ginecologia (FECASOG)
• Japanese Board of Obstetricians and Gynecologists (JBOG)

• Sociedad Chilena de Obstetricia y Ginecologia

ACOG is not affiliated with the American Board of Obstetricians and Gynecology (ABOG). Board certification qualifies Junior Fellow members for Fellow status but transfer to Fellow is only granted after a completed Fellow application has been received, processed and approved by the Executive Board. Please allow up to four (4) months to process. After approval has been granted, new Fellows are admitted and notified by mail on a monthly basis.

H1 NFPA 1192 Paragraph 5.4 Fuel Gas Piping Systems – 2005 Edition

The purpose of this document is to provide information about flexible gas hoses that bring propane to appliances located in the slideout portion of a recreation vehicle.

H2 NFPA 1192 Paragraph 5.4 Fuel Gas Piping Systems – 2005 Edition

The purpose of this document is to provide information about flexible gas hoses that bring propane to appliances located in the slideout portion of a recreation vehicle.

This document will review code requirements from NFPA 1192 Standard for Recreational Vehicles - 2005 Edition, and illustrate how those requirements can be implemented.

Please note that the information presented here does not provide the only methods of protecting Propane lines in a slideout. It is intended to be used as a guide for protection. There are many methods that can, and do, provide the required protection and that follow NFPA 1192 RV Standard.

H3 Sed posuere consectetur est at lobortis.

Maecenas faucibus mollis interdum. Nullam quis risus eget urna mollis ornare vel eu leo. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Fusce dapibus, tellus ac cursus commodo, tortor mauris condimentum nibh, ut fermentum massa justo sit amet risus. Vestibulum id ligula porta felis euismod semper. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit.

H4 Sed posuere consectetur est at lobortis.

Maecenas faucibus mollis interdum. Nullam quis risus eget urna mollis ornare vel eu leo. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Fusce dapibus, tellus ac cursus commodo, tortor mauris condimentum nibh, ut fermentum massa justo sit amet risus. Vestibulum id ligula porta felis euismod semper. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit.

H5 Sed posuere consectetur est at lobortis.

Maecenas faucibus mollis interdum. Nullam quis risus eget urna mollis ornare vel eu leo. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Fusce dapibus, tellus ac cursus commodo, tortor mauris condimentum nibh, ut fermentum massa justo sit amet risus. Vestibulum id ligula porta felis euismod semper. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit.

H6 Sed posuere consectetur est at lobortis.

Maecenas faucibus mollis interdum. Nullam quis risus eget urna mollis ornare vel eu leo. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Fusce dapibus, tellus ac cursus commodo, tortor mauris condimentum nibh, ut fermentum massa justo sit amet risus. Vestibulum id ligula porta felis euismod semper. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Lorem ipsum dolor sit amet, consectetur adipiscing elit.

Duis mollis, est non commodo luctus, nisi erat porttitor ligula, eget lacinia odio sem nec elit. Nullam id dolor id nibh ultricies vehicula ut id elit. Aenean lacinia bibendum nulla sed consectetur. Aenean eu leo quam. Pellentesque ornare sem lacinia quam venenatis vestibulum.

"We are thrilled to help the aftermarket community grow their event, while delivering value to members and the community"

Nullam quis risus eget urna mollis ornare vel eu leo. Morbi leo risus, porta ac consectetur ac, vestibulum at eros. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Vestibulum id ligula porta felis euismod semper. Etiam porta sem malesuada magna mollis euismod. Integer posuere erat a ante venenatis dapibus posuere velit aliquet.

Donec sed odio dui. Aenean lacinia bibendum nulla sed consectetur. Nullam quis risus eget urna mollis ornare vel eu leo. Duis mollis, est non commodo luctus, nisi erat porttitor ligula, eget lacinia odio sem nec elit. Nullam id dolor id nibh ultricies vehicula ut id elit. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec sed odio dui.

Nullam quis risus eget urna mollis ornare vel eu leo

Maecenas faucibus mollis interdum. Nullam quis risus eget urna mollis ornare vel eu leo. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Fusce dapibus, tellus ac cursus commodo, tortor mauris condimentum nibh.

• Schedule one-on-one, private meetings with top distributors and suppliers in the aftermarket industry.
• Get a first-look at new products and programs before the fall/winter RV shows.
  • Nullam quis risus eget urna mollis ornare vel eu leo.
  • Maecenas faucibus mollis interdum.
• Hear what's on the minds of RV dealers and their thoughts about the aftermarket.
• Network and catch up with colleagues from around the country who are all learning new ways to navigate in today's dynamic industry.

Maecenas faucibus mollis interdum. Nullam quis risus eget urna mollis ornare vel eu leo. Integer posuere erat a ante venenatis dapibus posuere velit aliquet. Fusce dapibus, tellus ac cursus commodo, tortor mauris condimentum nibh.

