WO1993010715A2 - Surgical treatment of stress urinary incontinence - Google Patents

Abstract

The surgical treatment of stress urinary incontinence can be improved by modifications that increase safety, efficacy and reproducibility. Thirty women with stress urinary incontinence underwent consecutive endoscopic bladder neck suspension with modifications designed to achieve those goals. Those modifications included: 1) a technique of probe passage to avoid injuring the bladder and to provide a more accurate and reproducible capture of the pubocervical fascia lateral to the bladder neck and urethra, 2) anchor fixation of the suspending sutures to the pubic bone to decrease the risk of suture pull through from above and to decrease post-operative pain and 3) a simple and reproducible technique to set a limited tension of the suspending sutures. procedures were outpatient or with one day of hospitalization beyond the day that their catheter was removed. The immediate post-operative success rate was 100 %. There was one failure in a follow-up to 8 months. Urinary urgency dropped from 63 % pre-operatively to 17 % post-operatively. The patients' satisfaction with the procedure was high. A description of these modifications and results of procedures with these modifications are disclosed. Novel drill guides suture passers and suture tensioners for use in the surgical method are also disclosed.

Description

SϋRGICAL TREATMENT OF STRESS URINARY INCONTINENCE

Background of the Invention

The present invention relates to the treatment of stres urinary incontinence "SUI," and, in particular, to improve methods and surgical devices for the surgical treatment of SU in females. The devices disclosed herein are additionall useful in a wide variety of other surgical procedures.

Genuine stress incontinence is the involuntary loss o urine due to a sudden rise in intra-abdominal pressure. I has been estimated that between 40% and 50% of young, health nuiliparous women admit to occasional mild stres incontinence; however, at least 80% of stress incontinenc patients are in the perimenopausal age group and ar multiparous. Raz³ has suggested that the female urethra continence mechanism is dependent on the interaction of fou urethral factor: urethral closing pressure, urethral length urethrotrigonal anatomy, and urethral reception of intra abdominal pressure. The urethral closing pressure is predominantly a resul of the interaction of smooth and striated muscle sphincte activity, but there is also some contribution by nonmuεcula urethral factors such as the submucosal vascular plexus, th elaεtin and collagen content of the urethral tissues, and sphincter like effect of the mucosa. There has bee considerable diversity of opinion regarding the anatomi structure and the innervation of the urethral sphincters, an a variety of views have been expressed in the literature.

Lapides and associates have stressed the importance o urethral length in the maintenance of continence in th female. However, although it certainly interacts with othe factors to contribute to continence, a short urethra alon will not produce incontinence. Urethral length varie considerably in normal women, and women with proven genuine stress urinary incontinence do not invariably have urethral shortening.

Urethrotrigonal anatomy, which can be demonstrated by lateral cystourethrograph , should fulfill certain criteria. The bladder base should lie above the level of the inferio ra us of the symphysiε, and with straining should not descen more than 1.5 cm. There should be a normal urethrotrigona alignment with an angle normally less than 100 degrees, an the urethral axis should be approximately 35 degrees from th vertical. In the hypermobile situation loss of all of the normal anatomic features may occur, a radiologic finding that correlates with the clinical finding of cystourethrocele. However, clinical experience has shown that the coexistence of cystourethrocele and incontinence does not predict that the incontinence is of a genuine stress variety.

The transmission of intra-abdominal pressure to the intra-abdominal portion of the proximal urethra is also reported to be important in the maintenance of continence.

This is a passive phenomenon, and is the result of the normal anatomic configuration just described. Whenever there is a rise in intra-abdominal pressure during such stresses as coughing or straining, the pressure is transmitted not only to the bladder but also to the proximal urethra, with resultant increase in the closing pressure, and prevention of leakage.

If the urethral axis is altered, rotational descent will drop the proximal urethra and bladder base from its intra-abdominal location, and will obviously impair such pressure transmission.

A wide variety of operations have been used to correct, this condition, generally involving the principles of elevating the bladder neck anteriorly and/or elongating and narrowing the proximal urethra. One of the most popular operations today for female stress incontinence is the Marshall-Marchetti-Krantz vesicourethropexy. It has at least an eighty-five percent success rate, against which other operative success rates must be measured. Recently, the Pereyra operation and its modifications have enjoyed some popularity.

Notwithstanding the foregoing, however, there remains a need for an improved treatment for SUI. Preferably, the treatment is as noninvasive as possible under th circumstances, and will eliminate or minimize hospitalizatio and the use of general anesthetics. In addition, ther remains a need for improved medical instrumentation such a drill guides and suture passers for use in connection with SU treatment and other medical procedures.

Summary of the Invention There is provided in accordance with one aspect of th present invention a drill guide for directing a drill bit a a selected site on a bone. The drill guide comprises housing, and at least two chambers extending axially withi the housing. Each of the chambers has an opening at th distal end. A plunger is provided in each of the chambers, each plunger axially movable from a first retracted positio to a second extended position. A probe is mounted on th distal end of each of the plungers, and adapted for retractio within the open end of the chamber and extension outside o the open end of the chamber. In a simplified embodiment, eac of two or more probes is axially ovably disposed within th housing, without the use of a distinct plunger. A drill guid channel extends axially through the housing, within a plan parallel to the plane joining the axes of the first and secon chambers, and in between the axes of the first and secon chambers. Preferably, one or both of the plungers is provided wit a releasable lock for releasably retaining the plunger in th retracted position, thereby minimizing the likelihood o accidental needle sticks. The preferred probe comprises hypodermic needle or a sharpened solid wire. In a two prob embodiment, the axes of the first and second probes ar separated by a distance within the range from about .5 t about 1.5 cm. Preferably, the axis of the drill guid channel is approximately equidistant from the axes of each o the probes. In accordance with the further aspect of the presen invention, there is provided a method of positioning a drill guide over a drilling site on bone, comprising the steps of providing a drill guide of the type having a housing, at leas two axially extendable probes within the housing, and a dril guide extending through the housing. A first probe i extended from the retracted position to the extended position and advanced through the tissue until it contacts a bone. Th second probe is thereafter extended from the retracte position to the extended position, until the second prob contacts the bone. If the first extension of the second prob does not result in a contact, both probes are retracted withi the housing, and the drill guide is translated along th sagittal axis. The first probe is thereafter reextended an the foregoing steps are repeated until both the first an second probes contact the bone.

In accordance with another aspect of the presen invention, there is provide a method of installing a bone anchor in a bone, utilizing the drill guide defined above. In accordance with the installation method, each of the probes is sequentially extended and advanced through tissue as described until each of said probes is in contact with the bone. A drill bit is thereafter advanced through the drill guide channel and a hole is drilled in the bone. The drill bit is thereafter withdrawn from the drill guide channel, and a suture anchor is advanced through the drill guide shaft and into the bone. In accordance with another aspect of the present invention, there is provided a suture passer of the type adapted for releasably retaining a suture. The suture passer comprises a handle, and an elongate tubular probe guide extending in a distal direction straight or curved from the handle. An elongate probe is axially movably disposed within the tubular probe guide, for motion between a first retracted position and a second extended position in which the sharpened distal tip of the probe is exposed. An annular recess is provided on the probe, to cooperate with an opening on the tubular guide for receiving a suture. The probe is axially movable with respect to the probe guide between a first position in which the annular recess is aligned with the opening for receiving a suture therein, a second positio wherein the annular recess is out of alignment with th opening, to trap or retain a suture therein and a thir position in which the distal probe tip is exposed. In accordance with a further aspect of the presen invention, there is provided a surgical bladder nec suspension procedure, for the treatment of stress urinar incontinence. In accordance with the method, a technique o creating a suspension web comprising a plurality of lengths o suture is constructed extending between the pubocervica fascia and the pubic bone, on each of the right and left side of the midline. Sutures are carried through tissue utilizin the suture passer disclosed herein, and sutures are tied dow to the pubic bone utilizing a bone anchor positioned on eac of the right and left sides of the midline by a drill guide a disclosed herein. Prior to tying, sutures are appropriatel tensioned by advancing the suture around the suture tensione disclosed herein and tying in a conventional manner Thereafter, the suture tensioner is removed and the surgica site prepared and closed in a conventional manner.

