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Give us a shout.
Whatever your requirements please contact us to discuss how our passions can create solutions for you.
t: +44 (0) 20 7940 4910e: firstname.lastname@example.com
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Launch partners include Endemol Beyond, Channel 4 News, ITN, Scripps Networks International, Little Dot, MyMovies, Trinity Mirror, Telegraph Media Group and TalkTalk.Read more
The British Board of Film Classification (BBFC) and mymovies have extended their existing partnership to see the digital agency providing the latest film trailers, posters and artwork for the new BBFC website for children, CBBFC.Read more
The British Board of Film Classification (BBFC) and mymovies have announced an extension to their existing partnership that sees the digital agency providing a comprehensive film content and video technology service for the new BBFC website....Read more
UK cinema chain Picturehouse and digital agency mymovies have announced an exciting new two-way content deal, that sees the leading entertainment supplier become exclusive video content and technology provider for Picturehouses....Read more
Virgin Media and mymovies have extended their multi-platform partnership with the creation of a new app, celebrating the launch of Virgin Media's...Read more
"From the first meeting with mymovies it was clear they offered a level of service far beyond anything we had experienced before. Much time and effort was spent to understand Spencer Ogden's culture and it was a joy to collaborate with such a creative and knowledgeable production team. The video mymovies produced is the driving force behind our very successful internal recruitment campaign and light years ahead of our competitors, I'll look forward to working with them again."
"mymovies consistently go above and beyond in meeting our video needs, delivering fresh, imaginative and engaging content on demand and on time. Working with them is a joy - a more professional and friendly team you could not hope to meet."
"DCM have always had an excellent working relationship with mymovies. The level of talent access is second to none and their production levels are to the highest standards. We find the team professional and easy to work with and we are looking forward to continuing our partnership in 2012/2013."
"Working with mymovies is a no-brainer. We get our most powerful marketing assets – our trailers and AV content – rapidly distributed to exactly when and where people want to watch them. Their highly collaborative, enthusiastic approach ensures mymovies are a valuable promotional partner across our releases, big and small."
Whatever your requirements please contact us to discuss how our passions can create solutions for you.
t: +44 (0) 20 7940 4910e: email@example.com
40 Oxford Drive


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Wind: 0 mph
On Saturday, November 21, the HUMS seventh- and eighth-grade spelling team competed at Northfield High School for the 2009-10 Vermont Principal's Association Regional Spelling Competition state championship title.
Competing schools included Barre Town, Manchester Middle School and Edmunds Middle School -- each winners of their regional competitions held a few weeks prior to the event. After 12 grueling rounds, Harwood emerged as the winner and the new Vermont State Spelling Team Champions. Coached by Judi Gross of Waitsfield, the team consists of eighth-graders Sophie Rayfield, Sarah Hoyne, Nathanial Kazlow and Morgan Becker, as well as seventh-graders Ray Parker and Katy Rosen. English teacher Jacki McCarty is the Harwood faculty advisor for the team and Coach Gross' assistant.
The team faced some challenging words like "dichotomy," "paraphernalia," "excision" and "ostentatious," yet each member kept their composure, spelling the vast majority of their given words correctly. A sea of black and gold filled an entire section of the Northfield auditorium and the cheering crowd slightly resembled that of a sporting event as scores were announced between rounds and Harwood consistently maintained the lead. The Harwood team finished with a score of 134, virtually blowing away the competition.
On Monday morning, the champions were honored at an HUMS assembly, where the plaque from the regional competition and the trophy from the state competition were presented and displayed. They are available for viewing in the HUMS trophy case, located by the middle school office.
Unfortunately there is no national team competition for spelling as of yet, but the Harwood team will hold the Vermont State Regional Spelling Team Championship title for the academic year 2009-10.

subset: commoncrawl


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Thoracic outlet syndrome
* Not a rare disease
Other Names for this Disease
- Thoracic outlet compression syndrome
See Disclaimer regarding information on this site. Some links on this page may take you to organizations outside of the National Institutes of Health.
fibromyalgia, multiple sclerosis, complex regional pain syndrome, and tumors of the syrinx or spinal cord. Symptoms of this condition vary depending on the type. The different types include neurogenic, venous, and arterial thoracic outlet syndrome. There are many different causes of TOC. Symptoms usually occur between 20 and 50 years of age.[1]Thoracic outlet syndrome (TOS) describes a group of conditions that are characterized by compression of the nerves, arteries, and veins in the lower neck and upper chest area. This can result in pain in the arms, shoulders, and neck. Currently, there is considerable disagreement about its diagnosis and treatment. A number of disorders have symptoms similar to those of TOS, including rotator cuff injuries,
Last updated: 1/26/2012
- NINDS Thoracic Outlet Syndrome Information Page. National Institute of Neurological Disorders and Stroke (NINDS). December 2011; http://www.ninds.nih.gov/disorders/thoracic/thoracic.htm. Accessed 1/26/2012.
GARD Video TutorialsLearn how to find information on treatment, research, specialists, and more.
Your Questions AnsweredView questions about this condition answered by GARD Information Specialists. You can also submit a new question.
On this page
Basic Information
- MedlinePlus was designed by the National Library of Medicine to help you research your health questions, and it provides more information about this topic.
- The Merck Manuals Online Medical Library provides information on this condition for patients and caregivers.
- The National Institute of Neurological Disorders and Stroke (NINDS) collects and disseminates research information related to neurological disorders. Click on the link to view information on this topic.
- The National Organization for Rare Disorders (NORD) is a federation of more than 130 nonprofit voluntary health organizations serving people with rare disorders. Click on the link to view information on this topic.
In Depth Information
- Medscape Reference provides information on this topic. You may need to register to view the medical textbook, but registration is free.
- Orphanet is a European reference portal for information on rare diseases and orphan drugs. Access to this database is free of charge.
- PubMed is a searchable database of medical literature and lists journal articles that discuss Thoracic outlet syndrome. Click on the link to view a sample search on this topic.
Other Names for this Disease
- Thoracic outlet compression syndrome
See Disclaimer regarding information on this site. Some links on this page may take you to organizations outside of the National Institutes of Health.


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Kane injury may benefit Boykins
HUNTINGTON -- DeVince Boykins hardly played at all for the Marshall University men's basketball team before last weekend.
Now, he might be playing a lot more.
Dre Kane walked into practice Monday with a cast on his right hand and will be out of action indefinitely because of an unspecified injury. Kane, a 6-foot-4 junior, is Marshall's leading scorer (15.0 per game), is ranked third in the nation in assists (8.5) and plays more minutes (38.2 a game) than anyone in Conference USA.
No timetable for the all-conference guard's return was given.
Boykins, a 6-4 redshirt freshman, gained some valuable experience last weekend, playing for 11 important minutes when Marshall (6-4) defeated Coppin State (1-8), 69-63, in Cam Henderson Center.
His minutes could increase Saturday when Marshall plays No. 11 Cincinnati (9-0) at 2 p.m. in the Charleston Civic Center.
Marshall redshirted Boykins in 2011-12 and he missed the first seven games of this season recovering from a right knee injury. After months of rehabilitation, he joined the team for practice Nov. 14. Seven games later he was on the court for two minutes against UNC Wilmington, then played for one minute against West Virginia.
Then came last weekend when Boykins and true freshman guard Tamron Manning played for 11 and 12 minutes, respectively.
"It was rough being hurt and knowing I was eligible to play this year," Boykins said. "The biggest thing was making sure I was in game shape."
Boykins had three points, three rebounds, one assist, one assist and one turnover in the longest stint of his career.
His contributions were most noticeable when Marshall went with some trapping, full-court pressure defense that derailed Coppin State's upset bid.
Marshall assistant coach Mark Cline recruited Boykins out of East Rutherford High School in North Carolina as an all-around performer who averaged 17 points, 13 rebounds and four assists as a senior for the 2011 Class 2A state champions.
His approach hasn't changed.
"I'm looking to score when I go in, but I'm mostly looking to do whatever needed to win," Boykins said.
Marshall fall semester classes end Tuesday, Wednesday is a study day and final exams are Thursday through Tuesday, Dec. 18.
Boykins has four finals to take in addition to practices and a game. Most of his studying gets done during evening sessions with tutors, he said.
"Other than that, it's pretty much all basketball," he said.
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Monday, January 14, 2013
Top, Faye Campbell pours tea for Susan Chellis at the Flowertown Garden Club Tea Monday at the home of Mrs. Berlin G. Marlena Myers. The club was celebrating the season at its annual Christmas Tea Party.
Bottom, Marlena Myers arranged the rose centerpiece for the tea.
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4-3-1 in Sig Bets.
"If you fuck with me I'm going to fuck with you" Kevin "The Monster" Randleman
Well, wherever he goes should be a def. win. He hasn't suprised me at all recently.
I respect him for what he has done, but man, I don't see him as a real threat in the division.
As long as I see a good fight.
I really don't like a gauranteed win in MMA...not even if Anderson Silva made it....too many lucky shots on the jaw have created many flukes over the years.
Goulet guaranteeing a win isn't exactly reliable.
Maybe he got a new chin for Christmas?
Goulet shouldnt even be fighting in the UFC. His fights are highlight reels in the making.....highlight reels for his opponents.
McCrory is just a better all around fighter then Goulet is, and McCrory doesn't have a paper mache chin like Goulet does.
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CHARLESTON, W.Va. (AP) — West Virginia Gov. Earl Ray Tomblin is proposing changing state law to make it clear that police officers can test drivers for drugs just as they test them for alcohol.
The legislation would explicitly permit officers to test for drugs. The current law outlines only that authorities have the right to test for alcohol. While law enforcement authorities welcome the proposal, they say that proving a driver is impaired by drugs remains difficult.
