|Year : 2009 | Volume
| Issue : 2 | Page : 44-46
Transobturator tape for female stress incontinence: A day surgery case
Waleed Al Taweel
Department of Urology, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
|Date of Submission||17-Jan-2009|
|Date of Acceptance||15-Mar-2009|
|Date of Web Publication||26-Sep-2009|
Waleed Al Taweel
Department of Urology, King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh - 11211
| Abstract|| |
Aim: To evaluate the effectiveness of transobturator vaginal tape (TOT) in the treatment of female stress urinary incontinence (SUI) and to analyze functional results and quality of life after12 months follow up.
Materials and Methods : All women with SUI who underwent TOT procedure from outside to inside under general or regional anesthesia from December 2004 to January 2007 were included in the study. All must have had a minimal follow up of one year. The patients were prospectively evaluated with history including pads use/day, physical examination - pelvic examination, urinalysis, urogenital distress inventory (UDI-6), and analog global satisfaction scale - and urodynamic studies - filling cystometry, pressure-flow studies, and Valsalva leak point pressure.
Results: Sixty two consecutive patients who fulfilled the inclusion criteria underwent TOT procedure by one surgeon. The mean age was 52 ± 9 years (range, 34-70 years) and minimal follow up was one year (12-24 months). The mean operative time was 17 ± 4 minutes (15-31) with average amount of bleeding 62 ± 22 cc. We found objectively 89% cure or improvement rate after one year.
Conclusion: The out-in transobturator approach is a very effective treatment of SUI with low morbidity and high success rate. However, longer follow up in larger populations should assess the long-term reliability of this attractive procedure.
Keywords: Stress urinary incontinence, transobturator tape, day surgery
|How to cite this article:|
Al Taweel W. Transobturator tape for female stress incontinence: A day surgery case. Urol Ann 2009;1:44-6
| Introduction|| |
Midurethral slings are becoming the first-line surgical treatment for stress urinary incontinence (SUI) in women. SUI is defined as the complaint of involuntary urine leakage on effort or exertion or on sneezing or coughing without rise in detrusor pressure.  The surgical treatment of female SUI due to urethral hypermobility changed radically a few years ago when Ulmsted and Petros  described a new concept of midurethral support without tension. The transobturator vaginal tape (TOT) approach for suburethral tension-free vaginal tapes (TVTs) has gained wide popularity in surgical treatment of SUI over the last few years. It has a theoretical advantage of less obstruction and postoperative voiding dysfunction.
The midurethral sling provides continence by creating functional kinking of the midurethra during increased intra-abdominal pressure and the associated rotational descent of the bladder neck and proximal urethra. Karramet  found that TVT is a safe and successful procedure but serious, though rare, complications have been reported with this technique including vascular and bowel injuries related to the passage of the sling through the retropubic space. ,
In 2001, Delorme  described a new method of inserting the tape, which passes through the obturator foramen, thus theoretically avoiding some of the complications such as bladder perforation and bowel perforation. Later, DeTayrac  reported a one-year cure rate of 84% with the TOT procedure. Nowadays, the minimal invasive technique of midurethral sling has become the standard procedure for stress incontinence management and we report in this study the objective and subjective outcome of TOT after one year follow up.
| Materials and Methods|| |
All female patients with SUI undergoing TOT from December 2004 to January 2007 were prospectively evaluated. The procedure was done under general or regional anesthesia. All patients were required to have a minimal follow up of one year.
Patients with urge incontinence or pure intrinsic sphincter deficiency were not included in the study. All patients were evaluated with history including pads use/day, physical examination including pelvic examination, urinalysis, urogenital distress inventory (UDI-6), analog global satisfaction scale (GSS), and urodynamic studies including filling cystometry, pressure-flow studies, and Valsalva leak point pressure (VLPP). VLPP was recorded via an 8F urethral catheter, and both Valsalva maneuver and coughing were used to provoke SUI. The intravesical pressure (PVes) was used to calculate the VLPP starting at 250 ml bladder volume and subsequent increments of 50 ml until SUI was demonstrated or perceived by the patient. The history of SUI or the demonstration of SUI during physical examination or urodynamic studies constituted the indication for the TOT procedure. We defined the cure of SUI as the disappearance of subjective and objective SUI using UDI-6 and UDS after one year. The patient was considered cured if she answered no stress incontinence in UDI-6 and absence of SUI on UDS and physical examination.