These and additional features and advantages of th present invention will become apparent from the detaile description of preferred embodiments which follows, when take together with the attached drawings and claims. Brief Description of the Drawings

Figure 1 is an elevational partial cross sectiona schematic view of a drill guide in accordance with the presen invention.

Figure 2 is a cross sectional view along the lines 22 i Figure 1, showing the actual orientation of the drill guid channel with respect to the probes.

Figure 3 is a side elevational schematic view of th drill guide of Figure 1.

Figure 4 is a front elevational view of the drill guid shown in Figure 3.

Figure 5 is a cross sectional view of a suture passer i accordance with the present invention. Figure 6 is an enlargement of the distal tip of the suture passer illustrated in Figure 5.

Figure 7 is a perspective and detailed view of the suture tensioner in accordance with the present invention. Figure 8 illustrates the location of incision sites for the method of the present invention.

Figure 9a represents the positioning of the vertical passage of a Stamey needle to just below the rectus fascia. Figure 9b illustrates the placement of a needle point on the underside of the pubic bone.

Figure 9c represents the distal passage of the needle to the level of the introitus.

Figure 9d represents the withdrawal of the needle from the pubourethral ligament and the path of the sweep back along the pubocervical fascia to the area of the bladder neck and first entry site.

Figure 10a illustrates the initial passage of the needle through the pubocervical fascia at point 1 (proximal and medial) . Figure 10b represents the withdrawal of the suture through the pubic wound.

Figure 10c illustrates the passage of the needle through the lateral aspect of the pubic wound and through the pubocervical fascia at point 2 (proximal and lateral) . Figure lOd illustrates the withdrawal of the suture into the retropubic space.

Figure lOe illustrates the passage of the needle and suture through point 3 (distal and medial) .

Figure lOf illustrates withdrawal of the needle into the retropubic space.

Figure lOg illustrates the passage of the needle through point 4 (distal and lateral) .

Figure lOh illustrates the withdrawal of the suture through the pubic wound. Figure 11a illustrates an early generation Mitek Gl anchor.

Figure lib illustrates a Mitek G2 anchor. Figure 12a illustrates drilling a hole in the pubic bon for placement of an anchor.

Figure 12b illustrates placement of an anchor with suture into the pubic bone using an anchor inserter. Figure 12c illustrates extraction of the inserter leavin an anchor and suture in place.

Figure 13a is an end-on view of the urethra emphasizin volume of pubocervical fascia captured and showing relativ locations of suture entry points. Figure 13b is a lateral view emphasizing the length o pubocervical fascia captured from the bladder neck to th pubourethral ligament.

Figure 14 illustrates the tying of the suspension sutur on pulp of finger leaving a small amount of suture slack whe finger is removed.

Figure 15 illustrates the duration of hospitalizatio following surgery of the patients discussed in Example 1.

Figure 16 illustrates the period of intermitten catheterization following removal of in-dwelling catheter fo the patients discussed in Example 1.

Figure 17 illustrates urinary urgency before and afte surgery for the patients discussed in Example 1.

Figure 18 illustrates patient subjective satisfactio with results of the procedure conducted in accordance with th present invention, for patients discussed in Example 1. Detailed Description of Preferred Embodiments SUI is generally curable with any of a variety o surgical procedures that properly suspends the bladder neck However, limitations of known procedures include 1) the exten of surgical morbidity 2) the ever present threat of long ter failures and 3) the reproducibility between differen surgeons.

Pereyra¹ introduced the transvaginal bladder nec suspension as a less invasive alternative to open retropubi procedures. Stamey² limited morbidity and improved th reproducibility of the transvaginal bladder neck suspension b introducing endoscopic control and confirmation of sutur placement. Raz³ has improved reproducibility by introducin full palpatory control of needle passage through th retropubic space, thereby limiting disability through injur to the bladder or other retropubic structures. The distal passage of the suture passer disclosed herei or other needle followed by a sweep back to the bladder nec area described herein accomplishes a similar goal but withou the necessity of entering the retropubic space. Passage o the needle point to the level of the introitus along th underside of the pubic bone obviates the need to turn th needle down toward a bladder neck that has been digitall elevated, thereby reducing the risk of bladder injury. Extraction of the needle from the pubourethral ligament i necessary to allow a "capture" of the more pliabl pubocervical fascia alongside the urethra. The subsequent, gentle sweep back of the needle along the surface of th pubocervical fascia provides an easy and safe means of introducing the needle to the bladder neck area under the vaginal digital guidance. Gittes and Loughlin⁵ have further popularized the technique of Pereyra and demonstrated an advantage of increased long-term efficacy by creating an autologous bolster with the transvaginal passage of a curved needle. As an alternative manner of creating an autologous bolster, the proposed modification described herein uses the suture passer disclosed herein, or a Stamey needle through a suprapubic approach to carry the suture through all of its vaginal passes. The full carriage of the suture by the suture passer needle offers the benefits of 1) improving accuracy and reproducibility by allowing palpation of the needle at each vaginal entry point in reference to the bladder neck and catheter, 2) potentially decreasing morbidity by reducing the risk of injury and/or irritation through inadvertent entry into any part of the urethra or bladder and 3) possibly contributing to long term efficacy by assuring that a full thickness layer of pubocervical fascia is captured. This technique permits the capture of a large lateral volume of pubocervical fascia similar in an area to that available fo suturing in an open retropubic urethropexy.

Leach⁴ has limited morbidity by decreasing post-operativ pain and has potentially improved long-term efficacy wit pubic fixation of the suspending sutures. However, th trochar needle passage through the pubic bone as described b Leach can be difficult through the limited exposure that i used with some forms of endoscopic bladder neck suspension Other various forms of pubic bone fixation have also bee described with transvaginal and open bladder neck suspensio surgery^6,7 _' ⁸. To facilitate the anchoring of the suspensor suture to the pubic bone with minimal soft tissue dissection the present inventor has used a new set of devices called th Mitek Anchor System. The latest generation of Mitek anchor the G2, consists of a titanium body coupled to nickel-titaniu arcs. These anchors have recently been used most commonly fo tenodesis and ligamentous reconstruction of the shoulder an foot⁹'¹⁰.

In the present setting of bladder neck suspensions, th Mitek anchor with attached suture is passed into a hol drilled in the pubic bone. Care must be taken to assure tha the hole has been drilled into the pubic bone and no inferiorly through the tendon of the adductor longus o superiorly through the rectus fascia over the surface of th pubis. Proper location of the drill and placement of the bon anchor in the bone is facilitated by the drill guid illustrated in Figures 1-4 and discussed infra.