When people are arrested on suspicion of driving under the influence, they usually are taken to a station or a precinct for further testing. If they have been drinking and fail a chemical breath test, the case is usually pretty straightforward. But if they are on drugs and pass a breath test — which tests only for alcohol — it becomes difficult to prove that they are impaired.
"It's not that the police can't do anything," said Bob Tipton, the state's director of highway safety. "They just don't have tools in their tool belt to deal with drugged driving."
According to federal figures, one in 10 adults in West Virginia has a drug problem, and that state has the nation's highest rate of drug overdoses.
About 1,000 drivers were arrested statewide on suspicion of drugged driving last year — accounting for about 10 percent of all DUI arrests, Tipton said.
If drivers refuse to take a test that checks the level of alcohol in their system, it's the same as failing a test when introduced as evidence in court. Tomblin's legislation, introduced Friday, applies the same standard to drug tests.
It's more difficult to determine whether there are drugs in someone's system than alcohol. Drug testing usually requires more intrusive procedures than breath tests, such as blood or urine tests.
"There's no test that is not somewhat invasive," said Joe Barki, the Brooke County prosecutor and a former state trooper. "For alcohol, you can do a breath test. Drugs don't show up the same way in a breath test. You have to get either a blood or urine test and you can't force somebody to give you a blood sample, you'd have to get a search warrant in order to get that type of information, which takes time, which decreases the likelihood that something will show up."
In concert with the new legislation, Tipton said the state police will begin specially training certain officers to serve as experts in drug recognition. These officers would administer examinations, similar to what a nurse might do, to help establish that a driver is impaired. The officer would check things like pulse rate, blood pressure and pupil dilation. If the officer determines that the driver is impaired, they could proceed to further blood and urine testing.
"It's not intrusive like, 'Go into a room, put on a hospital gown,'" Tipton said. "He's doing more things to test your reflexes and reactions."
Tipton said that about 20 officers probably would be trained to do the examinations in the first year and a half after the program is introduced.
Sgt. Michael Baylous, a spokesman for the state police, recalls from his time in the field that it was often difficult to prove impairment and said he welcomed any changes that would make drugged driving easier to prove.
"I remember one guy who had been huffing gasoline, and he was obviously impaired but when you have him blow into an Intoximeter it doesn't show anything," Baylous said.
Tomblin first announced the legislation at his State of the State address on Wednesday, saying he wanted to make it clear that officers had more power so that when "drivers who are under the influence of drugs are pulled over, they can be properly identified, tested, and removed from our roadways."
At Tomblin's request, the legislation has been introduced in both the Senate and the House of Delegates and has been assigned to committees.


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Our goal is to help you create a vital and ongoing conversation at your company, to expand thinking, and influence strategies.
As your partner in navigating an increasingly complex landscape, we recognize that the best ideas come from others who are wrestling with the same challenges. That is why we sought input from our members to identify these key business issues you should be thinking about now.
- What does the coming labor shortage from retiring baby boomers mean for your company?
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- What is the global economic outlook for 2015
- How should you measure social impact?
- How are CEOs addressing the issues they consider most critical?
- How can employers close the gap between global talent supply and demand?
- What is the DNA of a high-performing organization?
- China: Which regional developments have global implications for corporate sustainability practices?
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- What does the era of big data mean for human capital analytics?
- Which geographies and industries are winning in productivity and competitiveness, and why?
- How are top companies driving revenue growth with sustainable products and services?


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Is this the quickest turn around for a fight that Silva has done?
Normally he's off for 9 months before another fight.
Is this the quickest turn around for a fight that Silva has done?
Normally he's off for 9 months before another fight.
Favorite Fighter: JIM MILLER.
Scariest Dude on the Planet: TYRONE SPONG.
Other Favorites: Anderson Silva, Gegard Mousasi, Joe Lauzon, Khabib Nurmagomedov, Conor McGregor, Paul Daley, Ross Pearson, Donald Cerrone, Renan Barao, Glover Texiera, & Alistair Overeem.
"He doesn't write his own material. Some homo in Queens living in his mother's basement in his underwear is writing Chael's material for him." - DON FRYE.
It is kind of weird that the title is gonna be defended in a timely manner. I wonder what is causing that to happen?
Big Hairy American Winning Machine
My Favorite Fighters
1)Gray Maynard 2)Dan Henderson 3)Minotauro Nogueira 4)Wanderlei Silva 5)Roy Nelson 6)Tim Boetsch 7)Mark Hunt 8)Shogun Rua 9)Lyoto Machida 10) Connor McGregor
Sure is mysterious.It is kind of weird that the title is gonna be defended in a timely manner. I wonder what is causing that to happen?
I'm glad that this fight is happening and so quickly. Either Silva wins and we'll get a trilogy for the belt which hasn't really happened at middleweight, or Weidman pulls an Edgar and solidifies his claim.
I expect Silva to be the aggressor this time around which he hasn't really done too much of his UFC career. Even his destructions of Frankin and Leben involved keying off of his opponents striking attempts. I do wonder if Weidman will play that game.
Last edited by Goremire; 07-14-2013 at 02:40 PM. Reason: Quoted the wrong post somehow
All I gotta say is...what will Anderson's fans say when he's not showboating and gets ktfo?!
It's shocking to hear so many people giving CW no chance in the rematch. A large number of fighters believed he would win the first fight and not only did he win but he finished Silva. I'm not saying it was this thread specifically, just many threads since the fight was over and rematch speculation began.
I'm betting all those fighters still believe in CW. Silva getting ktfo while employing a strategy he's used often has many fans believing he'll just be less cocky and throttle CW. Haven't read any posts thinking Silva will grind out a hard fought victory. There seems to be delusion on a grand scale. CW proved himself in that fight. I'd say it's a pick'em.
I think a focus and serious Silva is a serious problem for any fighter. Wiedman should not engage in much stand up in the rematch and try to make it a grappling match on the ground. Even the clinch plays to anderson's strengths. The worse mistake wiedman can make is thinking he can strike with this version of Silva. I think it would be a big mistake. Now if Silvas self confidence and chin have gone south then maybe he can catch him again. But if Silva is the same guy who destroyed Franklin come december then weidman will most likely lose a stand up war. He need to jon fitch this shit and hold on to his title. I think if Silva wins a third fight will look a lot like the second.
Silva is not known for evoking that kind of strategy against wrestlers let alone dangerous strikers. He didn't do that against Dan Hendreson, Chael in either fight, Okami, Vitor, or Carlos Newton.
Anderson Silva:
Best Fighter on the planet.
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Eight Kent State University Student Choreographers Unveil Exciting New DancesPosted Feb. 12, 2013
Kent State University School of Theatre and Dance will continue its 2012-13 production season with the BFA Senior Dance Concert/Student Dance Festival, Cre-8-tivity. Performances will take place on Friday and Saturday, March 15-16 at 8 pm and Sunday, March 17th at 2 pm in the Louis O. Erdmann and William H. Zucchero Theatre (E.Z. Theatre) located in the Music and Speech Center. Tickets are $16 Adults, $14 KSU Faculty/Staff, $12 Seniors, and $8 Students with valid I.D./under 18 at 330.672.2787 or online at www.dance.kent.edu. Tickets for Kent campus KSU Students are free with a valid student I.D. through the box office. The box office is open weekdays from noon to 5 p.m. and one hour prior to each performance. Visa, MasterCard, checks and cash are accepted. Free parking is available and the theatre is fully accessible.
Cre-8-tivity showcases new choreography by junior and senior dance performance and dance education majors and minors at Kent State University. In addition, dance performance major and B.F.A. candidate Lauren Kengla-Graber will perform a solo created for her by Assistant Professor Erin LaSala. These premiere performances will offer audience members the opportunity to view original works that showcase the versatility and creativity of the choreographers.
The concert will present a dynamic array of works about overcoming adversity, recognizing important relationships, finding stillness within chaos, and looking for control. Thirty-six dancers will perform in nine different pieces of modern and contemporary choreography.
The Unknown, choreographed by Lauren Kengla-Graber, B.F.A. candidate and student director, contrasts two couples as their relationships transpire and change as they grow. One relationship will evolve as the couple begins their lives together after college, while the other will experience the dark emotions that come with a break up. The dance reflects the contrasting emotions present in this life-changing experience.
Color Me, choreographed by SDF Student Director Emily Perrott, encourages the dancers, as well as the audience, to identify the things or people in their lives who keep them going through all of life's continuous battles. Each dancer receives their sense of strength and life through the piece's soloist, who is there to lift them, encourage them and give them their color. Every dancer gets their push from the soloist, just as the color white reflects all colors, giving color to the universe.
In Game Changer, choreographer Stacey Ubelhart illustrates the meaning of silence in loud chaos. Eight dancers fill the space with large, quick, fragmented movements, searching for a moment of stillness in an abundance of motion.
Choreographer Shayna Fischer was inspired by her experience as an intern at a dance therapy workshop. Under the Sun [a time to dance] strives to show the audience that dance can bring light to the darkest of places and that everyone has dance in their heart.
The BFA Senior Dance Concert/Student Dance Festival offers audiences a diverse selection of modern and contemporary dance. Audience members are sure to find something that inspires, entertains and moves them.
For more information contact:
Effie Tsengas, email@example.com, 330-672-8398
Joan Meggitt, 330-672-0130


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(November 14, 2012) -- A number of Central Texas athletes inked National Letters of Intent on Wednesday. The following is a list of students from the area, along with the college their signed with today.