1. Donec ullamcorper nulla non metus auctor fringilla.
   1. Nullam quis risus eget urna mollis ornare vel eu leo.
   2. Maecenas faucibus mollis interdum.
2. Curabitur blandit tempus porttitor.
   • Nullam quis risus eget urna mollis ornare vel eu leo.
   • Maecenas faucibus mollis interdum.
3. Sed posuere consectetur est at lobortis.

ul 5 deep:

• Schedule one-on-one, private meetings with top distributors and suppliers in the aftermarket industry.
• Get a first-look at new products and programs before the fall/winter RV shows.
  • Nullam quis risus eget urna mollis ornare vel eu leo.
  • Maecenas faucibus mollis interdum.
    • Nullam quis risus eget urna mollis ornare vel eu leo.
    • Maecenas faucibus mollis interdum.
      • Nullam quis risus eget urna mollis ornare vel eu leo.
      • Maecenas faucibus mollis interdum.
        • Nullam quis risus eget urna mollis ornare vel eu leo.
        • Maecenas faucibus mollis interdum.
• Hear what's on the minds of RV dealers and their thoughts about the aftermarket.
• Network and catch up with colleagues from around the country who are all learning new ways to navigate in today's dynamic industry.

ol 5 deep:

1. Schedule one-on-one, private meetings with top distributors and suppliers in the aftermarket industry.
2. Get a first-look at new products and programs before the fall/winter RV shows.
   1. Nullam quis risus eget urna mollis ornare vel eu leo.
   2. Maecenas faucibus mollis interdum.
      1. Nullam quis risus eget urna mollis ornare vel eu leo.
      2. Maecenas faucibus mollis interdum.
         1. Nullam quis risus eget urna mollis ornare vel eu leo.
         2. Maecenas faucibus mollis interdum.
            1. Nullam quis risus eget urna mollis ornare vel eu leo.
            2. Maecenas faucibus mollis interdum.
3. Hear what's on the minds of RV dealers and their thoughts about the aftermarket.
4. Network and catch up with colleagues from around the country who are all learning new ways to navigate in today's dynamic industry.

Retropubic Slings

• Doug Miyazaki, MD, FACOG
  Novant Health Forsyth Medical Center, Obstetrics and Gynecology

Level 1: Declarative Knowledge

1. The learner should be able to list the benefits midurethral slings"
   • Lower morbidity
   • Less pain
   • Short OR time
   • Rapid recovery
   • Outpatient
   • Faster return to normal activities
   • Simple and reproducible
   • Highly effective
   • Low rate of serious adverse events
   • Less voiding dysfunction than traditional open retropubic procedures

   Mechanism of Action

   Midurethral sling placement involves the introduction of a polypropylene tape (approximately 1 cm in width) covered in a plastic sheath beneath the midportion of the urethra. This sling functions as a that offers resistance beneath the urethra during increases in intraabdominal pressure, but is tension-free at rest. Ultrasound data suggest that continence is achieved by compression of the urethra between the sling and the pubic symphysis [1,2].

2. The learner should be able to list indications for midurethral slings:
   • Stress incontinence ‐ Hypermobile urethra
   • Women who are planning repair of prolapse of the vaginal apex and who have known or suspected occult SUI
   • Indications for Transobturator approach
     • Stress incontinence-uncomplicated
   • Indications for Retropubic approach
     • Stress incontinence-complicated
     • Intrinsic sphincter deficiency
     • Previous failed procedure
3. The learner should be able to list the contraindications for midurethral slings"
   • Previous radiation to the area
   • Current urinary tract infection
   • Current pregnancy
   • Anticoagulation
   • Structures in the retropubic space that are in the path of sling placement (e.g., vascular graft, bowel, transplanted pelvic kidney)
4. The learner should be able to document examination under anesthesia:
   • Appropriate gynecologic anatomy: uterus, ovaries, anterior and posterior cul de sacs ACOG Surgical Curriculum Working Group Midurethral Transobturator and Retropubic Slings
   • Any associated pelvic organ prolapse: cystocele, rectocele, enterocele, paravaginal defects, and uterine prolapse
5. The learner should be able to identify anatomic landmarks:
   • Urethra and midurethra
   • Obturator fossa
   • Adductor longus tendon
   • Arcus Tendineous Fascia Pelvis
6. Basic knowledge
   • There are two main variations of full-length retropubic midurethral slings, based upon the initial incision site and direction of insertion:
     • Bottom-to-top – Two needle trocars are inserted through a vaginal incision and passed through the retropubic space, exiting at the abdominal wall (e.g., TVT, TVTExact, Advantage, Retroarc).
     • Top-to-bottom – Two needle trocars are inserted through abdominal incisions and passed through the retropubic space, exiting through a vaginal incision (e.g., SPARC).
   • Complications: Bladder injury — Intraoperative bladder perforation is the most common complication of retropubic midurethral sling placement. In studies of 200 or more procedures, the reported rate ranges between 3.5 to 6.6 percent [3-7]. Bladder perforation does not appear to be associated with reduced SUI cure rates or with longterm sequelae [3].
   • The likelihood of bladder perforation depends upon the surgeon’s experience. A report of 600 procedures performed by an experienced surgeon had a 1 percent rate of bladder perforation [8], while inexperienced operators have reported rates ranging from 15 to 34 percent [9,10].
   • Urethral injury — Intraoperative urethral perforation or laceration occurs in approximately 0.9 percent of midurethral retropubic sling placements [11]. ‐ Urinary tract infection
   • Urinary tract infection is a common complication after midurethral sling placement. Urinary tract infections have been reported in up to 34 percent of patients within the first three postoperative months [12]. At one-year followup, the rate is 50 percent [12].
   • Voiding dysfunction — Urinary retention or incomplete bladder emptying are commonly reported after retropubic midurethral sling placement [13]. The reported rate of voiding dysfunction varies from 19.7 to 47 percent of cases, depending upon the definition and diagnostic criteria used [14,5].
   • Sling release — Most cases of postoperative urinary retention resolve with conservative management. Urinary retention that persists after four to six weeks may require surgical intervention in the form of a sling release [15,16]. In a study of billing codes of over 180,000 women who underwent a midurethral sling procedure between 2001 and 2010, the cumulative rate of sling release performed for the indication of urinary retention was 1.3 percent at nine years postoperatively [17].
   • Vaginal mesh exposure- Approximately 0.9%-2.5% [17].
   • Pelvic pain- chronic pelvic pain following retropubic midurethral sling placement up to 7.5% [5].

