in fig1 tape 1 is shown in position in the patient &# 39 ; s body , its ends not yet having been cut off at the surface of the abdominal cutaneous wall 2 . tape 1 is positioned along the posterior wall of the pubis 3 and forms a loop around the urethra 8 terminated by the urethral meatus 9 . an incision or opening has been made in the anterior wall 7 of the vagina 6 , beneath the uterus 5 . 1 ) the penetrating needle is produced from stainless steel . it is constituted by two integral portions screw connected to each other . the active distal portion 13 of needle 12 is partially curved and has a round cross - section ; its proximal end 15 is terminated by a male screw connecting piece . each end of the proximal 16 and distal 17 ends of the straight portion 14 of the needle has a female screw connecting piece . the length of this straight portion is 20 to 25 cm . the diameter of the needle assembly does not exceed 25 mm . the proximal portion 16 of the needle is flattened and ribbed . this enables the surgeon to grip it and allows the needle to be oriented correctly . 2 ) the intermediate traction element is constituted by a hollow pvc tube with a diameter which is identical to that of the needle . it is 40 to 50 cm long . its distal end 19 and proximal end 20 comprise a male screw connecting piece . this screw connecting piece is integrally fixed to the traction element by adhesion and screwing . the intermediate traction element is blue in colour so that it can readily be located during cystoscopy in the event of a vesical puncture . 3 ) the tape - sleeve system . the support tape is hermetically surrounded by a plastic sleeve . the tape is constituted by a knitted macroporous material , for example a wide mesh monofilament polypropylene . the tape is between 10 and 14 mm wide ; it is 30 to 50 cm long , preferably about 40 cm . tape 21 can have a re - absorbable hydrophilic film in its central portion which reduces the risk of erosion or sclerosis of the urethra to a minimum . this central zone is indicated by a coloured marker . in a variation , the tape can be constituted by other biologically acceptable materials . a plastic sleeve completely surrounds the tape in a sealed manner . it is constituted by a strong low friction material such as a fluoropolymer . its proximal end is closed . the other is heat - shrunk over a female screw connecting piece . the centre of the sleeve has a means for cutting and separating such as a cutting filament located perpendicular to the longitudinal axis of the sleeve , or any other means which enables the sleeve to be separated at the end of the procedure into two halves which will slide eccentrically to completely free the tape . the first stage is illustrated in fig2 a : the patient is placed in the gynaecological position . a sterile operating area is made . a urethral balloon probe 11 is positioned in the bladder and connected to a sterile collecting bag to empty and collapse the bladder . a short vertical incision 10 , maximum 30 mm in length , is made in the middle of the vaginal wall 7 centred in the middle third of the urethral canal 9 . each lip 26 of the vaginal incision 10 is detached from its subjacent tissues using scissors as shown in fig2 b . detachment is carried out until the index finger 33 of the surgeon , introduced via the opening 27 , can reach the lower rim 32 of the pubis outside the urethra and the periurethral tissues ( fig2 c ). then a very small cutaneous incision 34 less than 10 mm in length is made in the abdominal skin 2 immediately above the pubis 3 either side of the medial line and about 20 mm beyond it , to allow percutaneous passage of needle 12 by skimming the posterior surface of pubis 3 in the direction of the vagina . index finger 33 of the surgeon is insinuated into the vaginal track already prepared by detachment and the active distal end of needle 12 will come into direct contact with this index finger 33 . the needle can then exit via the vaginal opening 27 and the bladder is completely safe . in general , the right percutaneous track is made first . distal end 19 of the intermediate traction element 18 exits after needle 12 from the vaginal opening . this distal end 19 of the traction element is unscrewed from the proximal end 16 of the needle ( arrow in fig2 d ). the needle is then passed into the second side ( left ) ( fig2 e ) in the same manner as for the first side ( right ). once the curved distal portion 13 of needle 12 is well outside the vaginal opening 27 , it can be detached by unscrewing ( single arrow in fig2 e ) its proximal straight portion . the next stage consists of screwing to connect the distal end 19 of the intermediate traction element to the straight portion 14 of the needle ( double arrow in fig2 e ). this straight portion 14 of needle 12 is then pulled out from the abdomen and as a result , a portion of the traction element to which it is attached is pulled along the second track in the direction of the arrow which is shown in fig2 f . the intermediate traction element thus forms a loop around the urethra and the two ends exit respectively via abdominal incisions 34 , 35 ( fig2 g ). urethral probe 11 is then withdrawn and cystoscopy is used to verify the absence of puncturing by this traction element . once verified , the end with the female connecting piece of the sleeve - tape assembly 21 is screwed to the male connecting piece of the proximal end 20 of the intermediate traction element and the assembly is pulled to position the tape surrounded by its sleeve which forms a loop around the urethra , in the place of the traction element , and the two ends exit via the abdominal cutaneous orifices 34 , 35 . the two ends of the sleeve and tape are sectioned and the sleeve is separated into two halves at its middle at opening 27 ; the two halves are completely removed via incisions 34 , 35 , finally freeing the support tape . the denuded tape is then adjusted to be placed below the inferior face of the urethra , usually in its central portion , without traction and without crushing . if cystoscopy establishes that the track of the loop formed by the intermediate traction element is unsuitable , and more specifically confirms a vesical puncture , the side of the loop where the track is unsuitable is