Jimmy Brooks (Midway) - Ottawa University (Kansas)/tennis
Lindsey Cargill (Robinson) - Baylor/softball
Ketara Chapel (Temple) - Mississippi State/basketball
Brianne Coffman (Jarrell) - Oklahoma State/basketball
Courtney Colunga (Midway) - Arkansas Tech/softball
Morgan Cooper (Jarrell) - Texas/baseball
DeChriston McKinney (La Vega/MCC) - Southern/basketball
Jason Prevatt (China Spring) - University of Arkansas-Little Rock/baseball
Kramer Robertson (Midway) - LSU/baseball
Cory Scott (Copperas Cove) - Stephen F. Austin/basketball
Zach Sullivan (Robinson) - Texas State/baseball
Case Smith (Midway) - Baylor/baseball
Sarah Beth Toben (Reicher) - Baylor/softball
Jennifer Vrazel (Clifton) - UT-Tyler/softball


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An implantable article and method of use are disclosed to treat urological disorders. The biocompatible device includes a sling assembly configured to be minimally invasive and provide sufficient support to the target site. In addition, the configuration of the sling assembly also allows the position of the sling to be permanently changed during and/or after implantation.
1. A sling for treating incontinence in a patient comprising:
an elongate body comprising a mesh and having a pair of end portions
a support portion located between the end portions for placement in a therapeutically effective position relative to a physiological environment intended to be supported, and
a tension adjustment mechanism operably connected to the support portion and the pair of end portions, wherein the tension adjustment mechanism is configured to transfer force from the pair of ends to the support portion without adversely affecting the therapeutic effect of the sling.
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28. A sling for treating incontinence in a patient comprising:
an elongate mesh member having first and second major surfaces, first and second end portions, and a central support portion located between the end portions; and
a tension adjustment member operably connected to the central support portion and the end portions and configured to permit manual adjustment of the central support portion.
29. A sling for treating incontinence in a patient comprising:
an elongate mesh member having first and second major surfaces, end portions, and a support portion located between the pair of end portions; and
a filament operably connected along the length of the mesh to permit manual adjustment of the tension in the support portion.
30. The sling of
The present application claims priority of U.S application Ser. No. 10/616,925, filed Jul. 11, 2003; U.S. application Ser. No. 09/917,562, filed Jul. 21, 2001; U.S. Provisional Application Ser. No. 60/263,472, filed Jan. 23, 2001; and U.S. Provisional Application Ser. No. 60/269,829 filed Feb. 20, 2001; U.S. Provisional Application Ser. No. 60/281,350 filed Apr. 4, 2001; and U.S. Provisional Application Ser. No. 60/295,068 filed Jun. 1, 2001; and U.S. Provisional Application Ser. No. 60/306,915 filed Jul. 20, 2001; each of whose contents are fully incorporated herein by reference
Over 13 million American men and women of all ages suffer from urinary incontinence. The social implications for an incontinent patient include loss of self-esteem, embarrassment, restriction of social and sexual activities, isolation, depression and, in some instances, dependence on caregivers. Incontinence is the most common reason for institutionalization of the elderly.
The urinary system consists of the kidneys, ureters, bladder and urethra. The bladder is a hollow, muscular, balloon-shaped sac that serves as a storage container for urine. The bladder is located behind the pubic bone and is protected by the pelvis. Ligaments hold the bladder in place and connect it to the pelvis and other tissue.
Incontinence may occur when the muscles of the urinary system malfunction or are weakened. Other factors, such as trauma to the urethral area, neurological injury, hormonal imbalance or medication side-effects, may also cause or contribute to incontinence. There are five basic types of incontinence: stress incontinence, urge incontinence, mixed incontinence, overflow incontinence and functional incontinence. Stress urinary incontinence (SUI) is the involuntary loss of urine that occurs due to sudden increases in intra-abdominal pressure resulting from activities such as coughing, sneezing, lifting, straining, exercise and, in severe cases, even simply changing body position. Urge incontinence, also termed "hyperactive bladder" "frequency/urgency syndrome" or "irritable bladder," occurs when an individual experiences the immediate need to urinate and loses bladder control before reaching the toilet. Mixed incontinence is the most common form of urinary incontinence. Inappropriate bladder contractions and weakened sphincter muscles usually cause this type of incontinence. Mixed incontinence is a combination of the symptoms for both stress and urge incontinence. Overflow incontinence is a constant dripping or leakage of urine caused by an overfilled bladder. Functional incontinence results when a person has difficulty moving from one place to another. It is generally caused by factors outside the lower urinary tract, such as deficits in physical function and/or cognitive function.
A variety of treatment options are currently available to treat incontinence. Some of these treatment options include external devices, behavioral therapy (such as biofeedback, electrical stimulation, or Kegal exercises), injectable materials, prosthetic devices and/or surgery. Depending on age, medical condition, and personal preference, surgical procedures can be used to completely restore continence. One type of procedure, found to be an especially successful treatment option for SUI in both men and women, is a sling procedure.
A sling procedure is a surgical method involving the placement of a sling to stabilize or support the bladder neck or urethra. There are a variety of different sling procedures. Slings used for pubovaginal procedures differ in the type of material and anchoring methods. In some cases, the sling is placed under the bladder neck and secured via suspension sutures to a point of attachment (e.g. bone) through an abdominal and/or vaginal incision. Examples of sling procedures are disclosed in U.S. Pat. Nos. 5,112,344; 5,611,515; 5,842,478; 5,860,425; 5,899,909; 6,039,686, 6,042,534 and 6,110,101.
Although serious complications associated with sling procedures are infrequent, they do occur. Complications include urethral obstruction, development of de novo urge incontinence, hemorrhage, prolonged urinary retention, infection, and damage to surrounding tissue and sling erosion.
The TVT Tension-free Vaginal Tape procedure utilizes a Prolene™ nonabsorbable, polypropylene mesh. The mesh is a substantially flat, rectangular woven article. The mesh includes a plurality of holes that are sized to allow tissue ingrowth to help avoid infection. A plastic sheath surrounds the mesh and is used to insert the mesh. During the sling procedure, incisions are made in the abdominal (i.e. suprapubic) area and in the vaginal wall. Two curved, needle-like elements are each connected to an end of the vaginal sling mesh. A sling-free end of one of the needle-like elements is initially pushed through the vaginal incision and into the paraurethral space. Using a handle attached to the needle, the needle is angulated laterally (for example, to the right) to perforate the endopelvic fascia, guided through the retropubic space and passed through the abdominal incision. The handle is disconnected and the needle is then withdrawn through the abdominal wall, thereby threading a portion of the sling through the tissue of the patient. The handle is then connected to the other needle and the technique is repeated on the contralateral side, so that the mesh is looped beneath the bladder neck or urethra. The sling is positioned to provide appropriate support to the bladder neck or urethra. Typically a Mayo scissors or blunt clamp is placed between the urethra and the sling to ensure ample looseness of the sling. When the TVT mesh is properly positioned, the cross section of the mesh should be substantially flat. In this condition, the edges of the mesh do not significantly damage tissue. The sling ends are then cut at the abdominal wall, the sheath is removed and all incisions are closed.
Complications associated with the TVT procedure and other known sling procedures include injury to blood vessels of the pelvic sidewall and abdominal wall, hematomas, urinary retention, and bladder and bowel injury due to passage of large needles. Further, a separate cystoscopy procedure is usually required in order to confirm bladder integrity or recognize a bladder perforation after each insertion of the needle-like element. One serious disadvantage of the TVT procedure, particularly for surgeons unfamiliar with the surgical method, is the lack of information concerning the precise location of the needle tip relative to adjacent pelvic anatomy. If the needle tip is allowed to accidentally pass across the surface of any blood vessel, lymphatic duct, nerve, nerve bundle or organ, serious complications can arise. These shortcomings, attempts to address these shortcomings and other problems associated with the TVT procedure are disclosed in PCT publication nos. PCT WO 00/74613 and PCT WO 00/74594.
Additional problems are associated with the TVT and other sling procedures. Due to the tough fibrous nature of fascia and muscle tissues, forceps or similar instruments are needed to withdraw the needles through the abdominal wall. However, the smooth surface of the needles, which facilitates insertion through the tissues, prevents secure attachment of the forceps onto the needles, causing slippage or detachment of the forceps during the withdrawal procedure. Removal and reuse of the handle of the TVT product is also a cumbersome, time consuming process, requiring the surgeon to manually rotate the handle until the handle is unscrewed from the needle. Reusing the handle presents a contamination risk, particularly if the handle and screw threads are not properly cleaned and sterilized after use on one side of the patient.
The problems associated with improper placement of the TVT mesh are particularly troublesome. If the mesh is too loosely associated with its intended physiological environment, the mesh may be ineffective in supporting the urethra and treating incontinence. Several complications can arise from a mesh that is too tightly placed including retention, sling erosion and other damage to surrounding tissue such as the urethra and vagina.
Once the sheath is removed from the mesh of the TVT product, friction between the mesh and tissue keeps the mesh in position and it becomes very difficult to subsequently adjust the position of the mesh relative to tissue. Because the tension of the sling is an important part of the sling procedure, surgeons will nonetheless attempt to adjust the tension of a sling even after the sheath is removed. TVT mesh is elongate, substantially flat and elastic. When pulled on longitudinally, the TVT mesh deflects elastically. If insufficient adjustment force is applied, the sling will simply exhibit a memory property and return to its original, unacceptable position. As a result, surgeons are tempted to use a great deal of force in order to loosen a sling that is perceived to be too tightly associated with its intended physiological environment. If excessive force is applied, the mesh will plastically deform and the cross section of the mesh will become arcuate. Under excessive deformation, the holes of the TVT mesh become significantly smaller, and risk deterring tissue ingrowth. Without tissue ingrowth, the potential for infection is believed to increase. In the excessively deformed state, the edges of the mesh tend to curl up and present a relatively sharp, frayed surface. In this curled or deformed state, the edges of the TVT mesh present sharp surfaces that can readily abrade or otherwise damage adjacent tissue such as the urethra, bladder or vagina.