Once the anchor is passed into the bone, the anchor' unique memory forces the arcs to spring open to their origina shape and to engage in the cancellouε portion of the pubi bone. The complication of infection with use of the ancho has not been noted, which may, in part, be due to the emphasi on broad spectrum antibiotics and sterile technique with us of video endoscopy, when possible. Anchor pubic bone fixation in one study by the invento herein waε associated with a limitation of poεt-operative pai allowing the procedure to be performed on an outpatient basi in many of the patients. Pubic anchor fixation may limi suspending suture pull through at the level of the rectu fascia. Any assessment of resultant improvement of long ter efficacy will require longer follow-up. Certain specific embodiments of the methods and device of the present invention will follow, together with an exampl of the inventive bladder neck suspension procedure.

I. DRILL GUIDE

In accordance with one aspect of the present invention there is provided a drill guide for locating drill site inside a patient's body. More specifically, the inventio relates to a multi-probe bone locator and drill guid centering device for locating a desired site on a bone guiding a drill bit to the located εite, retaining access t the site following drilling, and installation of a bone ancho for anchoring sutures.

Referring to Figure 1, there is shown a surgical dril guide 10 in accordance with one aspect of the invention. Generally, drill guide 10 comprises a body 15 carrying two o more plungers 20, 21, each having a bone probe 25, 26 at it end. A guide shaft 30 is located between two adjacent bon probes 25, 26. Alternatively, one or more of the plungers 20, 21 can be eliminated, so that one or more probes 25, 26 i directly mounted within or to body 15. Thus, in a simplified design, a drill guide channel is held in proximity to two or - more elongate probes such as hypodermic needles which are preferably axially movable.

Body 15 is the support structure for the drill guide 10. The body 15 may have any of a variety of exterior configurations; however, it is preferred that the body be sufficiently axially elongate to facilitate withdrawal of the sharpened distal tips 27, 28 of the probes 25, 26 therein to minimize accidental needle sticks, and generally oval or rectangular in cross section. See, e.g., Figure 2. The inside of the body 15 has two or more identical chambers 35, 36 spaced apart from each other to accommodate a drill guide shaft 30, as will be discussed. Preferably, an annular tissue compreεεion portion 37 of body 15 adjacent the guide εhaft 3 extendε slightly farther in the distal direction than th lateral εidewallε 38, 39 of the body 15. Tissue compressio portion 37 is optimally provided with a rough or serrated edg surface for contacting the tissue surrounding the drill sit as will be discussed.

Each chamber 35, 36 extends from the distal end of th body 15 to a point near the proximal end of the body 15. I this manner, chambers 35, 36 are provided with open dista ends to permit reciprocal axial motion of the bone probes 25 26 therethrough. Proximal ends of chambers 35, 36 ar provided with a εtop εuch aε end wallε 40, 41 having centra paεεagewayε 42, 43 therethrough for movably accepting th plungerε 20, 21. Similarly, diεtal ends 44, 45 of chamber 35, 36 can be provided with an end wall (not illustrated having a probe opening therein, or a pierceable septum fo permitting pasεage of probes 25, 26 therethrough.

The exact distance between the axes of adjacent chamber 35, 36 dependε on the procedure for which the device is to b used. For example, in a bladder neck suspension procedure the axes of chamberε 35 should be separated by a distance o no more than about 10 mm from their centerlines, in a embodiment having coaxial probes and plungers, so that th corresponding probe separation is also no more than about 1 mm. Preferably, the separation between adjacent probes i within the range of from about 5 mm to about 15 mm.

Due to the bilateral symmetry of the illustrate embodiment, only one side will be particularly describe below. The plunger 20 preferably comprises three mai portions: an engaging knob 46, a main shaft 47 and a stop 50 The knob 46 is generally a cylindrical body attached to th top of the shaft 47 and shaped for easy engagement with thumb or hand. This knob 46 may be attached to shaft 47 in variety of manners. For example, knob 46 is illustrated a having a recessed portion on its diεtal εurface for acceptin the proximal end of shaft 47. A screw 55, preferably fla headed, iε then passed through the top of the knob into th top of the shaft 47 to securely lock them togethe Alternatively, the shaft 47, knob 46 and stop 50 can integrally molded from any of a variety of thermoplast materials well know in the art of surgical instrume anufacturing.

The plunger shaft 47 extends from the knob 46 through t opening 42 in the proximal end wall 40 of the body 15 and in chamber 35. Shaft 47 preferably is at least about 25 mm lo from the distal surface of the knob 46 to the proximal surfa of end wall 40 on body 15. In this manner, the plungers 2 21 have a sufficient range of axial travel between a firs retracted position in which the distal tips 27, 28 of prob 25, 26 are shielded, and a second, extended position in whi the distal tips 27, 28 of probes 25, 26 are exposed. It contemplated, however, that the length of the shaft 47, pro 25 and axial travel may vary depending on the intend procedure.

A stop 50 is positioned on the distal end of the sha 47. The stop 50 and shaft 47 may either be separate fabricated or may be fashioned from one piece of material su as by known molding or lathing techniques. The illustrat stop 50 comprises a radially outwardly extending portion o the plunger 20 which travels within the chamber 35 to produc a transverse abutment surface 56. The stop 50 thus limits th proximal range of travel of the plunger 20 by engagement o the abutment surface 56 with the distal surface of end wall 4 of the body 15. The stop 50 is preferably provided at it diεtal end with a connector such as a standard luer fo attachment of a probe 25. As will be appreciated by one o skill in the art, any of a wide variety of interlocking o complementary surface structures can be devised to accomplis the function of stop 50.

In the illustrated embodiment, the probe 25 is inserte into a threaded cap 60. This cap 60 is preferably threaded o its interior surface so that it may be attached to th correspondingly threaded distal end of stop 50

Alternatively, the probe 25 can be connected to the stop 50 o εhaft 47 such as by molding the proximal end of the probe therein.

Each probe 25, 26 extendε from the correεponding shaft 4 towards the distal end of the chamber 35. Probe 25 m comprise standard hypodermic tubing such aε a εtandard needl or a εolid wire probe preferably having a sharpened dist end.

The length of the probe 25 is preferably such that wh the plunger 20 is in a fully retracted state, the distal e of the probe 25 is spaced by at least about 4 mm from the op distal end of the chamber 35. In this manner, the probe e is protected against contamination and the user of the dril guide 10 is protected against accidental probe sticks

Alternatively, the probes 25, 26 can be rigidly secured to t body 15 or directly to a tubular drill guide shaft 30 as wil be apparent to one of skill in the art.

In an embodiment having axially movable plungers, th plunger 20 iε normally retracted proximally εuch that th diεtal tip 27 of probe 25 connected thereto is recessed fro the distal end 44 of the chamber 35. This position i preferably releasably maintained by engaging rods 65 which ar biased in the direction of annular recess 75 in the shaft 4 of the plunger 20.

In the illustrated embodiment, annular recess 75 i provided in the plunger shaft 47 at a point adjacent th proximal end of the body 15. When the plunger 20 i retracted, receεε 75 releaεably receives rod 65. This rod 6 iε biased such aε by a spring εo that it provideε a interference fit within receεε 75 and holds the plungers 20 i their retracted position. The rods 65 and springε ar preferably mounted within a housing adjacent the proximal en of the body 15.

