Do the Texas Two-Step to Harvest Fascia Lata.

BALTIMORE -- Porphysicians who appreciate clinical pearls for urogynecologic surgery, a recent urogynecology meeting sponsored by Johns Hopkins University was a Mikimoto boutique. Here are a few gems:

* Texas two-step. Fascia lata is far better than foreign materials for constructing slings in urinary incontinence procedures. But the process of harvesting fascia lata has become something of a lost art, said Dr. Clifford R. Wheeless, associate professor of ob.gyn. at the university.

While harvesting fascia lata is taught in residency, the availability of easy-to-use and pristinely packaged sling materials has made the process of harvesting fascia lata obsolete. "We're the only subspecialty in the world that puts a foreign body into a contaminated area. ... Most of the time, we get away with it." But when it doesn't work, removing the materials can be horrific.

Fascia lata, on the other hand, starts integrating into the area's blood supply within 72 hours and never requires removal.

The key to harvesting it is to be gentle. Make an incision above the knee and undermine the fascia with the handle of a knife. "You can clear a lot off with blunt dissection," he said. But when moving upward, Dr. Wheeless suggested doing what he calls a Texas two-step: Move the fascia stripper two steps forward and two steps back. "Don't Rambo the thing or you're going to break it," he cautioned.

And in determining how tight the sling should be, "Pull it until the resident says it looks a little too loose. That's just right," he said.

* Vaginal shortening. To avoid over-shortening the vagina when repairing vaginal vault prolapse, Dr. W Glenn Hurt, professor of ob.gyn. at Virginia Commonwealth University, Richmond, advised incising the vaginal apex at the level of the vaginal portico.