Attempts to reposition the TVT sling is likely to fail in two modes. First, the surgeon may apply insufficient elongation force to the mesh (e.g. with forceps), resulting in temporary elastic deformation of the mesh followed by a return by the mesh to its original, unacceptable position after the force is removed. Second, the surgeon may apply excessive force to the mesh resulting in the curling deformation described above with the attendant risk of tissue damage. Additionally, an axially deformed sling necks down (i.e. decreases in width) and provides less cross sectional area to support the urethra. Thus, even if the edges do not curl, excessive deformation of the TVT sling risks adversely affecting sling performance. In the case of an improperly positioned sling, some surgeons will cut the TVT mesh and attempt to remove the mesh as reported in the literature.
There is a desire to obtain a minimally invasive yet highly effective device that can be used with minimal to no side effects. Such a device should reduce the complexity of a sling procedure, be biocompatible, adjustable, and non-toxic. The treatment methods using the device should reduce pain, operative risks, infections and post operative hospital stays. Further, the method of treatment should also improve the quality of life for patients.
The present invention comprises an implantable article suitable for treating urological disorders in patients. In one aspect, the present invention comprises a sling for treating urinary incontinence in a patient. The sling has first and second major surfaces, a pair of end portions, and a support portion for placement in a therapeutically effective position relative to a physiological environment intended to be supported. The support portion preferably has an axially elongate mesh, and a pair of ends. The present invention includes repositioning means, associated with the sling, for transferring either sling tightening or sling loosening forces along the sling to afford effective, permanent repositioning of the sling without adversely affecting the therapeutic effect of the sling. The repositioning means transfers sling tightening or sling loosening forces along the sling while avoiding permanent deformation of the sling. Preferably, the repositioning means is constructed to afford transfer at least some of a repositioning force applied to the sling to an end of the support portion.
Preferably sling the sling is sized and shaped for treating female incontinence with a surgical procedure that includes a vaginal incision, and the repositioning means is free of any structure that extends through the vaginal incision. Preferably, the sling includes a removable sheath and the repositioning means affords permanent tightening of the sling when the sling is partially implanted and the sheath is removed, by pulling on the sling and repositioning means at a suprapubic location.
The sling is preferably initially placed via an access incision such as a vaginal incision, and the repositioning means affords post operative loosening of the sling after the vaginal incision is closed without any subsequent vaginal incision and without any structure extending through the original vaginal incision.
The repositioning means preferably comprises at least one, unitary, non-separated filament threaded along the mesh and is attached to the mesh at the ends of the support portion. Alternatively, the repositioning means may comprise at least one filament integrally woven in the mesh, or it can comprise a plurality of filaments that are each threaded along substantially the entire length of the mesh. The filament may optionally extend from an edge of the support portion to another edge of the support portion.
The mesh may be woven, braided or knitted or other structures. It may be constructed from synthetic or non-synthetic materials, bioresorbable, permanent or non-permanent materials. In a preferred embodiment, when the mesh of the support portion is woven, the repositioning means comprises a portion of the support portion that is more tightly woven than another portion of the support portion.
Preferably, instead of a separate elongate member, the repositioning means may comprises a portion of the mesh that is more tightly woven than another portion of the sling.
In a preferred embodiment, the repositioning member is woven in a weave pattern along the mesh so that the weave pattern affords an indication of proper sling orientation after implantation. For example, a majority of the repositioning member may protrude above the second major side of the support portion of the sling.
Optionally, a sheath may be included in the assembly. The sheath can include sheath indicia means for assisting the surgeon is properly orienting the sling relative to the urethra or separation means selected from the group consisting of tear scores, perforations or holes. Preferably, the sheath comprises first and second sections that overlap adjacent the support portion of the sling.
In a preferred embodiment, the repositioning means comprises a one piece, elongate member threaded in the mesh and extending axially along substantially the entire length of the sling, and wherein the one piece, elongate member is attached to the sling at the ends of the support portion. Optionally, the sling may include a means for locating and detaching the one piece, elongate member, such as loops in the elongate, one piece member at the ends of the support portion.
Other optional features may be provided for article of the present invention. For example, the repositioning means may include a handle situated in the support portion.
In another aspect, the present invention comprises a method of treating urinary incontinence in a patient comprising the steps of establishing a pathway in tissue on both sides of a patient's tissue intended to be supported, the pathways extending between an abdominal wall of the patient and a pubic space of the patient; atraumatically dilating the pathways after the establishment of the pathways; introducing a sling material into the pathways while the pathways are being atraumatically dilated; positioning the sling material so that in the pathways in a therapeutic relationship relative to the tissue of the patient that is intended to be supported (e.g. the urethra), and so that the sling extends upward toward the abdominal wall; and repositioning the sling to support the urethra of the patient.
The method affords both tightening and loosening of the sling during the surgical procedure. Preferably, the step of establishing a pathway comprises making an original vaginal incision and the step of repositioning the sling occurs after the vaginal incision is closed and is accomplished without any structure passing through the original vaginal incision. The step of repositioning the sling may occur post or perioperatively.
Other features and advantages of the present invention will be seen as the following description of particular embodiments progresses in conjunction with the drawings, in which:
The following description is meant to be illustrative only and not limiting. Other embodiments of this invention will be apparent to those of ordinary skill in the art in view of this description.
Referring to
The sling assembly 46 preferably includes an implantable member (e.g. a hammock, sling or strip) 42 within a protective sheath 44. The sheath 44 is used during insertion of the strip 42. After the sling 42 is implanted, the sheath 44 is removed and discarded.
Each of the two ends 48, 50 of the elongate sling assembly 46 attaches to a first end 52 of a dilator 54 or needle-sling connector. The dilator 54 dilates a needle track for ease of sling introduction and positioning within the patient. A second end 56 of each dilator 54 is sized and shaped to quickly and securely connect to a first end 58 of a slim, arc-shaped needle 60. An adjustable handle 64 is preferably removably and repositionably attached to a second end 62 of the needle 60. Each end 58, 62 of the needle 60 is preferably keyed to allow for convenient, secure attachment of the needle 60 relative to the handle 64 and dilator 54. In a preferred embodiment, the key feature prevents rotation of the dilator 54 relative to the needle 60. Alternatively, the handle 64 may be rigidly affixed to the needle 60.
Referring to
The sling 42 is preferably at least substantially surrounded by the protective sheath 44, as shown in
Preferably, the overall dimensions of the sling assembly 46, including individual sheath 44, sling 42 and tension control member 66, are sufficient to extend from an abdominal incision, to an undersurface of the urethra and back to another abdominal incision with additional size to account for the imprecision associated with the range of human anatomy sizes. In a preferred embodiment, the sheath length L of the device 40 of the present invention is approximately within the range of 52.0 cm to 58.5 cm (20.5 inches to 23.0 inches), sheath width W is approximately within the range of 1.0 cm to 1.63 cm (0.482 inch to 0.642 inch) and sheath material thickness is approximately within the range of 0.127 mm to 0.203 mm (0.005 inch to 0.008 inch), respectively. The associated sling 42 has a length X, width Y and thickness approximately within the range of 49 cm to 51 cm (19.3 inches to 20.1 inches), 1.0 cm to 1.2 cm (0.394 inch to 0.472 inch) and 0.508 mm to 0.711 mm (0.020 inch to 0.028 inch), respectively. In addition, the length of the tension control element 66 should be approximately equivalent to or slightly longer than the length of the sling 42 to tighten or loosen the sling 42 after it is placed in the body. Alternative lengths, widths and thicknesses can also be used.
As used herein, the term "sling" is used generally to include a wide variety of shapes and sizes, materials and treatments. While the sling 42 is preferably rectangular for treating SUI in females, other shapes are also contemplated. Depending on the treatment addressed (e.g. to provide hammock support for the bladder or bladder neck, or to address a rectocele, enterocele or prolapse) the sling may be any of a wide variety of shapes. As an example, the sling may be of the general shape of the slings described and shown in Moir et al., The Gauze-Hammock Operation, Journal of Obstetrics and Gynaecology of the British Commonwealth, Volume 75, No. 1, Pps. 1-9 (1968).
In one embodiment, the sling 42 is made of a mesh material. The mesh material comprises one or more woven or inter-linked filaments or fibers that form multiple fiber junctions throughout the mesh. The fiber junctions may be formed via weaving, bonding, ultrasonic welding or other junction forming techniques, including combinations thereof. In addition, the size of the resultant openings or pores of the mesh should be sufficient to allow tissue in-growth and fixation within surrounding tissue. As an example, not intended to be limiting, the holes may comprise polygonal shaped holes with diagonals of 0.132 inches and 0.076 inches. The quantity and type of fiber junctions, fiber weave, pattern, and material type influence various sling properties or characteristics. Non-mesh sling configurations are also included within the scope of the invention. As another example, not intended to be limiting, the mesh may be woven polypropylene monofilament, knitted with a warp tricot. The stitch count may be 27.5 courses/inch (+ or −2 courses ) and 13 wales/inch (+ or −2 wales). The thickness of this example is 0.024 inches.
In a preferred embodiment, the mesh material of the sling 42 comprises a flexible, polypropylene monofilament that resists weakening or degradation when implanted within a patient. One such material is Marlex™ material. Other mesh and non-mesh materials including, but not limited to, synthetic biomaterials, allografts, homografts, heterografts, autologous tissues, materials disclosed in U.S. Provisional Applications Ser. No. 60/263,472, Ser. No. 60/281,350 and Ser. No. 60/295,068, whose contents are fully incorporated herein by reference, synthetic materials (such as metallics, polymerics, and plastics) and any combination of such materials may also be used with the device of the present invention. Specific examples of synthetic sling materials include, but are not limited to polypropylene, polyethylene, nylon, PLLA and PGA. Preferably, the sling material should cause minimal to no reaction with body tissues and fluids and indefinitely retain its particular material characteristics/properties. Further, portions or all of the sling 42 may be configured or fabricated from a material to either promote or prevent tissue in-growth, or are resorbable to accomplish the desired purpose.