Level 2 A Simulated and Clinical Performance Midurethral Slings: Transobturator Approach

1. Preparation:
   1. Time out
   2. SCDs/DVT prophylaxis as indicated
   3. Single dose antibiotics prophylaxis
   4. Position
      • Stirrups supporting the entire leg are preferable
      • Angles: 90 degrees between thigh and torso, and at the knee
   5. Exam under anesthesia
   6. Betadine/Ethanol scrub
   7. Drape: Self adherent Surgical Drape

   Procedure

   1. Place foley catheter
   2. Identify midurethra and infiltrate with local anesthetic solution of choice
   3. Make an approximately 1.5 cm incision through the full thickness of the vaginal wall
   4. Dissect laterally along the full thickness vaginal wall plane to the inferior edge of the pubic bone
   5. Insert fingertip to palpate bone edge
   6. Locate insertion of adductor longus tendon on patient’s right and left sides, palpate notch along internal edge of ischiopubic ramus and make small skin incisions
   7. With surgeon’s left fingertip in vaginal tunnel and thumb on top of needle curve, push needle tip through patient’s left skin incision until the obturator membrane is perforated and rotate needle tip toward vaginal incision keeping the needle tip on your finger to guide it through the vaginal incision
   8. Connect sling assembly to trocar needle
   9. Reverse the rotation of the trocar to bring the sling arm back through the skin incision, detach sling
   10. Repeat steps on contra lateral side and detach sling
   11. Perform cystoscopy
   12. Carefully position/”tension” sling underneath the midurethra and remove plastic sheath bilaterally
   13. Cut sling arms at the subcutaneous levels and close skin incisions
   14. Check for hemostasis and close vaginal incision with absorbable suture

Level 2 B Simulated and Clinical Performance Retropubic Slings

1. Preparation
   1. Time out
   2. SCDs/DVT prophylaxis
   3. Single dose antibiotics prophylaxis
   4. Position
      • Stirrups supporting the entire leg are preferable
      • Angles: 90 degrees between thigh and torso, and at the knee
   5. Exam under anesthesia
   6. Betadine/Ethanol scrub
   7. Drape: Self adherent Surgical Drape