A drill guide shaft 30 extendε axially in between the tw chamberε 35, 36 containing the plungerε 20, 21. Preferably drill guide shaft 30 is diεpoεed approximately equidistan from the longitudinal axis of each of chambers 35, 36 so tha when each of the probes 25, 26 is in contact with a bone, th axis of drill guide shaft 30 will be spaced well away from th edge of the bone. In addition, in the illustrated embodiment the axis of shaft 30 is offset laterally from the plan connecting the axes of chambers 35 so that the axes of the tw probes and the drill guide shaft 30 are disposed on vertice of a triangle. See Figure 2. This configuration facilitate the use of a slot 31 extending the length of guide shaft 3 for receiving a suture during the installation of the sutur anchor. Drill guide shaft 30 is optionally surrounded by a elongate tubular bushing 80 extending throughout at least portion of the body 15, and preferably positioned so that th distal end of the bushing 80 is slightly recessed from th distal portion 37 of body 15. This bushing 80 aidε i properly centering a later installed drill bit and acts as channel through which a suture anchor is introduced into th hole after drilling.

Referring to Figure 3, there is diεclosed a handle 9 connected to the outside of the body 15 for maneuvering th drill guide 10. This handle 90 is preferably generall tubular in shape, and approximately 10 mm in diameter for eas gripping by the user. The handle 90 as illustrated extend from its connection with the body 15 laterally away from sai body, then upward and outward at an angle, and finally ends i a gripping section 91 which extends generally along perpendicular to the axis of the body 15. This handle design permits the user to forcefully press the drill guide 10 against the body, as well as to facilitate controlled translation of the drill guide along a sagittal axis. The handle 90 may be connected to the body 15 in any of a variety of conventional manners. In the illustrated embodiment, the handle extends into a small recess in the body 15 and then is locked in place such as with a nut 85. The nut 85 as illustrated has a threaded portion for engaging the body, and a locking portion for pushing the handle 90 into the body 15. Alternatively, the handle 90 can conveniently be integrally molded with body 15, or secured thereto such as by thermal or εolvent bonding techniqueε or by adhesives we known in the art.

It is preferred that the components of the drill guide be made of a material which is sterilizable, relatively rig and biocompatible, such as stainless steel or any of a varie of polymers conventionally used for medical instruments of t type designed to enter the sterile field.

The operation of the surgical drill guide 10 will now described. When it iε desired to locate a bone for attachme of a suture anchor therein, the drill guide iε placed on t body over the area of the bone. The drill guide 10 i centered after visualization or digital palpation over t bone.

The user pushes one or both of the knobs 46 to distall extend at least a firεt probe 25. The probe 25 iε extende into the body by puεhing the plunger 20 down, until either th plunger has been fully extended or the bone iε contacted.

If the plunger extends fully without the probe contactin the bone, the probe iε retracted and drill guide 10 iε the repositioned for another attempt at locating the bone.

When the first probe 25 does engage the bone, pressure i released from the knob 46. The user then extendε the secon probe 26 by pushing on the correεponding knob of the secon plunger 20. Once again, the second probe 26 will eithe engage the bone or the plunger 20 will fully extend withou contact. If no contact is made by the second probe 26, it i retracted again by pulling upward on the appropriate knob The drill guide 10 may then be translated along the sagitta axis and one or both probes reextended. This proceεε iε continued until both probeε 25, 2 contact the bone. At this time, the user will be asεured tha the bone has been located and that the guide εhaft 30 i properly centered over the bone.

A drill bit is then extended through the drill bushing 8 and into the patient. The drill bit iε uεed to drill throug adjacent tissue and produce a small hole in the bone

Preferably, a step drill or other limiting structure i utilized for producing a hole having a predetermined a reproducible depth into the bone. For installation of th preferred Mitek G2 anchors disclosed herein, a 2.5 mm diamete drill bit is used to produce a hole of 15 mm depth into th bone.

The desirability of having a tissue compression portio 37 which extends distally slightly beyond the distal end o the adjacent body is now apparent. At the time the drill bi is retracted, the hole drilled would normally close upo itself becauεe of the resiliency of the surrounding tisεue However, by maintaining pressure on the body 15 in th direction of the bone, the tissue compression portion 37 tend to compress the adjacent tissue thereby minimizing migratio and maintaining the hole open. In this manner, the tissue located directly under th guide shaft is prevented from closing, and the anchor can b readily advanced through guide shaft 30 and into the bone Even without distally extending tissue compression portion 37 installation of the anchor is greatly simplified using th drill guide of the present invention because the axis of dril guide shaft 30 remains directed at the drill hole.

Following retraction of the drill bit, a suture anchor i advanced into the body through the drill bushing 80 and the connected within the hole in the bone. An installation too which facilitates holding the anchor body by means of a interference fit at the gripping point and guiding said anchor through the guide hole and compressed tissue into the bone hole is preferably utilized. The suture, typically previously connected to the anchor, is permitted to trail out through the slot 31 provided for that purpose.

II. SUTURE PASSER In accordance with another aspect of the present invention, there is provided a suture passer adapted for grasping and passing internal sutures, such as to construct the sling disclosed herein. The suture passer of the present invention is particularly suited for use in connection with such surgery as the bladder suspension procedure disclosed herein, where sutureε are required to be advanced an withdrawn without direct viεualization and through relativel long distances. Alternatively, the suture pasεer may be uεe with other techniques such as Pereyra, Stamey and Gitte methods.

The suture passer of the present invention enables th clinician to avoid accidental damage to the patient's interna structures and accidental needle sticks to himself an operating room personnel. The passive retraction of th needle point within the cannula, which will be discusεed facilitateε the foregoing safety features, and secure captur of the suture material. The ability to advance the cannul with a blunt (retracted needle tip) end also facilitate internal suturing without direct visualization. Safe direc tactile feedback is provided along organ surfaceε to localiz placement of the εuture. These and other features an advantageε of the suture pasεer of the present invention wil be diεcussed below.

Referring to Figure 5, there is disclosed a suture pasεe 105 in accordance with one aεpect of the preεent invention In general, εuture passer 105 comprises a handle 110, a axially movable probe 115, and a probe guide 125 having suture channel 130. Details of suture channel 130 and relate structureε can be seen in the enlarged view in Figure 6. Handle 110 serves both as a gripping area for the use and as a support structure for the εuture passer 105. Handl 110 preferably comprises a hollow tubular body having proxima end wall 111 and distal end wall 112. Handle 110 i preferably of such a size to be easily gripped by a user. handle 110 being at least approximately .75 incheε (20 mm) i diameter and 4 inches (110 mm) in length has been found t work well. Preferably, handle 110 is provided with knurlin or other surface texturing to produce a high friction grippin εurface. A support 135 is preferably mounted such that it extend from the diεtal end of the handle 110 to provide a mountin support for probe guide 125. The support 135 as illustrate is provided with a generally cylindrical proximal section 13 for engagement within the distal end of the handle 110 and tapered distal section 139 for securing probe guide 125. Th support 135 acts as a transition member from the handle 110 t support the probe guide 125.

The probe guide 125 comprises an elongated tubular membe which is at its proximal end inserted within or secured to th support 135. The probe guide 125 may be fixed to the suppor

135 in any variety of manners, including brazing, threading o others known in the art.

The probe guide 125 extends distally therefrom and i preferably within the range of from about 6 inches to about inches in length and may be straight or curved. The length o probe guide 125 may vary, of course, depending on the exac intended procedure.