In another embodiment of the invention, the sling 42, sling assembly 46 or portions thereof, may have one or more substances associated therewith through a process such coating. Examples of appropriate substances include, without limitation, drugs, hormones, antibiotics, antimicrobial substances, dyes, silicone elastomers, polyurethanes, radiopaque filaments or substances, anti-bacterial substances, chemicals or agents, including any combinations thereof. The substances may be used to enhance treatment effects, reduce potential sling rejection by the body, enhance visualization, indicate proper sling orientation, resist infection or other effects. For example, a dye may be coated on one surface of the sling 42. The dye provides the practitioner/surgeon with a visual indicator to aid in properly orienting the sling 42 at the target site within the patient and to avoid undesirable twists along the length of the sling 42. As another example, the sling may be coated by the process described in U.S. Pat. Nos. 5,624,704; 5,756,145; 5,853,745; 5,902,283 and 6,162,487 (the entire contents of which are hereby incorporated by reference).
The sling 42 of the present invention need not have additional sutures or other anchoring devices. Upon implantation, a portion of the sling 42 is passed and/or woven through various layers of abdominal/pelvic tissue. The frictional forces created between the sling 42 and patient tissue prevents movement and loss of tension once the sling 42 is properly located at the target site within the lower abdominal area of the patient. As a result, the sling 42 remains securely in place, even when subjected to various increased abdominal pressures.
The sling 42 is designed to remain within the body of a patient as an implant for a predetermined therapeutically effective amount of time. The sling may be non-absorbable, absorbable or resorbable, including any combinations of these material properties, depending on the desired treatment. For example, portions of the sling 42 or sling assembly 46 may be constructed of a bioabsorbable material designed to last for a predetermined period of time within the patient, that should be sufficiently long to afford treatment of the patient's need. The general characteristics of the sling material and design should be such as to withstand the various forces exerted upon it during implantation (for example, frictional forces associated with tissue resistance) and after implantation (for example, increased abdominal or bladder pressure caused by coughing, laughing, sneezing, or lifting). Preferably, the sling 42 is configured to exploit the healing process and provides adequate support to correct incontinence.
The sling assembly 46 preferably has a feature that assists the surgeon in placing the sling 42 in a therapeutically effective anatomical position. The precise, final location of the sling 42 will depend on a variety of factors including the particular surgical procedure(s) performed, and any preconditions of the patient such as scar tissue or previous surgeries. For example, it may be preferred to place the sling 42 in close proximity to, but not in contact with, a mid portion of the urethra 16 to treat incontinence. In a male patient, the sling 42 may be placed proximate, but not in contact with the bulbar urethra.
Several different embodiments of tension adjustment member are within the scope of the present invention. Referring to the embodiment shown in
Other attachment configurations for member 66 are also included within the scope of the claimed invention. The tension adjustment member 66 may be a separate element (e.g. threaded along the length of the sling 42) or it may be an integral part of the sling matrix. The tension adjustment means may comprise one filament threaded along the mesh. Alternatively, more than one filament may be used. The tension adjustment member 66 shown in
The tension adjustment means may be threaded axially along the sling mesh, through the middle of the sling or adjacent its ends. Preferably, this is done at the time of manufacture to provide an assembly that is conveniently used during a surgical procedure, without requiring the surgeon to assembly the sling and tension adjustment means during a surgical procedure. In one embodiment, the tension adjustment means 66 may comprise a plurality of elements woven axially along the sling. The plurality of elements may be parallel or non-parallel. For example, the elements may cross in the support portion II. As another example, the tension adjustment means may comprise a portion of the support portion that is more tightly woven than another portion of the support portion.
Preferably, the tension adjustment member is a continuous, uninterrupted member, as opposed to a member in separate pieces. A continuous, uninterrupted member allows the sling to be tightened and loosened and provides a plurality of locations that can be grasped along the sling 42 to modify the tension of the sling. Also preferably, the member extends the entire length of the sling, from one end to the other. A continuous, uninterrupted member allows the entire sling to be repositioned as opposed to merely isolated portions of the sling.
The tension adjustment member 66 may comprise a monofilament element or a braided member. The tension adjustment member 66 may be constructed from a biodegradable material or a non-biodegradable material or combinations thereof. The monofilament may be round, flat or other shapes to aid in fixation or identification.
The position adjustment member 66 enables surgeons to easily tighten or loosen the sling tension during the surgical procedure, even after the surgeon removes the sheath 44. To reduce the tension of the sling 42 using the position adjustment member 66, the surgeon contacts the sling 42 and position adjustment member 66 adjacent the urethra and pulls away from the urethra. The tension of the sling may be increased by grasping the sling 42 and position adjustment member 66 above the abdominal incision and pulling upward. One or both ends of the sling 42 and position adjustment member 66 may be grasped to increase the tension of the sling 42. Affording adjustment of the sling 42 position after removal of the sheath 44 facilitates proper sling placement and helps avoid complications such as retention and sling erosion arising out of improper sling placement.
The various configurations, properties or characteristics of the position adjustment member 66 may vary or remain constant along the length of the position adjustment member 66. For example, the position adjustment member 66 may be made of a variety of materials including, but not limited to, Prolene™, nylon, polypropylene, Deklene™, poly-L-lactide (PLLA), polyethylene glycol (PGA), polyester and any combination of materials. Depending on the desired treatment, the member 66 or portions thereof, may be absorbable, non-absorbable and/or resorbable. If the member 66 is constructed from an absorbable, bioabsorbable or bioresorbable material or the like, then the member 66 may be optionally left in the sling 42 after the surgical procedure. This offers the advantage of affording the use of the tension adjustment member 66 in a minimally or non-invasive near term, post operation sling tension adjustment procedure.
The individual fibers or filaments comprising the tension adjustment member 66 may be extruded, woven, braided, spun, knitted, non-woven or have other similar configurations. Member 66 properties, such as tensile strength, elongation at break point, stiffness, surface finish, etc., may be similar to or different from those of the sling 42 and may vary along the length of the member 66.
In one embodiment, the tension adjustment member 66 may be secured to the assembly 40 by attaching one or more ends of the tension adjustment member 66 to the sheath 44. In another embodiment, the tension adjustment member 66 is secured to the device 40 simply by interlacing or weaving the tension adjustment member 66 at predetermined points along the length of the sling 42. In yet another embodiment, the tension adjustment member 66 may include one or more points of attachment along the length of the sling 42. The tension adjustment member 66 may be attached to the sling assembly 46 via knotting, weaving, bonding, ultrasonic welding or other attachment techniques, including combinations thereof, to prevent tension adjustment member 66 detachment during and/or following sling implantation.
Preferably, the tension adjustment member 66 is knotted at preselected locations along the length of the sling 42 without any additional elements added to the assembly to connect the member 66 to the sling 42. Knotting allows attachment of the member 66 to the sling 42 without additional securement structure. This embodiment avoids contact between such additional retaining structure and tissue and any attendant complications. The knot may comprise a single throw, half hitch knot, square knot; single overhand knot, a slipknot or a heat formed knot. Optionally, a loop or other shape may be formed in the member 66 adjacent the end 61 of the support portion II to afford convenience in identifying the end 61 of the support portion II. Such a loop or other shape may be conveniently located and cut should it be desired to remove the portion of the member 66 associated with the support portion II.
It is noted that, in an embodiment with a continuous length position adjustment member 66 that is anchored at a plurality of locations 61 (as shown in
The means 66 for adjusting the tension or anatomical location of the sling 42 may optionally comprise a means for indicating proper orientation of the sling 42. Referring to
Referring to the embodiment of the invention shown in
In another embodiment of the invention, one or more substances may be associated with the member 66 by, for example, a coating process. The coatings may be selected from the same group mentioned above with respect to coatings for the sling 42. The substances may be used to enhance treatment effects, indicate proper sling orientation, enhance tension adjustment member visibility, and resist infection or other effects. For example, the tension adjustment member 66 may be dyed a contrasting color (e.g. blue) with respect to the sling color (e.g. white). The contrasting color of the tension adjustment member 66 provides the surgeon with a visual indicator that can be used to confirm proper sling orientation. In addition to coating substances, other components including, without limitation, tags, labels or indicia may also be used to indicate proper sling orientation or enhance tension adjustment member 66 visibility/identification.
Also optionally, the sling 42A may include a means for grasping the sling 42A and/or the tension member 66A in the support portion II of the sling. For example, the means may comprise a small handle 15 attached to the tension member 66 in the support portion II of the sling 42A.
Referring to
In a preferred embodiment, the sheath 44 is made of polyethylene. Other materials including, without limitation, polypropylene, nylon, polyester or Teflon may also be used to fabricate the sheath 44. The sheath material should be flexible and provide sufficient structural integrity to withstand the various forces exerted on the sheath 44 throughout the sling delivery procedure. In general, the sheath 44 is configured to have sufficient flexibility to facilitate user manipulation and adequate structural strength to withstand the various forces applied to the sheath 44 during delivery and/or positioning of the sling assembly 46. It should also conveniently separate from the sling material 42 after the sling 42 is implanted without materially changing the position of the sling 42.
As shown in
Alternatively, other configurations of the sheath 44 are within the scope of the present invention. In particular, the sheath may be unitary as opposed to telescoping with perforations, holes, scores or tear lines designed to allow separation and removal of the sheath 44.
During sheath removal, the first section 86 and the second section 86 of the sheath 44 are slid off the sling 42 by pulling each end of the sheath 44 away from the middle portion 80 of the sling assembly 46 (as shown by reference directional arrows in
In another embodiment of the invention, the sheath 44, or a portion thereof, is associated with one or more substances including those substances identified with respect to the member 66 and sling 42. The substances may be used to enhance sheath removal, identify twists along the sheath 44 (and thereby indicate proper sling orientation), indicate cutting/separation points, indicate center-point, resist infection or provide other desirable effects. For example, a first surface of the sheath 44 may include a colored stripe that should lie opposite the urethra 16 or bladder neck to ensure proper sling orientation. Thus, the stripe provides the practitioner/surgeon with a visual indicator to aid in properly orienting the sling assembly 46, and ultimately the sling 42, within the patient.