   Procedure: Placement of a bottom-to-top full-length retropubic midurethral sling

   1. Use of size 18 French will allow the rigid catheter guide to be introduced. This catheter guide is used to deviate the bladder away from the side of trocar placement.
   2. Marking abdominal incisions- Mark the two planned abdominal exit points for the tape at the superior margin of the pubic bone, 2 cm lateral to the midline. Some surgeons make small stab incisions at these locations to facilitate trocar passage through the skin
   3. Hydrodissection- Some surgeons hydrodissect the vaginal incision site and/or the path of the trocars. Either local anesthetic (with or without epinephrine) or sterile saline may be used. In the original description of the procedure, 40 ml of fluid was injected into the vaginal wall inferior and lateral to the urethra [18]. An additional 60 to 70 mL of fluid was injected at the planned abdominal incision sites and downward along the back of the pubic bone to the retropubic space. Alternatively, fluid may be injected into the retropubic space through the vaginal sulci
   4. Midurethral vaginal incision– Make a vertical (longitudinal) vaginal incision, starting 1 cm proximal to the urethral meatus and 1 to 1.5 cm in length to accommodate the width of the sling in the appropriate location. Place Allis clamps on the lateral edges of the incision to provide exposure by retracting the vaginal mucosa laterally. The best ways to prevent a midurethral sling from being too proximal are to start the vaginal incision for the midurethral sling 1 cm from the urethral meatus, as recommended by Ulmsten in the original TVT publication, and to never use an anterior repair incision to place the midurethral sling [18].
      Minimal dissection lateral to the midurethra, between the vaginal mucosa and the pubocervical fascia, is performed bilaterally with the Metzenbaum scissors. The scissors are angled towards the retropubic space just behind the pubic symphysis.
   5. Lateral deviation of the bladder– Drain the bladder completely and introduce the rigid catheter guide into the bladder catheter. Deviate the bladder to the side opposite of the first trocar insertion
   6. Initial trocar insertion— Insertion of the trocar along the correct path is the critical part of the procedure to ensure that the procedure is effective and to avoid complications.
   7. General trocar insertion: Insert the first trocar into the tract lateral to the urethra that was dissected out with Metzenbaum scissors. Pass the trocar behind the pubic symphysis (through the retropubic space) and exit through the abdominal incision sites. The trocar is left in place with the tip just past the level of the abdominal skin.
   8. Techniques for successful placement include:
   9. The operator must maintain a firm grasp of the trocar and handle while manipulating the needle through the tissues. Resistance of the tissues may sometimes result in deviation of the needle. Some surgeons use a hand in the vagina to control and direct the trocar while the opposite hand on the handle is used to apply gentle force to advance the trocar.
   10. Care should be taken to aim the trocar handle in the direction of the outer aspect of the patient’s ipsilateral shoulder [19].
   11. The tip of the trocar should be positioned just behind the pubic symphysis. It is often helpful to actually place the tip of the trocar on the underside of the pubic symphysis and to gently slide it behind the bone, staying as close to the bone as possible. To do this, the surgeon must lower the hand that is holding the trocar handle so that the curve of the insertion needle follows the posterior surface of the pubic bone through the retropubic space. The trocar should pass easily in the retropubic space in direct opposition to the posterior side of the symphysis. More force is needed when the trocar passes through the rectus sheath and then out through the skin at the suprapubic level.
   12. The trocar handle must be kept parallel to the floor during retropubic passage to prevent the lateral rotation of the trocar tip.
   13. After insertion, the anterior vaginal sulci are inspected and palpated to ensure that they have not been perforated by the trocar. If there is a perforation, then the trocar or the plastic sheaths with the mesh can be seen traversing the vaginal sulcus. The first sign of a vaginal perforation is often the onset of vaginal bleeding that does not appear to be coming from the midurethral vaginal incision.
   14. Cystourethroscopy— After each trocar is placed, perform cystourethroscopy to inspect for bladder perforation. A 70-degree cystoscope should be used and the bladder filled adequately to allow complete examination of the urethra and bladder surface [18]. Examination of the bladder requires an experienced clinician; a study of surgical trainees reported that 37 percent of bladder injuries were missed on cystourethroscopy [9].
   15. Adjusting the sling tension— To ensure that the sling is tension-free and does not compress the urethra while the patient is at rest, many surgeons insert an instrument (eg, Kelly clamp, needle holder, or number 8 Hegar dilator) between the sling and the urethra while adjusting the sling tension
   16. Sheath removal- With the spacer in place, remove the plastic sheaths; this prevents excess tightening of the mesh during plastic sheath removal. The surgeon should assess the entire plastic sheath to confirm that it has been completely removed.
   17. Trim the mesh at the abdominal incisions. Mesh protrusion and irritation at the skin surface can be prevented by depressing the skin slightly to trim the mesh just below the skin surface. The mesh does not require suturing, since it is held in by friction and then fibrosis [18].
   18. Incision closure: Vaginal- absorbable suture, Abdominal- per surgeon preference.

Procedure: Placement of a bottom-to-top full-length retropubic midurethral sling (as example)