withdrawn and a new track is formed with the needle , as before , to produce a suitable track on this side . the device allows top - to - bottom passage of the needle on both sides and the risk of lesions to vessels is removed and the risks of vesical lesion is much reduced . the top - to - bottom constitution of both sides is only possible because of the highly original nature of the penetrating needle which comprises two portions which can be screwed one onto the other . the concept of an intermediate traction element in the device of the invention is particularly innovative and advantageous ; it renders the needle and the sleeved tape both integral and independent . it allows prior formation of the whole of the looped track and verification of the proper positioning of the track before handling the tape - sleeve system . this advantage is rendered possible by the suitable length of the traction element . if it proves necessary , it enables a new track to be formed for the right side and for the left side before any manipulation of the sleeved tape . terminal manipulation of the sleeved tape reduces the risk of septic contamination , the surgeon changing gloves and cleaning the operating area again if necessary before this terminal phase . the tube can be formed from any suitable material with mechanical characteristics which are similar to that of pvc . this tube , in pvc or the like , can also be separated into two portions of similar length , for example equal lengths , by cutting it at its centre . a short intermediate piece , for example of metal , with a diameter similar to that of the tube and having a male screw portion 24 , 25 , can then be envisaged ; such a part 23 is shown in fig2 i , the male screw element corresponding to the internal diameter of the tube . any other means which can directly and integrally connect the two tubular halves can also be envisaged , once the right and left tracks formed using the needle passed from top to bottom to the right and the left in succession are joined . when using a tube , parts similar to part 23 can be used to removably fix the traction element to the needle and to the tape and the portions of the traction elements to each other . parts carrying a male and a female connecting piece can also be envisaged , for ease of fixing . other fixing systems other than screw systems can be provided for the removable or non removable fixings . in this variation , a one - piece needle is used which can terminate in a male screw connecting piece . passage of the track on each right and left side is made by screwing a portion of the traction element ( fig2 i ) to the proximal end of the needle . cystoscopy then verifies the absence of punctures ; then the two tubular halves are connected to each other using the small metal part to form a single traction element disposed in a loop beneath the urethra ( fig2 j ). the remainder of the intervention is identical . in a variation , a fluoropolymer lace can constitute the traction element . in this case , it is connected to the needle via an eye at its proximal end and is folded back on itself after passage through the eye and sewn to itself . in this variation of the device , the lace , which is about 40 cm long , can be sectioned at its centre when carrying out the operation employing the fundamental general principle of forming a top - to - bottom track ; and again it can be reconstituted by the surgeon by a simple mattress suture . the sleeve material , which may be formed from teflon or based on a fluoropolymer , provides the internal and external surfaces of the sleeve , firstly to endure good separation between said sleeve with advantageous non - stick properties and the tape and secondly to limit friction and avoid trauma during passage inside the patient &# 39 ; s body . a non - stick film opposite the lower surface of the urethra can be provided to protect the patient from the risk of erosion or sclerosis around the urethra . the needle is unique and , for its penetration , does not need any additional instrument to grip it , which saves time in preparation for surgery and during surgery . the ease of use and simplicity of the constituent elements of the device also have cost advantages . the ensemble of the elements of the device of the invention can be re - used in the event of poor manipulation and if the track inside the patient &# 39 ; s body is to be improved or optimised . this represents a considerable advantage over the prior art technique . since the tracks can be produced from top to bottom , the device improves safety for the patient and the quality of the therapeutic result . the effect of the tape on continence and regulation have not been evaluated in the method of the invention for at least the following two reasons : continence in the prone position is not comparable to that when upright ; and the efficacy of the tape is not only explained by a tightening effect ( which risks causing dysuria ) but also by a supporting effect on the inferior surface of the urethra and by a lateral bracing effect . in the prior art , continence was monitored after filling the bladder and coughing to adjust the tension of the tape . finally , using the device and operating procedure of the invention , the surgeon can choose the height of the position of the tape with respect to the urethral channel ( proximal or central portion ) for each patient based on clinical , urodynamic and possibly imaging and endoscopy data , a feat which cannot be achieved using a prior art technique .
in a device and method for the percutaneous treatment of urinary stress incontinence in women using a synthetic sub - urethral tape , the device includes a needle , an intermediate traction element , and a sleeved support tape ; and the method includes forming an opening in the vaginal wall and forming suprapubic incisions , creating tracks and following one track with a needle and intermediate traction element from a suprapubic incision to the opening in the vagina , following the other track with a needle and optionally an intermediate traction element , verifying the tracks by cystoscopy , passing a sleeved tape through the tracks to form a loop under the urethra , adjusting the loop , removing the sleeve , and leaving the tape implanted .