The ends of the sheath are preferably connected to a dilator. Alternatively, the sheath may be connected to the sling, and the sling can be associated with the dilator. The number of dilators will depend on factors such as the shape of the sling. For example, the sling 42P shown in
At least two dilators are preferred. The sling 42 shown in
The dilator 54 is a component that atraumatically creates and/or expands the passageway through the tissues for sling assembly delivery. The dilator 54 includes a means for associating with a needle 60. The dilator 60 is preferably short relative to a needle 60 for ease of passage of the assembly and to reduce the overall amount of tissue that is deflected at one time. Preferably, the dilator is less than 2.5 inches in length, and more preferably, it is less than one inch in length. The maximum radius of a dilator 54 is preferably less than 10 mm, more preferably less than 7.5 mm, even more preferably less than 5 mm. The tip of the dilator 54 is preferably blunt, as, in preferred embodiments, the leading tip of the dilator 54 will pass through tissue that has already been pierced by a needle 60.
The dilator 54 may be made from a variety of biocompatible and sterilizable materials including, without limitation, acetal, Delrin®, Acrylonitrile-Butadiene-Styrene (ABS), polyethylene, nylon and any combination of materials. Alternatively, the sheath 44 may be additionally or solely connected to an end portion of the sling 42.
The dilator 54 preferably includes means for associating with a surgical needle 60. In a preferred embodiment, the association means affords a permanent affixation between the dilator 54 and the needle 60. By "permanent affixation", it is meant that it would be very difficult to manually separate the dilator from the needle after they have become permanently affixed. After implantation of the sling 42, to separate the sling 42 from the dilator 54/needle 60, the surgeon cuts an end of the sling 42 as described more fully below. The association means preferably affords quick and convenient attachment of the dilator 54 to the needle 60 to avoid wasting time in the midst of a surgical procedure. The attachment should also be secure to avoid separation of the needle 60 and dilator 54 while the combination is passed through tissue.
The dilator 54 also includes a means for association with the sling 42 and/or the sheath 44. For example, the dilator 54 may be preattached to the sling 42 and/or sheath 44, particularly if the sling is a synthetic material. Alternatively, the dilator may include means for conveniently attaching to a sling material (e.g. cadaveric or autologous sling material) just prior to sling placement.
Referring to the embodiment of
Preferably, the first end 52 of the dilator 54 attaches to one end of the sling 42, or sheath 44 or sling assembly 46 (shown in
Alternatively, for dilators 54 manufactured via molding techniques, the end of the sheath 44 may be encased within and secured to the first end 52 of the dilator 54 during the molding process. In yet another embodiment, the end of the sheath 44 may be fixedly attached within a longitudinal slot located near the first end 52 of the dilator 44 using an adhesive, ultrasonic welding or other attachment techniques.
Referring to
One or more longitudinal slots 102 located on the outer surface of the dilator 54 and in communication with the second opening 96 allow the wall of the dilator 54 to expand in a radially outward direction when the first end of the needle 60 is inserted into the second opening 96 of the dilator 54. When the shoulder 98 of the dilator 54 passes the recess of the needle 60, the wall of the dilator 54 collapses around the needle 60 as the shoulder 98 seats into the recess, thereby securing the dilator 54 on the needle 60 and blocking separation of the dilator 54 and needle 60.
Although the invention has been described in terms of a shoulder 98 and mating recess, alternative dilator-needle attachment mechanisms such as bumps, grooves, slots, wedges, tabs and other mechanisms are also included within the scope of the claimed invention. The dilator 54 preferably includes one or more relief ports 104 to facilitate convenient needle connection. The relief ports 104 may be formed at the ends of the longitudinal slots 102 or at various high-resistance locations along the dilator 54. The relief ports 104 decrease the rigidity or resistance of radially outward expansion of the dilator wall and, reduce the amount of force required to insert or securely attach the needle 60 to the dilator 54. In yet another embodiment, superficial bands or rings, arc-shaped slots, superficial grooves or other mechanisms may be provided to provide improved expansion or attachment characteristics.
A portion of the dilator 54 includes a taper 88 having a decreasing profile toward the second end 96 of the dilator 54. The taper 88 preferably gently cams tissue out of the path of the sling assembly 46 as the sling assembly is inserted in the body. The taper 88 is also sized and shaped to reduce the amount of friction or resistance as the device is drawn through the tissues of the patient. The amount of force required to manipulate the device through the tissues is thereby reduced. This in turn provides the user of the assembly with additional control over device insertion and maneuverability through tissue and within the patient. In addition to tapered profiles, other dilator profiles such as conical, flared, frusto-conical, pyramid-shaped, elliptical or other applicable profiles may also be used. Overall, the profile of the dilator 54 is preferably configured to provide easy dilation of the tissue to accommodate smooth passage of the sling 42/sling assembly 46 and subsequent collapse of the surrounding tissue to securely anchor the sling 42 into the tissue (after sheath removal).
In other embodiments of the invention shown in
A snap-like element 112 is located on an outer surface near the first end of the dilator 54B. The snap-like element 112 includes a barb or spike 114 that fits within an opening 116 situated near the first end of the dilator 54B. The opening 116 for the barb 114, preferably configured perpendicular to the slot-shaped opening 110, is sized and shaped to match or mate with the barb 114 of the snap-like element 112. When the barb 114 is fully seated within the opening 116 of the dilator 54B, the tip 118 of the barb 114 extends into the slot-shaped opening 110 of the dilator 54B. A first ridge 120 and a second ridge 122 located along the length of the barb 114 further secure and/or fasten the barb 114 within the opening 116 of the dilator 54B. Other fastening configurations including, but not limited to, bumps, shoulders, tabs, detents, tongue in grooves, snaps and any combinations of fastening means may also be used with the present invention.
During use, one end of the sling 42, sheath 44 or sling assembly 46 is inserted into the slot 110 of the dilator 54B. With the end of the sling 42/sling assembly 46 properly positioned within the slot 110, the barb 114 of the snap-like element 112 is inserted into the opening 116 of the dilator 54B. The barb 114 is fully seated within the opening 116 when both ridges 120, 122 pass through the opening 116 of the dilator 54B. This causes the tip 118 of the barb 114 to bear down on or penetrate a portion of the sling 42/sling assembly 46 extending within the slot 110 of the dilator 54B, thereby securely fastening the sling 42/sling assembly 46 to the dilator 54B.
A keyed/locking mechanism 108 is located near the second end 56B of the dilator 54B. As shown in
The dilator 54B also includes a locking mechanism 128. Referring to
Referring to
In use, one end of the sling 42/sling assembly 46 of the present invention is configured into a tubular or appropriate shape that enables a sufficient portion of the end of the sling 42/sling assembly 46 to be inserted through the compression collet 132. The tongs 138 of the compression collet 132 are then inserted into the first end 142 of the adapter connector 134, causing the tongs 138 to snap into engagement with the adapter connector 134. The end portion of the sling 42/sling assembly 46 is compressed between the tongs 138 of the compression collet 132 and the internal prong 150 of the adapter connector 134, thereby securely fixing the sling 42/sling assembly 46 to the collet/adapter assembly. In a similar fashion, the tongs 152 of the adapter 134 are then inserted and snap-locked into the first end 52C of the dilator 54C, creating a secure fixation between the collet/adapter assembly and dilator 54C.
In another embodiment of the invention, the length of the dilator 54D is substantially equivalent to the length of the needle 60 used for the sling delivery procedure. For example, as shown in
Alternatively, the hollow portion or internal lumen 158 of the cystoscopy aid 54D may be sized and shaped to accommodate passage of a dilator 54 and/or sling 42 and/or sling assembly 46, similar to those previously described. As such, after the cystoscopy aids 54D are positioned over the needles 60, the dilators 54 and/or sling 42 and/or sling assembly 46 are connected onto the ends of the needles 60. The needles 60 and attached components are then pulled through the internal lumen 158 of the cystoscopy aids 54D until the sling 42 is positioned adjacent the target site or urethra 16 and the needles 60 connected components are withdrawn from the patient. With the sling 42 properly positioned in a therapeutically effective relationship with the urethra 16, the cystoscopy aids 54D are then removed from the patient, allowing the tissue to gently collapse around the sling 42. This configuration of the device allows components such as dilator 54, sling assembly and subsequent needle maneuvering to be performed substantially within the hollow portion 158 of the cystoscopy aid 54D, thereby reducing potential tissue trauma and infection.
In an alternate embodiment, one or more apertures or perforations 160, that function to facilitate verification of bladder and urethra integrity, are disposed along the length of the cystoscopy aid 54D. For example, during use, after the needles 60 have been inserted within the patient, the cystoscopy aid 54D may be pushed along the exterior surface of each needle 60. If the bladder has been punctured during needle insertion causing urine leakage or drainage within the patient, the urine or bladder fluid will enter the apertures 160 of the cystoscopy aid 54D and flow along the surface and out from the needle 60. This allows the practitioner to quickly and easily confirm urethra and bladder integrity.