1. Use of size 18 French will allow the rigid catheter guide to be introduced. This catheter guide is used to deviate the bladder away from the side of trocar placement.
2. Marking abdominal incisions - Mark the two planned abdominal exit points for the tape at the superior margin of the pubic bone, 2 cm lateral to the midline. Some surgeons make small stab incisions at these locations to facilitate trocar passage through the skin.
3. Hydrodissection - Some surgeons hydrodissect the vaginal incision site and/or the path of the trocars. Either local anesthetic (with or without epinephrine) or sterile saline may be used. In the original description of the procedure, 40 ml of fluid was injected into the vaginal wall inferior and lateral to the urethra [5]. An additional 60 to 70 mL of fluid was injected at the planned abdominal incision sites and downward along the back of the pubic bone to the retropubic space. Alternatively, fluid may be injected into the retropubic space through the vaginal sulci.
4. Midurethral vaginal incision - Make a vertical (longitudinal) vaginal incision, starting 1 cm proximal to the urethral meatus and 1 to 1.5 cm in length to accommodate the width of the sling in the appropriate location. Place Allis clamps on the lateral edges of the incision to provide exposure by retracting the vaginal mucosa laterally. Minimal dissection lateral to the midurethra, between the vaginal mucosa and the pubocervical fascia, is performed bilaterally with the Metzenbaum scissors. The scissors are angled towards the retropubic space just behind the pubic symphysis.
5. Lateral deviation of the bladder - Drain the bladder completely and introduce the rigid catheter guide into the bladder catheter. Deviate the bladder to the side opposite of the first trocar insertion.
6. Initial trocar insertion - Insertion of the trocar along the correct path is the critical part of the procedure to ensure that the procedure is effective and to avoid complications.
7. General trocar insertion, Insert the first trocar into the tract lateral to the urethra that was dissected out with Metzenbaum scissors. Pass the trocar behind the pubic symphysis (through the retropubic space) and exit through the abdominal incision sites. The trocar is left in place with the tip just past the level of the abdominal skin.
8. Care should be taken to aim the trocar handle in the direction of the outer aspect of the patient’s ipsilateral shoulder.
9. After insertion, the anterior vaginal sulci are inspected and palpated to ensure that they have not been perforated by the trocar.
10. Cystourethroscopy - After each trocar is placed, perform cystourethroscopy to inspect for bladder perforation. A 70 degree cystoscope should be used.
11. Adjust the sling tension - To ensure that the sling is tension-free, insert an instrument (eg, Kelly clamp, needle holder, or number 8 Hegar dilator) between the sling and the urethra while adjusting the sling tension.
12. Sheath removal - With the spacer in place, remove the plastic sheaths; this prevents excess tightening of the mesh during plastic sheath removal. The surgeon should assess the entire plastic sheath to confirm that it has been completely removed.
13. Trim the mesh at the abdominal incisions. Incision closure: Vaginal- absorbable suture, Abdominal- per surgeon preference. 

1. Assess actual performance during simulated midurethral sling placement according to the checklist

Checklist: Midurethral Transobturator and Retropubic Slings

Part 1: Knowledge

1. The learner is able to list benefits of midurethral slings
   1. Unable to list
   2. Able to list several
2. The learner is able to list indications/qualifications for a midurethral slings
   1. Unable to list
   2. Able to list several
3. The learner is able to identify anatomic landmarks
   1. Unable to list
   2. Able to list several
4. Knows incidence of urinary system injury

Part 2: Simulated and Clinical Performance

1. Preparation
   1. Time out
      Name
      Antibiotics
      Allergies
      Procedure to be performed
   2. SCDs/DVT prophylaxis
   3. Antibiotics
   4. Position/Stirrups/Angles
   5. Exam under anesthesia
   6. Scrub
   7. Drape
2. Procedure: Transoburator Outside in approach (as example)
   1. Place Foley catheter
   2. Appropriate placement of initial incision
   3. Proper Dissect laterally along the full thickness vaginal wall plane to the inferior edge of the pubic bone
   4. Palpate bone edge
   5. Locate insertion of adductor longus tendon on patient’s right and left sides, palpate notch along internal edge of ischiopubic ramus and make small skin incisions
   6. With surgeon’s left fingertip in vaginal tunnel and thumb on top of needle curve, push needle tip through patient’s left skin incision until the obturator membrane is perforated and rotate needle tip toward vaginal incision keeping the needle tip on your finger to guide it through the vaginal incision
   7. Connect sling assembly to trocar needle
   8. Reverse the rotation of the trocar to bring the sling arm back through the skin incision, detach sling
   9. Repeat steps on contra lateral side and detach sling
   10. Perform cystoscopy
   11. Carefully position/”tension” sling underneath the midurethra and remove plastic sheath bilaterally
   12. Cut sling arms at the subcutaneous levels and close skin incisions
   13. Check for hemostasis and close vaginal incision with absorbable suture

Retropubic Slings

• Doug Miyazaki, MD, FACOG
  Novant Health Forsyth Medical Center, Obstetrics and Gynecology

Level 1: Declarative Knowledge

1. The learner should be able to list the benefits midurethral slings"
   • Lower morbidity
   • Less pain
   • Short OR time
   • Rapid recovery
   • Outpatient
   • Faster return to normal activities
   • Simple and reproducible
   • Highly effective
   • Low rate of serious adverse events
   • Less voiding dysfunction than traditional open retropubic procedures

   Mechanism of Action

   Midurethral sling placement involves the introduction of a polypropylene tape (approximately 1 cm in width) covered in a plastic sheath beneath the midportion of the urethra. This sling functions as a that offers resistance beneath the urethra during increases in intraabdominal pressure, but is tension-free at rest. Ultrasound data suggest that continence is achieved by compression of the urethra between the sling and the pubic symphysis [1,2].

