C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings

Abstract

ABSTRACT The original technique for mesh midurethral sling, which utilized a retropubic approach for sling placement, also recognized a risk of simultaneous iatrogenic bladder injury. While synthetic mesh midurethral slings have the criterion standard for SUI treatment, there is still no available technique that entirely eliminates the risk of bladder injury at the time of implantation. The retropubic approach holds a 0.7% to 34% rate of bladder injury. Some providers still opt for the transobturator approach because of a perceived decreased risk of intraoperative bladder perforation. This article describes the “C-clamp technique,” a method directly addressing the perceived key causes of bladder injury via the retropubic approach. This study aimed to determine bladder injury rates upon surgical implantation of retropubic synthetic mesh midurethral sling by 1 provider using the C-clamp technique. The article provides step-by-step instructions for this technique, as well as a link to a video (https://links.lww.com/FPMRS/A362). Briefly, the technique involves use of a deflecting catheter guide in steep Trendelenburg, “clamping” the pubis with the operator's nondominant hand to decrease the retropubic distance, and using the nondominant thumb on the inner curve of the trocar to guide the trocar passage toward the nondominant finger tips and suprapubic exit through the skin. This retrospective review identified 201 bottom-up retropubic synthetic mesh midurethral slings placed using the C-clamp technique between April 2012 and June 2022. General data collected included average age (51 years), average weight (46–139 kg), average body mass index (BMI, 15–57 kg/m2), and a range of prior surgical procedures and concomitant procedures. Approximately 15% of patients had a history of prior retropubic urethropexy or some form of midurethral sling. There were no lower urinary tract injuries in the entire cohort. Strengths of this study include its description of the C-clamp technique, the extremes and range of data points included within the study, and the 10-year range of the study. Limitations include its retrospective nature, the single surgeon provider, the vast majority of slings used produced by 1 manufacturer, and limited comprehensive data collection. Using data from 201 consecutive bottom-up synthetic mesh midurethral sling outcomes during a 10-year span, the authors argue that this technique addresses key anatomic issues contributing to bladder and urethral injury during placement of such slings, with a promising ability to eliminate bladder and urethral injury. Favorable data in a larger number of patients and by multiple providers could provide further support to this technique and support retropubic sling as a preferred method of midurethral sling.