At its distal end, the probe guide 125 is provided wit a smooth tapered engaging face 140. The distal extreme of tapered face 140 iε slightly rounded or polished so that it can be pressed lightly against and swept along the surface of tissue such as the pubocervical fascia without cutting or traumatizing the tissue.

The probe guide 125 is preferably no more than about .1 inches (2.5 mm) in diameter and is provided with at least one central lumen for acceptance of an axially movable probe 115. An elongate probe 115 is mounted within the handle 110 and extends through the support 135 and the probe guide 125. Probe 115 is preferably provided at its proximal end with a relatively large diameter body portion 116 adapted for reciprocal motion within tubular handle 110. Body portion 116 is preferably provided with a slightly smaller diameter recessed portion 117 for receiving a return spring 142 which biases the probe in the proximal direction. Alternatively, any of a variety of means can be utilized to provide a proximal bias on probe 115. The length of body portion 116 is less than the axial length of the cavity within handle portion 110 so that the body portion 116 has an axial range of motion within the range of from about 2 mm to about 10 mm, and preferably about .1 inch (3 mm) . The proximal end wall 136 of support 135 whic extends into the handle 110 acts aε one limiting stop fo distal travel of body 116. The distal surface of end wall 11 limits proximal travel of body 116. Spring 140 pushes agains an annular shoulder 118 on body portion 116, biasing the prob 115 proximally.

The distal end of probe 115 is provided with a sharpene tip 120. Spring 142 normally biases tip 120 towards a firs retracted position within the distal end of probe guide 125 Axial distal force on body portion 116 extendε tip 120 into second exposed position as illustrated in Figures 5 and 6 Although the probe 115 may be actuated in any number of ways such as by use of a knob or button, it iε preεently preferre that a rotatable cam 122 be uεed.

The cam 122 is attached to a poεt 150 which extend proximally from the handle 110. The cam 120 is rotatabl mounted about a pin 155 which extends in an axis perpendicula to the longitudinal axis of the probe 115. The proximal en of the body portion 116 has a rod 145 which extends proximall through an opening 147 in the proximal end wall 111 of th handle 110.

The cam 122 has at least a two position engaging surfac which, when rotated into position, engages the rod 145 of th body 116. In a first position, the bias imposed by retur spring 142 is overcome and the sharpened distal end 120 o probe 115 iε extended outwardly from the probe guide 125. I a second engaged position, the diεtal end 120 remains withi probe guide 125, but the suture lock is actuated as will b discussed. In a third position, the distal tip 125 i paεsively fully retracted within guide 125, and the εutur lock iε open such aε for receiving or releaεing a suture.

The cam 120 is preferably provided with an actuato portion 156 which extends radially outwardly and which may b used by the operator for rotating the cam 122.

A suture channel 130 is provided near the diεtal end o probe guide 125. Channel 130 cooperateε with an annular o slotted recess 160 near the distal end of the probe 115 Suture channel 130 comprises an opening in the probe guide 12 which extends radially inwardly into the guide 125 and the generally axially along the guide 125 towards the distal end The annular or εlotted receεs 160 in the probe 115 is locate such that when the probe 115 is retracted to the proxima limit, the receεs 160 and the opening in the channel 130 ar aligned for receiving a suture therein.

At least a portion of the suture channel 130 extend generally axially along the guide 125 such that when a sutur 165 is located in the recess 160 of the probe 115, the prob 115 may be extended to an intermediate, "locked" position, o to a distal position in which tip 120 is exposed outside o the probe guide 125. In this extended probe position and a all positions between the proximal and distal limits, th suture 165 is trapped within the recess 160 in the probe 115 As with the drill guide discussed supra, it is preferre that this instrument be manufactured from a sterilizabl material having sufficient rigidity for its intended purpose. Many acceptable materials are well known in the art, such a stainless steel for the needle and needle guide, and stainles steel or a plastic for the handle portion.

The suture passer 105 is operated first by rotating th cam 122 that engages the rod 145 and extends the probe end 120 distally of the probe guide 125. The passer 105 is the extended into a patient's body by gripping the handle 110 and pushing the free end of the probe guide 125 into the body and through the layers of tissue in the same manner as the Stamey needle discussed in Example I, infra, and illustrated in Figs. 9A-10H. The cam 122 is then released and rotates to its neutral position 148 via action of spring 142 against the body 116 in turn pressing the rod 145 proximally against the cam ramp 149. The probe end 120 is thereby retracted into the probe guide 125 so that the suture passer can be manipulated without injury to surrounding tissue while keeping the suture 165 trapped in channel 130.

The suture passer 105 is then guided as discussed in Example I, to the deεired capture point (see Fig. 10A) and th cam 122 rotated to a position in which the εuture channel 13 is aligned with the receεε 160 of the probe 115. A length o εuture 165 is introduced at the transvaginally introitus an digitally pressed against the outside of the probe guide 12 at a point proximal to the suture channel opening 130.

The suture 165 is then moved proximally until the sutur 165 falls into the channel opening 130 and the annular o slotted recess 160 on the probe 115. The cam 122 is the released so that rod 145 slides down cam ramp 149 under th bias of spring 142. At this time, the suture 165 is hel εecurely within the channel 165, and diεtal tip 120 i retracted within guide 125. The passer 105 may then b retracted from the body, thus drawing the suture 165 fro inside the body. The construction of a bladder nec suspension web utilizing the suture pasεer will becom apparent from the method discloεed in Example I, infra.

III. SUTURE TENSIONING In accordance with another aεpect of the preεen invention, a reproducible technique of tying the suspendin suture is described. Tying down on εomething with th approximate dimension of the diεtal pulp of an index finge leaveε a small amount of slack in the suture which permits controlled and limited suspension of the bladder neck whe suspended in this way. The εlack iε acceptable becauεe of th large volume of pubocervical fascia lending support to th bladder neck. It haε been observed to be relatively difficul to place excessive tension on the bladder neck. Chroni urinary retention is avoided by utilizing the suture tensione disclosed herein, and the chance of acute retention i minimized, thereby promoting a reduction in periods o indwelling and intermittent catheterization.

Chronic retention with endoscopic bladder neck suspenεio has been reported in as many as 5 to 18.9 percent of patient in other series^11,12. Excesεive tension with overcorrection o the bladder neck is also known to account for bladde instability¹³. In the study by the present inventor, urinar urgency and urgency incontinence diminished following surge with the limitation of suture tension described herein. Th reduction in irritative urinary symptoms was also associat with the lateral placement of the pubocervical sutures. The period of hospitalization was reduced within t tension limiting group in the experimentation conducted by t inventor herein. A limit on suture tension may be found, ov time, to decreaεe suture pull through at the pubocervic fascia and, therefore, enhance long term efficacy. The o failure in the study conducted by the present invent occurred in a patient who had the suspending suture tied the prior art tighter and more arbitrary manner.

The modifications described herein attempt to furth reduce the limitations of the present forms of bladder ne suspension in a select group of patients with SUI (grade 1 a 2) . Safety and short term efficacy of the modifications we good. Patient inconvenience in terms of the period o hospitalization and intermittent catheterization was limited The period of indwelling catheter drainage will be shortene in the future. Satisfaction in the patient group was high The priority of improved long term efficacy is stressed i these techniques that allow the accurate and secure placemen of suspending sutures in a reproducible manner that minimize the tensions placed upon those tissues that are suεpended. As an alternative to tying down against the index finger there iε provided herein a suture tensioner for providin consistent, repeatable amounts of slack (tension) in th suture sling. As with the use of the index finger describe supra- the use of the suture tensioner minimizes post operative urinary blockage caused by excessive tension, an minimizes post-operative urinary incontinence due t insufficient tension. In addition, the suture tensione permits the visualization of suture knots during tying, thereby ensuring consistency of alignment and tension of kno loops.