2. The learner should be able to list indications for midurethral slings:
   • Stress incontinence ‐ Hypermobile urethra
   • Women who are planning repair of prolapse of the vaginal apex and who have known or suspected occult SUI
   • Indications for Transobturator approach
     • Stress incontinence-uncomplicated
   • Indications for Retropubic approach
     • Stress incontinence-complicated
     • Intrinsic sphincter deficiency
     • Previous failed procedure
3. The learner should be able to list the contraindications for midurethral slings"
   • Previous radiation to the area
   • Current urinary tract infection
   • Current pregnancy
   • Anticoagulation
   • Structures in the retropubic space that are in the path of sling placement (e.g., vascular graft, bowel, transplanted pelvic kidney)
4. The learner should be able to document examination under anesthesia:
   • Appropriate gynecologic anatomy: uterus, ovaries, anterior and posterior cul de sacs ACOG Surgical Curriculum Working Group Midurethral Transobturator and Retropubic Slings
   • Any associated pelvic organ prolapse: cystocele, rectocele, enterocele, paravaginal defects, and uterine prolapse
5. The learner should be able to identify anatomic landmarks:
   • Urethra and midurethra
   • Obturator fossa
   • Adductor longus tendon
   • Arcus Tendineous Fascia Pelvis
6. Basic knowledge
   • There are two main variations of full-length retropubic midurethral slings, based upon the initial incision site and direction of insertion:
     • Bottom-to-top – Two needle trocars are inserted through a vaginal incision and passed through the retropubic space, exiting at the abdominal wall (e.g., TVT, TVTExact, Advantage, Retroarc).
     • Top-to-bottom – Two needle trocars are inserted through abdominal incisions and passed through the retropubic space, exiting through a vaginal incision (e.g., SPARC).
   • Complications: Bladder injury — Intraoperative bladder perforation is the most common complication of retropubic midurethral sling placement. In studies of 200 or more procedures, the reported rate ranges between 3.5 to 6.6 percent [3-7]. Bladder perforation does not appear to be associated with reduced SUI cure rates or with longterm sequelae [3].
   • The likelihood of bladder perforation depends upon the surgeon’s experience. A report of 600 procedures performed by an experienced surgeon had a 1 percent rate of bladder perforation [8], while inexperienced operators have reported rates ranging from 15 to 34 percent [9,10].
   • Urethral injury — Intraoperative urethral perforation or laceration occurs in approximately 0.9 percent of midurethral retropubic sling placements [11]. ‐ Urinary tract infection
   • Urinary tract infection is a common complication after midurethral sling placement. Urinary tract infections have been reported in up to 34 percent of patients within the first three postoperative months [12]. At one-year followup, the rate is 50 percent [12].
   • Voiding dysfunction — Urinary retention or incomplete bladder emptying are commonly reported after retropubic midurethral sling placement [13]. The reported rate of voiding dysfunction varies from 19.7 to 47 percent of cases, depending upon the definition and diagnostic criteria used [14,5].
   • Sling release — Most cases of postoperative urinary retention resolve with conservative management. Urinary retention that persists after four to six weeks may require surgical intervention in the form of a sling release [15,16]. In a study of billing codes of over 180,000 women who underwent a midurethral sling procedure between 2001 and 2010, the cumulative rate of sling release performed for the indication of urinary retention was 1.3 percent at nine years postoperatively [17].
   • Vaginal mesh exposure- Approximately 0.9%-2.5% [17].
   • Pelvic pain- chronic pelvic pain following retropubic midurethral sling placement up to 7.5% [5].

Level 2 A Simulated and Clinical Performance Midurethral Slings: Transobturator Approach

7. Preparation:
   1. Time out
   2. SCDs/DVT prophylaxis as indicated
   3. Single dose antibiotics prophylaxis
   4. Position
      • Stirrups supporting the entire leg are preferable
      • Angles: 90 degrees between thigh and torso, and at the knee
   5. Exam under anesthesia
   6. Betadine/Ethanol scrub
   7. Drape: Self adherent Surgical Drape

   Procedure

   1. Place foley catheter
   2. Identify midurethra and infiltrate with local anesthetic solution of choice
   3. Make an approximately 1.5 cm incision through the full thickness of the vaginal wall
   4. Dissect laterally along the full thickness vaginal wall plane to the inferior edge of the pubic bone
   5. Insert fingertip to palpate bone edge
   6. Locate insertion of adductor longus tendon on patient’s right and left sides, palpate notch along internal edge of ischiopubic ramus and make small skin incisions
   7. With surgeon’s left fingertip in vaginal tunnel and thumb on top of needle curve, push needle tip through patient’s left skin incision until the obturator membrane is perforated and rotate needle tip toward vaginal incision keeping the needle tip on your finger to guide it through the vaginal incision
   8. Connect sling assembly to trocar needle
   9. Reverse the rotation of the trocar to bring the sling arm back through the skin incision, detach sling
   10. Repeat steps on contra lateral side and detach sling
   11. Perform cystoscopy
   12. Carefully position/”tension” sling underneath the midurethra and remove plastic sheath bilaterally
   13. Cut sling arms at the subcutaneous levels and close skin incisions
   14. Check for hemostasis and close vaginal incision with absorbable suture

Level 2 B Simulated and Clinical Performance Retropubic Slings

8. Preparation
   1. Time out
   2. SCDs/DVT prophylaxis
   3. Single dose antibiotics prophylaxis
   4. Position
      • Stirrups supporting the entire leg are preferable
      • Angles: 90 degrees between thigh and torso, and at the knee
   5. Exam under anesthesia
   6. Betadine/Ethanol scrub
   7. Drape: Self adherent Surgical Drape