In another embodiment of the invention, shown in
Alternatively, the cystoscopy aid 54E or dilator 54 may include a hollow portion configured to house the sling assembly 46. In other words, the sling 42/sling assembly 46 would be folded, rolled or similarly configured for placement inside the hollow portion of the dilator or cystoscopy aid 54E. One role of the dilator 54E or cystoscopy aid 54E in this embodiment, similar to that of the sheath 44, is to reduce friction or tissue trauma as the sling 42 is drawn through the various tissues. It is noted that the sheath 44 is a wholly optional element of the present invention. The embodiment of the present invention shown in
In an alternate embodiment of the invention, a set of grasping jaws 164 may incorporate a dilator, as shown in
The mechanism by which the jaws 164 attach to and release the sling 42 or sling assembly 46 may be similar to that of a bioptome. Other exemplary mechanisms such as a ball-detent used on a ratchet wrench, spring loaded clamps, memory alloys, and other mechanisms may also be used. The jaws 164 may optionally be operably connected to and controlled by the handle 64 of the device. Manipulation of the handle 64 causes the jaws 164 to open and close, thereby enabling the device to clamp onto and/or release the sling 42 or sling assembly 46. In addition, the handle 64 may be further manipulated to detach the jaws 164 or a portion thereof from the needle 60. As such, once the sling 42 or sling assembly 46 is properly located within the patient (further described below), the bioresorbable jaws 164 are detached from the needle 60 either inside or outside the body of the patient.
Referring to
Overall, the shape of the needle 60 should facilitate and provide controlled passage of the needle 60 through tissue, preferably from an abdominal incision to the vagina or, alternatively, from the vagina to an abdominal incision. The ends or tip of the needle 60 are preferably not sharpened, but may be tapered to afford easy passage through tissue while providing a blunt surface that avoids cutting sensitive tissue such as the bladder or urethra. In a preferred embodiment, the length N of the needle 60 is approximately within the range of 16.5 cm to 24.1 cm (6.5 inches to 9.5 inches) and has a preferred external diameter of approximately 3.175 mm (0.125 inch). It is preferred that the diameter of the needle 60 be small relative to the prior art to reduce tissue trauma.
The needle 60 is made of a malleable, yet durable, biocompatable surgical instrument materials such as, but not limited to, stainless steel, titanium, Nitinol, polymers, plastics and other materials, including combinations of materials. The needle 60 should have sufficient structural integrity to withstand the various forces (e.g. forces caused by dilator attachment, cystoscopy aid passage, and penetration/passage of the needle 60 through the various tissues) without undergoing any significant structural deformation. Optionally, the needles 60 could be sufficiently malleable to allow a practitioner or user of the device to modify the needle 60 to a desired shape and, thereby, optimize the procedural approach.
As shown in the embodiment of
In an alternate embodiment, the keying feature of the needle 60B comprises an end cap 172 and an elongate reduced width segment 174 having a square-shaped cross sectional profile, as shown in
The present invention may optionally include structure that allows the surgeon to change the orientation or position of the handle relative to the needle. The handle may be rotatably repositioned relative to the needle or, in some embodiments, the handle may be axially slidable and repositionable along the length of the needle. The handle may be repositioned in any orientation as determined by the surgeon or it may be indexed between a plurality of predetermined orientations depending on the particular embodiment of the present invention.
In an alternate embodiment of the invention, the needle 60C comprises an assembly 184 having one or more detachable components. For example, referring to embodiments shown in
In another embodiment, the handle 64 may be permanently attached to an end 62 of the needle 60. More particularly, the handle 64 may be rigidly affixed to the needle 60 so that substantially no relative movement may occur between the needle 60 and the handle 64.
Referring to
A push button 198 and keyed opening 200 are located near the needle attachment end 196 of the handle 64G shown in
When the assembly is in a locked position (shown in
The quick-release push button of the handle 64G enables a user of the device to easily attach or detach the handle 64G from the needle 60 or reposition the orientation of handle 64G relative to the needle 60, using one hand. While gripping the handle 64G, the user of the device simply depresses the push button 202 with one finger to unlock the handle. Still using a single hand to control the handle 64G, the user can then insert one end of the needle 60 into the keyed opening 200 of the handle 64G and, upon releasing the button 202, secure the handle 64G to the needle 60.
As previously disclosed, the needle 60 includes a similar keying feature configured for complementary engagement with the keyed portion of the handle 64G. These complementary, square-shaped keying features allow a practitioner or user of the device to rotatably index the handle 64G between predetermined positions located in ninety-degree increments around the needle axis. Thus, the practitioner may position the handle 64G in a preferred configuration on the needle 60 that provides the greatest comfort and ease of insertion. In addition, via the locking mechanism, the keying features also prevent the handle 64G from uncontrollably rotating around the axis of the needle 60, for instance, during a sling or needle insertion procedure. Although the invention has been described with respect to a square-shaped keying feature, other geometrical configurations and keying means are also included within the scope of the present invention.
Another embodiment of needle attachment mechanism for a handle is shown in
During use, a practitioner or user of the device simply compresses the levers 214 of the handle 64H together using, for example, a thumb and forefinger. Compression of the levers 214 changes the configuration of the frame 216 and opening 218 to allow insertion of a needle 60 therein. The user of the device releases the levers 214 when the needle 60 is properly positioned within the handle 64I, causing a portion of the frame 216 to compress against a portion of the needle 60 (e.g., a recessed portion) thereby blocking axial movement of the needle relative to the handle 64I and securely attaching the handle 64I onto the needle 60. The handle 64I can be quickly released from the needle 60 by pressing on the handles 214.
Another embodiment of a quick-release feature for the handle 64K is shown in
In another embodiment of the invention, the keyed, locking portion and/or quick release feature of the handle 64K may be located near the middle of the handle 64K, near the end of the handle 64K close to the needle (
The associated quick-release feature (such as push button 198, button 224, levers 214, etc.) may also be positioned at any preferred location on the handle 64 of the present invention. For example, referring to
Various configurations of the overall size, weight and shape of the handle 64 are also included within the scope of the claimed invention. Still referring to
The second handle 64′ may optionally be locked in a position that blocks inadvertent lurching of the needle 60 within the tissue. Preferably, the second handle 64′ is sized and shaped to engage the abdominal tissue to act as a stop to prevent further penetration of the needle 60 until the second handle 64′ is unlocked and moved to a location closer to the handle 64. This feature is believed to be useful in resisting uncontrolled passage of the needle 60 into the retropubic space after the end 58 of the needle 60 bursts through the tough rectus fascia. Once the rectus fascia is penetrated, the second handle 64′ is unlocked and moved to a location closer to the handle 64 and the needle can be controllable passed through tissue.
Optionally, the second handle 64′ may include means for affording sliding of the handle 64′ toward the handle 64, but that resists movement of the handle 64′ away from the handle 64. The means may comprise a plurality of ribs within handle 64′ that engage the needle 60 and that are angled toward the handle 64.
Referring to another embodiment shown in
The frustro-concially shaped spring ring 212 comprises a first end 214, a second end 216 and a lumen 218. In general, the external diameter of the first end 214 of the spring ring 212 is greater than the external diameter near the second end 216 of the spring ring 212, thereby forming an inclined surface. The lumen 218, situated along the axis of the spring ring 212, is configured to slidably engage a needle 60.
Located adjacent to the spring ring 212 is a frusto-cylindrically shaped o-ring 210. The o-ring 210 comprises a first end 220, a second end 222 and a lumen 224 having a first surface 226 and a second surface 228. The first surface 226 of the lumen 224 is located near the first end 220 of the o-ring 210 and forms an incline configured for complimentary engagement with the inclined surface of the spring ring 212. In contrast, the second surface 228 of the lumen 224 is located near the second end 222 of the o-ring 210 and is designed to slidably engage the needle 60.
Adjacent to the o-ring 210 is a latch 208 comprising two posts 230 and two tabs 232, wherein similar ends of each post 230 are attached to a tab 232. In addition, the posts 230 border the needle 60 in perpendicular alignment with the needle axis, thereby forming, together with the tabs 232, a frame around a portion of the needle 60. One end 234 of each post 230 also includes a flange 236 that triggers the locking mechanism of the handle 204. The handle 204 is locked onto a needle 60 by depressing a tab 232 so that the flange 236 contacts a portion of the o-ring 210 and causes the o-ring 210 to engage the spring ring 212. The force of the o-ring 210 against the spring ring 212 compresses the longitudinal length and causes radial expansion and compression of the spring ring 212, thereby generating frictional forces among the spring ring 212, needle 60 and handle cavity 207. These frictional forces prevent needle movement in the longitudinal direction (i.e. along the needle axis). To prevent handle 204 rotation on the needle 60, a projection 238 may be formed on an external surface of the o-ring 210 and configured for complimentary engagement with an indentation 240 formed on an internal surface of the handle 204. Further, the handle 204 may be unlocked in a similar fashion by simply depressing the other tab 208 and, thereby, releasing the compressive forces which causes the components to disengage.
Referring to
The slider 242 of the handle 204 comprises two shafts 246, that pivot on a rod (not shown) about a pivot point 248, and a switch 250. In general, the shafts 246, switch 250 and rod 244 may be made from substantially the same materials, such as delrin, ABS, nylon, polycarbonate, acetal, polyetherimide, polysulfone or other similar materials. The first end 252 and second end 254 of each shaft are configured to securely engage the switch 250 and rod 244, respectively, thereby forming the slider assembly. The slider 242 in combination with the o-ring 219 and spring ring 212 are the mechanisms by which the needle 60 and handle 204 may be locked and unlocked.
For example, a user locks the handle 204 by pushing or pressing the switch 250 in one direction. This action causes the shafts 246 to move the o-ring 210 into complementary engagement with the spring ring 212. As previously described, the resulting frictional forces prevent linear displacement of the needle 60, thereby securely locking the handle 204 onto the needle 60. The handle 204 may be unlocked by simply pushing the switch 250 in the opposite direction.
In another embodiment, shown in
Referring to
The handle of
Referring to
In another embodiment of the present invention, the slidable handle 204 comprises a body portion 206 and locking mechanism 282. The body portion may be made from silicone rubber or other elastomeric materials. As shown in
Another embodiment of the locking mechanism is shown in
In another aspect, the present invention comprises a kit for treating a patient (e.g. for SUI). The kit preferably comprises at least two needles, an implantable material for supporting structure and at least two dilators. Two or more needles reduces the need to reuse a needle at a different location with a patient, thereby eliminating cross contamination issues. Additional needles, dilators and other elements may also be included for surgical convenience, for avoidance of contamination from one portion of the body to another, for ease of manufacturing or sterilization or for surgical requirements. For example, four needles may be utilized to implant the sling of
Optionally, the sling 42 may includes a means for determining the tension in the sling. The tension determination means may comprise an element attached to the sling or incorporated in the sling that is capable of measuring sling tension.