Referring to Figure 7, there is disclosed one embodimen of a suture tensioner in accordance with the presen invention. The εuture tenεioner 170 may be constructed in a of a variety of ways which will be well understood by one skill in the art of constructing medical devices, such as injection molding or lathing processes. The suture tenεioner 170 comprises generally an elonga handle 172 and a body portion 174. The handle 172 may integrally formed with the body 174, or may be separate produced and affixed such as by insertion into an opening 17 in the body 174, and retained therein such as by thread adhesives or other conventional means.

The main body 174 comprises a generally cylindrical mass having a relatively blunt distal end 176 and an annular o εemi-annular receεε 178 extending about an axiε of the mai body 174 which iε generally perpendicular to the longitudina axiε of handle 172. Other configurations will also becom apparent to one of skill in the art in view of the presen discloεure.

In the illuεtrated embodiment, the annular recess 17 extends into the main body 174 to a depth of about 0.2 mm, an has a radiuε of approximately 0.5 mm. These dimensions hav been found suitable for tying down the sutures typicall utilized in the bladder suspenεion procedure, which typicall have a diameter of about .5 mm. The main body 174 has a axial length of about 15 mm, and a distance between distal en 176 of main body 174 and annular recesε 178 of about 8 mm.

The handle 172 extendε into the main body 174 to a dept of approximately 14 mm, and the remaining expoεed handle ha a length of approximately 100 mm. The diameter of the mai body 174 iε approximately 16 mm. As will be apparent to one of skill in the art in view o the foregoing diεclosure, any of a wide variety o modifications can be made to the basic dimensionε recite herein, and still permit accruing the advantages of thi aspect of the present invention. In addition to providing a reproducible amount of slac in the tied suture, the use of suture tensioner 170, space the knot tying region apart from the tisεue during tying Isolation of the joining region of the suture ends from t tissue facilitates the use of chemical or thermal bonding suture ends as an alternative to conventional knotti procedures. For example, opposing lengths of suture can be wrapp part way around the suture tensioner towards each other provide an overlap zone in which the sutures are held again each other within the groove 178. In the case of suture ma from polypropylene or other thermally bondable material, heat source can be applied to the area of suture overlap rapidly fuse the two ends together. Excesε suture can then cut and discarded. Depending upon the intensity of the he source, the suture tensioner 170 may provide sufficient hea capacity to prevent injury to adjacent tissue, or additiona heat sink structures or fluid cooling systems can be used Suitable heat sources include conventional laser and fibe optic systems currently available for cautery and surgica procedures.

Alternatively, adjacent lengths of suture can be bonde by applying a quantity of a solvent or a monomer or othe polymerization imitator for initiating a chemical bondin therebetween. Fugative solvent or other agent can be drive from the bonding site by application of heat prior to remova of the suture tensioning tool. EXAMPLE I

A. Patient History

The records of 30 women with SUI who were treated wit modified endoscopic bladder neck suspensions consecutively b the author were reviewed. Twenty-eight patients underwen modified endoscopic bladder neck suspensions alone, while tw patients had modified endoscopic bladder neck suspensions wit concomitant vaginal procedures such as rectocele and/o cystocele repairs. The patients' ages ranged from 38 to 74. The grading of SUI, based on the Stamey system², was grade in 13 patients and grade 2 in 17 patients. There were n grade 3 patients. Patients had a median of 2 vaginal deliveries. Fifty-seven percent of patients had had a previouε hysterectomy. Twenty percent of patients had had a least one previous surgical procedure to correct urinar incontinence.

All patients had a hiεtory demonεtrating botherεom urinary leakage with activitieε and phyεical examinatio demonstrating a hypermobile urethra and pliable pubocervica fascia. Complaints preoperatively included urgency in 63% an urgency incontinence in 40% of patients. Preoperative testin in all patients included 1) a Marεhall test that demonstrate leakage with coughing and one finger control of leakage wit bladder neck elevation and 2) a cystometrogram that did no demonstrate uninhibited contractions. B. Technigue

All patients received gentamicin and ampicilli preoperatively unleεε an allergy exiεted. Aneεthesia wa regional in 16 patients and general in 14 patientε. surgical asεistant waε not used. The patients were placed i the lithotomy position. Preparation emphasized isolation o the anuε with a stapled towel or plastic drape. A Fole catheter was pasεed.

Two εeparated, one inch tranεverse incisions were mad over the pubic bone (Fig. 8) and disεection waε carried dow to the area of the rectuε faεcia. Beginning on the righ side, the wound was stretched cephalad to allow the vertica passage of a Stamey needle (Pilling Company, Fort Washington Pennsylvania) through the rectus fascia (Fig. 9A) . The needl was then sharply angled onto the abdomen so that the poin rested on the underside of the pubic periosteum (Fig. 9B) .

The point of the needle, while maintaining contact wit the underside of the pubis, was thereafter paεεed diεtall toward the introitus. At the completion of this dista passage, the needle could be palpated through the introitus t the right of the urethra (Fig. 9C) . Palpation through th vagina was avoided during this distal passage of the needle t avoid pushing the bladder or urethra into the path of th needle. The tip of the needle was withdrawn from th pubourethral ligament and gently swept along the pubocervica fascia to the area of the bladder neck (Fig. 9D) under t guidance of a finger within the vagina.

The needle was then passed through the pubocervic fascia and vaginal mucosa at point 1 (Fig. 10A) . A number polypropylene suture was passed through the needle hole a withdrawn with the needle through the pubic wound (Fig. 10B The needle was then reintroduced through the rectuε fascia cm. lateral to the initial passage and through the vagin mucosa at point 2 (Fig. IOC) using the same needle passa technique described above (Fig. 9A-D) . The tip of the need with the vaginal end of the suture was then withdrawn into t retropubic space (Fig. 10D) and then advanced to point 3 whe it was passed through the vaginal mucosa and passed distal the introitus (Fig. 10E) . The suture was then removed from the needle and t needle tip was once again withdrawn to the retropubic spa (Fig. 10F) and passed through the vaginal mucosa at point (Fig. 10G) . The vaginal end of the suture was then pass into the needle and pulled up through the pubic wound usin the needle (Fig. 10H) . An attempt was made with the 4 entr points through the pubocervical fascia to maximize l) thei separation (approximately 2 cm. apart) , and 2) thei laterialization from the bladder neck and urethr (approximately 2 cm. away) (Fig. 13A) . The identical procedure was performed on the left side

Direct or video cystoscopic confirmation of suture positio was performed on the left side. Direct or video cystoscopi confirmation of suture position was performed with specia attention to avoid handling the contaminated eyepiece of th cystoscope (when video cystoscopy was not done) .