   Procedure: Placement of a bottom-to-top full-length retropubic midurethral sling

   1. Use of size 18 French will allow the rigid catheter guide to be introduced. This catheter guide is used to deviate the bladder away from the side of trocar placement.
   2. Marking abdominal incisions- Mark the two planned abdominal exit points for the tape at the superior margin of the pubic bone, 2 cm lateral to the midline. Some surgeons make small stab incisions at these locations to facilitate trocar passage through the skin
   3. Hydrodissection- Some surgeons hydrodissect the vaginal incision site and/or the path of the trocars. Either local anesthetic (with or without epinephrine) or sterile saline may be used. In the original description of the procedure, 40 ml of fluid was injected into the vaginal wall inferior and lateral to the urethra [18]. An additional 60 to 70 mL of fluid was injected at the planned abdominal incision sites and downward along the back of the pubic bone to the retropubic space. Alternatively, fluid may be injected into the retropubic space through the vaginal sulci
   4. Midurethral vaginal incision– Make a vertical (longitudinal) vaginal incision, starting 1 cm proximal to the urethral meatus and 1 to 1.5 cm in length to accommodate the width of the sling in the appropriate location. Place Allis clamps on the lateral edges of the incision to provide exposure by retracting the vaginal mucosa laterally. The best ways to prevent a midurethral sling from being too proximal are to start the vaginal incision for the midurethral sling 1 cm from the urethral meatus, as recommended by Ulmsten in the original TVT publication, and to never use an anterior repair incision to place the midurethral sling [18].
      Minimal dissection lateral to the midurethra, between the vaginal mucosa and the pubocervical fascia, is performed bilaterally with the Metzenbaum scissors. The scissors are angled towards the retropubic space just behind the pubic symphysis.
   5. Lateral deviation of the bladder– Drain the bladder completely and introduce the rigid catheter guide into the bladder catheter. Deviate the bladder to the side opposite of the first trocar insertion
   6. Initial trocar insertion— Insertion of the trocar along the correct path is the critical part of the procedure to ensure that the procedure is effective and to avoid complications.
   7. General trocar insertion: Insert the first trocar into the tract lateral to the urethra that was dissected out with Metzenbaum scissors. Pass the trocar behind the pubic symphysis (through the retropubic space) and exit through the abdominal incision sites. The trocar is left in place with the tip just past the level of the abdominal skin.
   8. Techniques for successful placement include:
   9. The operator must maintain a firm grasp of the trocar and handle while manipulating the needle through the tissues. Resistance of the tissues may sometimes result in deviation of the needle. Some surgeons use a hand in the vagina to control and direct the trocar while the opposite hand on the handle is used to apply gentle force to advance the trocar.
   10. Care should be taken to aim the trocar handle in the direction of the outer aspect of the patient’s ipsilateral shoulder [19].
   11. The tip of the trocar should be positioned just behind the pubic symphysis. It is often helpful to actually place the tip of the trocar on the underside of the pubic symphysis and to gently slide it behind the bone, staying as close to the bone as possible. To do this, the surgeon must lower the hand that is holding the trocar handle so that the curve of the insertion needle follows the posterior surface of the pubic bone through the retropubic space. The trocar should pass easily in the retropubic space in direct opposition to the posterior side of the symphysis. More force is needed when the trocar passes through the rectus sheath and then out through the skin at the suprapubic level.
   12. The trocar handle must be kept parallel to the floor during retropubic passage to prevent the lateral rotation of the trocar tip.
   13. After insertion, the anterior vaginal sulci are inspected and palpated to ensure that they have not been perforated by the trocar. If there is a perforation, then the trocar or the plastic sheaths with the mesh can be seen traversing the vaginal sulcus. The first sign of a vaginal perforation is often the onset of vaginal bleeding that does not appear to be coming from the midurethral vaginal incision.
   14. Cystourethroscopy— After each trocar is placed, perform cystourethroscopy to inspect for bladder perforation. A 70-degree cystoscope should be used and the bladder filled adequately to allow complete examination of the urethra and bladder surface [18]. Examination of the bladder requires an experienced clinician; a study of surgical trainees reported that 37 percent of bladder injuries were missed on cystourethroscopy [9].
   15. Adjusting the sling tension— To ensure that the sling is tension-free and does not compress the urethra while the patient is at rest, many surgeons insert an instrument (eg, Kelly clamp, needle holder, or number 8 Hegar dilator) between the sling and the urethra while adjusting the sling tension
   16. Sheath removal- With the spacer in place, remove the plastic sheaths; this prevents excess tightening of the mesh during plastic sheath removal. The surgeon should assess the entire plastic sheath to confirm that it has been completely removed.
   17. Trim the mesh at the abdominal incisions. Mesh protrusion and irritation at the skin surface can be prevented by depressing the skin slightly to trim the mesh just below the skin surface. The mesh does not require suturing, since it is held in by friction and then fibrosis [18].
   18. Incision closure: Vaginal- absorbable suture, Abdominal- per surgeon preference.