The elements of the assembly of the present invention may be any color. Preferably, the elements are of constructed to be a color that contrasts with the intended physiological environment and with other elements. For example, the sling 42 is preferably white and the position adjustment member 66 may be blue. This helps the surgeon identify the location and discern the elements of the assembly.
Many methods are contemplated herein. Although the methods of use as disclosed herein generally relate to female incontinence conditions and treatments/procedures, male incontinence conditions and treatments/procedures are also included within the scope of the present invention. Procedures that address problems other than incontinence (e.g. cystocele, enterocele or prolapse) are also contemplated alone or in conjunction with the present invention. Further, the term "urethra," with respect to sling positioning, is used for brevity and reader convenience. It should be noted that the present invention is particularly suitable for placing a sling in a therapeutically effective position. The method may be utilized to support a variety of structures at different anatomical locations. As such, the terms "target site," "bladder", "urethro-vesical juncture", "vaginal vault", "U-V juncture" and "bladder neck" are also included within the scope of the present invention.
Referring now to
A handle 64 is optionally adjusted relative to needle 60 according to surgeon preference and securely associated with the second end 62 of the needle 60. Optionally, the attachment and configuration of the needle-handle assembly may be adjusted or customized to user preference. The handle 64 may be optionally released from the needle 60 by pushing a button or compressing levers located on the handle 64. Once released, the handle 64 can then be rotated or displaced along an axis of the needle 60 to a preferred position. After the handle 64 is properly positioned on the needle 60, the button or levers are released, thereby causing the handle 64 to become securely attached to the needle 60.
The small diameter and curvature of the needles 60 help to provide precise passage of the needles 60 to the vaginal incision 404. In addition, this needle configuration creates a minimally invasive pathway through tissue extending between the abdominal wall and pubic space, thereby reducing the risk of perforating the bowel and/or blood vessels and nerves located lateral to the bladder 14.
The steps described above are repeated as needed for a second needle 60 on the other side of the urethra 16.
Alternatively, in another embodiment of the invention, the dilator need not be directly connected to the needles 60 and, instead, a flexible dilator with a lumen (e.g. dilator 54E shown in
Returning to
Dilators 54, including a pre-attached sling assembly 46, are attached to the first ends 58 of the needles 60 protruding from the vagina 20. As discussed above, after the first dilator 54 is attached to one needle 60, the sling assembly 46 is properly oriented so that the sling assembly 46 is not twisted prior to attaching the second dilator 54 to the end of the other needle 60. In addition, the sling assembly 46 is oriented so that the larger filament loops (of the position adjustment member 66) are facing outward or away from the urethra 16. After the dilators 54 and sling assembly 46 are properly positioned, the dilators 54 are securely attached to the needles 60 to ensure that they do not become detached as the needles 60 are preferably pulled simultaneously through the tissues of the patient.
Once the dilators 54 are securely attached, the needles are pulled up through the suprapubic incisions as shown by the arrows in
The sling is placed in a therapeutically effective position. The precise anatomical position will depend upon a variety of factors including the type and degree of anatomical damage or insufficiency, whether the sling procedure is combined with other procedures and other surgeon decisions. Typically, the sling is placed midurethra, without tension, but in position to support the midurethra. Alternatively, the sling could be placed to support the bladder neck and/or UV junction.
Once the sling assembly 46 is carefully positioned under the midurethra or target site to provide sufficient support to the target site, the overlapping portion of the sheath 44 located near the center of the sling assembly 46 and the axially located member 66 (i.e. tensioning filament) may then be used to center and properly position the sling assembly 46 under the midurethra. The sheath 44 is then removed.
Preferably, the position adjustment member 66 is a continuous member that extends the length of the support portion II (
After achieving the desired sling location, the position adjustment member 66 laterally located on both sides of the urethra 16 may be cut (e.g. at the ends 61 of the support portion II) and removed. Alternatively, the position adjustment member 66 may be left in place, particularly if it consists of a degradable material or is an integral part of the sling 42. The sling 42 is also trimmed adjacent to the suprapubic incisions 400, thereby removing the excess sling material extending outside the body of the patient.
Preferably the position adjustment member 66 extends substantially along the entire length of the sling 42 (see
Generally, the surgeon grasps the mesh and tensioning filament together adjacent the suprapubic incision 400 and pulls to increase the tension of the mesh. Adjustment may occur before or after the dilators 54 or sheath 44 are separated.
The position adjustment member 66 may be cut lateral to the urethra on both sides (e.g. at 61 in
The surgeon verifies the proper placement of the sling 42 as the sling mesh may be difficult to move after the plastic sheath 44 is removed. After the dilators 54 are trimmed off as shown in
In an alternate embodiment, the member 66 is not cut and remains attached to the sling 42. Maintaining filament 66 attachment to the sling 42 affords convenient post-operative adjustments to sling tension. Further, with respect to the embodiment of the invention whereby the member 66 is coated with a radiopaque substance, retaining the member 66 allows the practitioner to track post-operative changes to the position of the sling 42 and/or urethra 16.
The position of the sling may be adjusted using the member 66 even after the surgical procedure without requiring a subsequent vaginal incision and without having any structure passing through the original vaginal incision 404.
Referring to the alternate embodiment shown in
In another embodiment of the invention, the previously described cystoscopy aids 54D (
In an alternate embodiment, the slidable handle 204 is used in place of or in combination with the handle 64. As previously described, the slidable handle 204 is positioned in a locked configuration near the first end 58 of the needle 60 and handle 64 is positioned near the second end 62 the needle 60. The repositionable handle 204 may be used as a stop to prevent inadvertent lurching of the needle 58 into sensitive tissue. As the needle 60 is inserted into the incision, the user or practitioner pushes the needle 60 through the incision 400 using handle 64 and guides or maneuvers the needle 60 through the various tissues and spaces using slidable handle 204. When the slidable handle 204 comes in close proximity to the incision, the user unlocks the handle 204 and slides the handle 204 along a length of the needle 60. The slidable handle 204 is thereby repositioned away from the incision and closer to the first end 62 of the needle 60. Once properly located, the slidable handle 204 is then locked in place and the insertion procedure continues. The unlocking, repositioning and locking actions are repeated at the convenience and discretion of the surgeon until the needle 60 is fully inserted. Thus, this embodiment provides a system with more controlled and precise maneuverability than prior art structures.
In another embodiment of the invention, shown in
As shown in
Referring to
When using the embodiment of the present invention described in conjunction with
As previously described, the device of the present invention can also be used for male patients. Just as the vaginal approach may be used for female patients, a perineal approach may be used for male patients. One end of a needle 60 is initially passed through a perineal incision 406 and toward one of the suprapubic incisions 400. The insertion of the second needle 60 and the remainder of the procedure are similar to that previously described.
In an alternate embodiment, sheath tags, center markers or other means may be used to aid the practitioner in accurately centering the sheath 44 under the urethra or bladder neck in females or bulbar urethra in males. Thus, end and/or center markings may be used as additional aids for separating the delivery system from the sling 42 and centrally placing the sling 42 at the target site.
In another embodiment of method according to the present invention, four needles may be utilized to implant the sling shown in
Although the invention has been described in terms of particular embodiments and applications, one of ordinary skill in the art, in light of this teaching, can generate additional embodiments and modifications without departing from the spirit of or exceeding the scope of the claimed invention. Accordingly, it is to be understood that the drawings and descriptions herein are proffered by way of example to facilitate comprehension of the invention and should not be construed to limit the scope thereof.
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Pizza Workshop
Saute Culinary Academy
Tuesday, April 2, 2013 from 7:00 PM to 10:00 PM (PDT)
Who's Going
San Francisco, California
London, United Kingdom
Florence, Italy
Event Details
We will introduce the students to two amazing pizza doughs and the versatile range of uses for them. We will make both a pre-ferment and simple straight-mix pizza dough. Students will learn how to shape the dough balls, stretch and shape the dough, and how to finish and bake. Students will also prepare their own dough, which they will take home.
When & Where
14 E. Duarte Rd
Tuesday, April 2, 2013 from 7:00 PM to 10:00 PM (PDT)
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Saute Culinary Academy
Saute Culinary Academy offers classes to serve every kind of cook, from beginners to advanced. We offer recreational classes on a vareity of subjects, featuring seasonal produce and focusing on proper techniques. Most classes run for three hours and all our classes are hands-on, so students truly learn through participation.


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Last summer I spent part of two days at the DAR Library in Washington, DC examining the documents in their files relating to my ancestors Jonathan and Philip Mulkey. I had, and continue to have, doubts regarding the records used to prove their Revolutionary War service for DAR membership. There were two Philip Mulkeys, possibly three, in what is now East Tennessee in the late 18th century. It has never been clear to me that the rosters naming Philip Mulkey are in fact referring to my 6th great-grandfather, Rev. Philip Mulkey (b. 1732, Edgecombe Precinct, NC) or that those naming John Mulkey are referring to his son, Rev. Jonathan Mulkey.
Nevertheless, it was a joy to finally see the records used by my grandmother and her cousins in their membership applications. The DAR files included digitized copies of family Bible records and transcriptions that I had never seen. The records support the information about the Mulkeys in the family record my grandmother gave to me in 1968.
Included was a transcription of a Bible record belonging to my 3rd great-grandfather (yet another) Philip Mulkey that was copied by Margaret Bayless McNees (my first cousin, 3 times removed) in 1937. The Bible was then owned by Mulkey's son-in-law, John Horner of St. Clair, Hawkins County, TN.