The Mitek Anchor System (Mitek Surgical Products, Ine. Northwood, Massachusetts) was then used in all patients fo pubic bone fixation of the suspensory sutures. Mitek G anchors (Fig. 11A) were used in the first seven patients an the newer Mitek G2 anchors (Fig. 11B) were used in th remaining 23 patients. Two holes were drilled into the pubi bone approximately 2 cm. lateral to the εymphysis (Fig. 12A) . One anchor for each side (2 per patient) was loaded with medical εuture end (which had had less vaginal contact tha the lateral ends, thereby, potentially reducing the chance o bacterial contamination) . Each anchor was placed into it hole uεing an inεerter (Fig. 12B) . The inεerter was extracte leaving each anchor in place (Fig. 12C) . Traction was place on the sutures to assure adequate fixation of the anchors.

The sutures on each side were then tied down wit sufficient tension so as to develop a gentle elevation an cradle-like support of the bladder neck (Fig. 13A and 13B) A modification to limit and control the tension on th suspending suture web in a reproducible manner was institute in the last 17 patients within the study. The sutures i these patients were tied down snugly on the distal pulp of th index finger (Fig. 14) .

The wounds were irrigated with a bacitracin solution The wound edges and the rectus faεcia at the εuture entr pointε were infiltrated with bupivacaine. A Foley cathete was placed in 80% of the patients. The remaining patients ha a suprapubic tube placed because of the dexterity problems o their aversion to learning intermittent catheterization.

Following surgery, patients were given eithe ciprofloxacin or ofloxacin for 10 days. The patients' Fole catheters were removed one week following surgery. Th patients performed intermittent catheterization as necesεar until the post-void residuals were less than 75 cc. on tw consecutive catheterization. Patients with suprapubic tube generally began voiding trials at 4 dayε following surgery The suprapubic tubes were removed when the poεt-void reεidual were leεε than 75 cc. following two consecutive urinations. C. Resultε

All 30 women who underwent this procedure were evaluate within the first month post-operatively ("post-op" follow-up) The initial 16 conεecutive patients of thiε group wer evaluated up to eight monthε after surgery by mai questionnaires ("short-term" follow-up) . Three patients wh did not return their questionnaires were contacted by phone The procedure was performed on an outpatient basis in 12 the last 17 patients with the suture tension limiti technique (71%) compared to 2 of the first 13 patients witho the technique (15%) (Fig. 15). Many patients did not requi narcotic analgesics following discharge. Seventy-thr percent of patients did not require intermitte catheterization beyond the day that their indwelling cathet was removed (Fig. 16) . All patients became catheter fre The prevalence of urinary urgency was similar at the post- and short term follow-ups at 17 and 19 percent, respecti (Fig. 17) . Six percent of patients complained of urgen incontinence on short term follow-up. Twenty-nine of 3 patients (97%) had cure of stress incontinence on follow-up all 30 patients on post-op follow-up and 15 of 16 (94%) o short-term follow-up. Cure was defined as the lack of urinar leakage with activity. One woman developed urinary leakag three months following her surgery. She had the first set o Gl anchors placed and also had the suspending suture tie without the technique of tension limitation. That patient' anchors appeared to be within the pubic bone on an anterior posterior view of the pelvis. Figure 18 indicates th patients* satisfaction with the results of their procedure a taken from their short term questionnaire. There were n wound or bone infections. EXAMPLE II

A group of patients are prepared in the manner describe in Example I. Two separated, one inch transverse incision are made over the pubic bone (Fig. 8) and dissection i carried down to the area of the rectus fascia. Beginning o the right side, the wound is stretched cephalad to allow th vertical passage of a suture passer of the type illustrated i

Figs. 5 and 6 through the rectus fascia with the probe ti fully exposed (Fig. 9A) . Distal advancement of the εutur passer is accomplished with the needle (probe) tip proximall retracted within the probe guide. The suture passer i acutely angled into the abdomen so that the point rests on th underside of the pubic periosteum (Fig. 9B) . While maintaining contact with the underside of t pubis, the suture passer with the probe tip retracted thereafter passed distally toward the introitus. At t completion of this distal pasεage, the εuture passer can palpated through the introituε to the right of the ureth (Fig. 9C) . The distal end tip of the suture pasεer withdrawn from the surface of pubourethral ligament and gent swept along the pubocervical fascia to the area of the bladd neck (Fig. 9D) under the guidance of a finger within t vagina. Palpation through the vagina may be safely preform to asεiεt in localization of εuture passer tip.

The probe tip is then distally extended. The sutu pasεer is then pasεed through the pubocervical faεcia a vaginal mucoεa at point 1 (Fig. 10A) . The probe is th retracted maximally to the unlocked position to allow a numb 1 polypropylene εuture to be manually placed into the εutur channel. The probe is moved distally to lock the sutu therein. The suture paεεer iε thereafter withdrawn throug the pubic wound (Fig. 10B) and the suture is released from th suture channel by manually retracting the probe.

The suture passer with the probe tip extended iε the reintroduced through the rectus fascia 2 cm. lateral to th initial passage and through the vaginal mucosa at point (Fig. IOC) using the same passage technique described abov (Fig. 9A-D) . The vaginal end of the εuture iε then place into the open end of the εuture channel and locked. Th suture passer is then withdrawn into the retropubic spac (Fig. 10D) and then advanced to point 3 where it iε passe through the vaginal mucosa aε with point 1 and 2 and paεse out of to the introitus (Fig. 10E) .

The suture is then removed from the suture passer b maximally retracting the probe tip to the "unlocked" positio to align the suture channel and opening in the probe guide and the suture paεser is once again withdrawn into th retropubic space (Fig. 10F) . The probe tip iε then extende and the εuture passer iε pushed through the vaginal mucosa at point 4 (Fig. 10G) . The vaginal end of the suture is th placed into the unlocked suture channel and locked into plac and pulled up through the pubic wound. An attempt is ma with the 4 entry points through the pubocervical fascia maximize 1) their separation (approximately 2 cm. apart) , a 2) their laterialization from the bladder neck and ureth (approximately 2 cm. away) (Fig. 6A) .

The identical procedure is performed on the left sid Direct or video cyεtoεcopic confirmation of suture position performed on the left side. Direct or video cystoscopi confirmation of suture position is performed with specia attention to avoid handling the contaminated eyepiece of th cystoscope (when video cystoscopy is not done) .

The Mitek G2 Anchor System (Mitek Surgical Products Inc. , Northwood, Massachusetts) is then used in all patient for pubic bone fixation of the suspensory sutures. Dril sites are located by placing a drill guide 25 illustrated i

Fig. 1 over the pubic bone and extending the bone probe distally until both bone probes have made contact with th pubic bone. A 2.5 mm drill bit is advanced through the dril guide to produce two holes drilled into the pubic bon approximately 2 cm. lateral to the symphysis (Fig. 5A) . On anchor for each side (2 per patient) is loaded into the dril guide channel and advanced into its hole before removing th drill guide after drilling. Traction is placed on the suture to assure adequate fixation of the anchors.

The sutures on each side are then tied down wit sufficient tension so as to develop a gentle elevation an cradle-like support of the bladder neck (Fig. 6A and 6B) . Tension is regulated by tying the sutures across a sutur tensioner as illustrated in Fig. 7, and thereafter removin the tensioner.

The patients are thereafter postoperatively treated as described in Example I. Although this invention has been described in terms of certain preferred embodiments, other embodiments that are apparent to those of ordinary skill in the art in view of t foregoing are also within the scope of this inventio Accordingly, the scope of the invention is intended to defined only by reference to the appended claims.