Procedure: Placement of a bottom-to-top full-length retropubic midurethral sling (as example)

1. Use of size 18 French will allow the rigid catheter guide to be introduced. This catheter guide is used to deviate the bladder away from the side of trocar placement.
2. Marking abdominal incisions - Mark the two planned abdominal exit points for the tape at the superior margin of the pubic bone, 2 cm lateral to the midline. Some surgeons make small stab incisions at these locations to facilitate trocar passage through the skin.
3. Hydrodissection - Some surgeons hydrodissect the vaginal incision site and/or the path of the trocars. Either local anesthetic (with or without epinephrine) or sterile saline may be used. In the original description of the procedure, 40 ml of fluid was injected into the vaginal wall inferior and lateral to the urethra [5]. An additional 60 to 70 mL of fluid was injected at the planned abdominal incision sites and downward along the back of the pubic bone to the retropubic space. Alternatively, fluid may be injected into the retropubic space through the vaginal sulci.
4. Midurethral vaginal incision - Make a vertical (longitudinal) vaginal incision, starting 1 cm proximal to the urethral meatus and 1 to 1.5 cm in length to accommodate the width of the sling in the appropriate location. Place Allis clamps on the lateral edges of the incision to provide exposure by retracting the vaginal mucosa laterally. Minimal dissection lateral to the midurethra, between the vaginal mucosa and the pubocervical fascia, is performed bilaterally with the Metzenbaum scissors. The scissors are angled towards the retropubic space just behind the pubic symphysis.
5. Lateral deviation of the bladder - Drain the bladder completely and introduce the rigid catheter guide into the bladder catheter. Deviate the bladder to the side opposite of the first trocar insertion.
6. Initial trocar insertion - Insertion of the trocar along the correct path is the critical part of the procedure to ensure that the procedure is effective and to avoid complications.
7. General trocar insertion, Insert the first trocar into the tract lateral to the urethra that was dissected out with Metzenbaum scissors. Pass the trocar behind the pubic symphysis (through the retropubic space) and exit through the abdominal incision sites. The trocar is left in place with the tip just past the level of the abdominal skin.
8. Care should be taken to aim the trocar handle in the direction of the outer aspect of the patient’s ipsilateral shoulder.
9. After insertion, the anterior vaginal sulci are inspected and palpated to ensure that they have not been perforated by the trocar.
10. Cystourethroscopy - After each trocar is placed, perform cystourethroscopy to inspect for bladder perforation. A 70 degree cystoscope should be used.
11. Adjust the sling tension - To ensure that the sling is tension-free, insert an instrument (eg, Kelly clamp, needle holder, or number 8 Hegar dilator) between the sling and the urethra while adjusting the sling tension.
12. Sheath removal - With the spacer in place, remove the plastic sheaths; this prevents excess tightening of the mesh during plastic sheath removal. The surgeon should assess the entire plastic sheath to confirm that it has been completely removed.
13. Trim the mesh at the abdominal incisions. Incision closure: Vaginal- absorbable suture, Abdominal- per surgeon preference. 

9. Assess actual performance during simulated midurethral sling placement according to the checklist

Checklist: Midurethral Transobturator and Retropubic Slings

Part 1: Knowledge

1. The learner is able to list benefits of midurethral slings
   1. Unable to list
   2. Able to list several
2. The learner is able to list indications/qualifications for a midurethral slings
   1. Unable to list
   2. Able to list several
3. The learner is able to identify anatomic landmarks
   1. Unable to list
   2. Able to list several
4. Knows incidence of urinary system injury

Part 2: Simulated and Clinical Performance

1. Preparation
   1. Time out
      Name
      Antibiotics
      Allergies
      Procedure to be performed
   2. SCDs/DVT prophylaxis
   3. Antibiotics
   4. Position/Stirrups/Angles
   5. Exam under anesthesia
   6. Scrub
   7. Drape
2. Procedure: Transoburator Outside in approach (as example)
   1. Place Foley catheter
   2. Appropriate placement of initial incision
   3. Proper Dissect laterally along the full thickness vaginal wall plane to the inferior edge of the pubic bone
   4. Palpate bone edge
   5. Locate insertion of adductor longus tendon on patient’s right and left sides, palpate notch along internal edge of ischiopubic ramus and make small skin incisions
   6. With surgeon’s left fingertip in vaginal tunnel and thumb on top of needle curve, push needle tip through patient’s left skin incision until the obturator membrane is perforated and rotate needle tip toward vaginal incision keeping the needle tip on your finger to guide it through the vaginal incision
   7. Connect sling assembly to trocar needle
   8. Reverse the rotation of the trocar to bring the sling arm back through the skin incision, detach sling
   9. Repeat steps on contra lateral side and detach sling
   10. Perform cystoscopy
   11. Carefully position/”tension” sling underneath the midurethra and remove plastic sheath bilaterally
   12. Cut sling arms at the subcutaneous levels and close skin incisions
   13. Check for hemostasis and close vaginal incision with absorbable suture