The transobturator approach was performed as described by Delorme in 2001 using a helical tunneler from the outside entrance point to adjust the tape without any tension.  Cystoscopy was performed during the procedures in all patients and catheter removed in recovery room before discharge.
Wilcoxon matched pair test was used to compare preoperative and postoperative symptoms, quality of life, maximum flow, and postvoid residual. P < 0.05 was considered statistically significant.
| Results|| |
A total of 62 consecutive patients fulfilled the inclusion criteria. The mean age was 52 years (34-70) and minimal follow up was one year. Two patients were lost to follow-up after one year. The mean operative time was 17 ± 4 minutes (15-31 minutes) with average amount of bleeding 62 ± 22 cc. The mean abdominal leak point pressure for the patient was 71 ± 9 cm H 2 O with no statistically significant differences between failure and cured/improved patients.
On objective analysis, we found 89% cure or improvement rate after one year [Table 1].
However, the subjective cure rate as seen in the UDI-6 was 81% cure or improvement rate after one year [Table 2]. The overall objective and subjective cure rates were significantly different (P < 0.05).
Eleven percent of our patients developed denovo urgency [Table 3]. It disappeared spontaneously after two months in all but one patient. Her symptoms persisted despite using anticholinergics. The tape was cut and she improved significantly. We encountered lateral vaginal injury in two cases and the tunneler had to be removed and correctly reinserted without any further consequence. None developed erosion or bladder injury or urethral injury. Urinary tract infection (UTI) occurred in three patients and was managed with oral antibiotics. Two patients developed transient urinary retention after removal of the catheter in the recovery room. They had a successful trial of voiding the next day.
The global satisfaction rate was 82% with patients satisfied or very satisfied.
Postoperatively there was a slight decrease in maximum flow [Table 4]. However, no significant differences were seen in maximum flow or residual volume before and after 6 and 12 months of the TOT procedure.
| Discussion|| |
The retropubic placement of suburethral TVT had been associated with a number of perioperative and postoperative complications, including bowel, vascular, and bladder injuries. ,,, This encouraged urologists to develop a procedure based on similar principles but with minimal morbidity to treat SUI. In 2001, Delorme  described a new method of inserting the suburethral tape, TOT.
In our series we treated patients of pure stress incontinence with hypermobilty and avoided patients of intrinsic sphincter deficiency without hypermobility. So far, none has developed erosion and this is due to the use of the nonwoven polypropylene monofilament with macropores that allow good fibroblasts colonization of the tape, which is essential in preventing erosion and local infection. We performed cystoscopy in all patients and no bladder or urethral injury was identified. This resulted in shorter operative time and cost. Sivanesan and his group, in a literature review, found that of many bladder injury cases cystoscopy is recommended in cases of associated pelvic surgery or presence of prolapse, previous retropubic surgery or difficult insertion of the tapes. 
Urine retention and voiding dysfunction rates actually vary from 0-15.6% and it is thought to be less common after the transobturator approach.  In our series 11% developed denovo urgency, however, we did not have urinary retention except for transient retention that was relieved in one day. Unrecognized vaginal laceration may predispose the patient to mesh extrusion. We encountered two cases of vaginal wall injury during passage of tunneler and it was reinserted again without any sequela, so it would be highly recommended to inspect the lateral vaginal wall after passing the needle through transobturator foramen. 
The most important step to avoid erosion and voiding dysfunction was found to be tape adjustment without any tension or any contact with the urethra. 
We did not have any complaint of thigh pain in our series. This confirms the findings of a recent meta-analysis that revealed out-in technique is usually not associated with thigh pain. 
Controversy exists regarding transobturator approach efficacy in patients with low VLPP, however Anast et al, showed that it is effective for patients with low VLPP. They used intravenous sedation during sling placement to allow the surgeon to perform an intraoperative cough test, permitting tensioning of the TOT in relation to the patient's intrinsic sphincter defficiency 15] The subjective global satisfaction rate recorded at one year by a analog GSS is 82%. As it is often the case the rate of our subjective assessment is inferior to the one observed during objective clinical examination. 
| Conclusion|| |
The out-in trans-obturator approach is a very effective treatment of SUI with low morbidity. We have enough data to support the use of the transobturator approach as a very good alternative to the retropubic access. However, longer follow up in larger populations should assess the long-term reliability of this attractive procedure.
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[Table 1], [Table 2], [Table 3], [Table 4]