REFERENCES

¹Pereyra, A.J.: A simplified surgical procedure for t correction of stress incontinence in women. West. Surg. , 67:223, 1959.

²Stamey, T.A. : Endoscopic Suspension of the vesical neck f urinary incontinence in females: Report on 2 consecutive patients. Ann. Surg., 192:465, 1980. ³Raz, S.: Modified bladder neck suspension for female stres incontinence. Urology, 17:82, 1981.

^ALeach, G.E.: Bone fixation technique for transvaginal needl suspension. Urology, 31:388, 1988. ⁵Gittes, R.F. and Loughlin, K.R. : No-inciεion pubovagina suspension for stress incontinence. J. Urol. 138:568 1987.

°Winter, CC: Peripubic urethropexy for urinary stres incontinence in women. Urology, 20:408, 1982. ⁷McKiel, C.F., Jr., Graf, E.C and Callahan, D.H. : Marshall Marchetti procedure: modification. J. Urol., 96:737 1966.

⁸Hancock, R. , Brandstetter, L.H. and Hodgins, T.E.: Transpubi suspension of the bladder neck for urinary incontinence J. Urol., 123:667, 1980. 'Richmond, J.C, Donaldson, W.R. , Fu, F. and Harner, CD. Modification of the Bankart reconstruction with a sutur anchor: report of a new technique. Am. J. Sports Med., 19:343, 1991. ¹⁰Pederson, B. , Tesoro, D. , Wertheimer, S.J. and Coraci, M. : Mitek anchor system: a new technique for tenodesis an ligamentous repair of the foot and ankle. J. Foot Surg. ,

30:48, 1991. ¹Spencer, J.R. , O'Conor, V.J. and Schaeffer, A.J. : comparison of endoscopic suspension of the vesical nec with suprapubic vesicourethropexy or treatment of stress urinary incontinence. J. Urol., 137:411, 1987. ²Araki, T. , Takamoto, H. , Hara, T. Jujimoto, H. , Yoshida, M. and Katayama, Y. : The loop loosening procedure for urination difficulties after Stamey suspension of th vesical neck. J. Urol., 144: 1990. Webster, G.D. and Kreder, K.J.: Voiding dysfunctio following cystourethropexy: Its evaluation an management. J. Urol., 144:1990.

Claims

I CLAIM:

1. A drill guide for directing a drill bit at selected site, comprising: a housing; at least two probes on the housing; and a drill guide channel extending through the housin wherein the drill guide channel lies on a plane whi extends in between the two probes.

2. A drill guide as in Claim 1, wherein at least first one of said probes is axially movable from a firs proximal position to a second distal position.

3. A drill guide as in Claim 2, wherein the diεtal ti of the first probe is shielded within the housing when th probe is in the first position, and the distal tip of th first probe is exposed outside of the housing when the prob is in the second position.

4. A drill guide as in Claim 2, wherein at leaεt two o said probes are axially movable between a first proxima position and a second distal position.

5. A drill guide as in Claim 1, further comprising a actuator for moving the first probe between the first an second positions.

6. A drill guide aε in Claim 1, wherein th longitudinal axiε of the drill guide channel is approximatel equidistant from the longitudinal axes of each of the probes

7. A drill guide as in Claim 2, further comprising drill bushing extending through the drill guide channel.

8. A drill guide as in Claim 1, wherein said prob comprises an elongate solid wire.

9. A drill guide aε in Claim 1, wherein εaid prob comprises an elongate hollow tube.

10. A drill guide as in Claim 1, further comprising tw chambers extending axially within said housing, each of sai chambers having an open distal end, and wherein a plunger is located in each of said chambers, each of said plungers bein axially movable from a first retracted position to a second extended position, and wherein one of said probes is located on the distal end of each of said plungers.

11. A drill guide as in Claim 10, further comprising releasable lock for releaεably retaining at leaεt one plung in the retracted position.

12. A drill guide aε in Claim 10, wherein the fir probe and the εecond probe are separated by a distance within the range of from about .05 to about 1.5 cm.

13. A drill guide as in Claim 10, wherein the axis the drill guide channel is in a plane extending between t axis of each of the probes.

14. A drill guide as in Claim 10, further comprising axially extending slot in the wall of the drill guide chann for receiving a suture therethrough.

15. A drill guide as in Claim 10, further comprising textured tissue contacting surface adjacent the distal end the drill guide channel, for reεiεting the migration of tiεε into the drill bore.

16. A method of poεitioning a drill guide over drilling site on a bone, comprising the stepε of: providing a drill guide of the type co priεing houεing, at leaεt two axially extendable probes with the houεing and a drill guide extending through t housing; extending a first probe from the retracted positi to the extended position; advancing the first probe through tissue until contact a bone; extending a second probe from the retracted positi to the extended position until said εecond probe contac bone; and if either one of the probeε doeε not contact t bone, retracting that probe from the extended poεition the retracted poεition, and tranεlating the drill gui along the superior/inferior axiε, and then reextendi that probe from the retracted position to the extend position until it contacts the bone.

17. A method of installing a bone anchor in a bon co prising the steps of: providing a drill guide of the type defined in Cla i; advancing each of said probes through tissue unt each of said probes contacts the bone; advancing a drill bit through the drill gui channel and drilling a hole in the bone; withdrawing the drill bit from the drill gui channel; and thereafter advancing a suture anchor through the drill gui channel and into the bone.

18. A suture passer of the type adapted for releasab retaining a suture, comprising: a handle; an elongate tubular probe guide extending in distal direction from the handle; an elongate pointed probe axially movably dispos within the tubular probe guide to facilitate penetratio of tissue; and a recess on the probe and an opening on the tubula probe guide for receiving a suture, wherein the probe i axially movable with respect to the probe guide betwee a first position in which the annular recess is aligne with the opening for receiving a suture therein, and second position wherein the annular recess is out o alignment with the opening to trap a suture within th recess.

19. A suture passer as in Claim 18, further comprisin a third position so that in a first position the recess i aligned with the opening for receiving a suture and the dista tip of the probe is retracted within the probe guide; in second position the recess is out of alignment with th opening and the distal tip of the probe is retracted; and i a third position the recess is out of alignment with th opening and the diεtal tip of the probe is exposed.

20. A suture passer as in Claim 18, wherein said reces comprises an annular or slotted recess extending radiall inwardly about the periphery of the probe.

21. A suture passer as in Claim 18, further comprisi a spring for biasing the probe in the proximal direction.

22. A suture pasεer aε in Claim 19, further comprisi a control on the handle for selectively positioning the pro in any desired one of the three positionε.

23. A εuture passer as in Claim 18, wherein the dist end of the probe guide iε provided with a blunt atrau atic t which allowε tactile positioning digitally.

24. A suture passer is in Claim 22, further comprisi an axially movable actuator pin extending proximally from t probe.

25. A suture passer as in Claim 24, wherein the contr comprises rotatable cam having a contoured engagement surfa for engaging the actuator pin and holds actuator pin in stable position.

26. A εuture paεser as in Claim 25, wherein t engagement εurface compriεes a ramp which cooperates with t actuator pin and the proximal bias on the probe εo that th distal tip of the probe is normally retracted within th distal end of the probe guide, and distally extended beyon the probe guide only during manual manipulation of th control.

27. A suture passer as in Claim 26, further comprisin an indicium on the control for indicating the axial poεitio of the probe.

28. A suture passer as in Claim 27, wherein the indiciu comprises the rotational position of the cam.