Background and Objectives:
In 2001, Delorme described a novel technique of inserting a sling using the trans-obturator route1. A less invasive modification of TVT, with lower potential morbidity and similar success rate. However, other complications were reported to be associated with TOT, like tape erosions, urethral laceration and vascular complications.
We aimed to evaluate short term satisfaction (cure and improvement) and complications of TOT procedure.
Materials and Methods:
A retrospective study included 136 patients who had TOT from April 2006 to November 2011 in Heatherwood and Wexham Park hospitals. The project was approved by the hospital audit committee. Case notes were retrieved and reviewed. The data were collected on a proforma. We mainly looked at outcome and patients’ satisfaction (subjective) to the operation at their earliest postoperative follow up visit after two to three months from operation. We also included patients’ age, presentation, urodynamic study, concomitant surgical procedures and related complications.
The cohort included women with pure urinary stress (USI) and mixed incontinence. All patients had pre-operative urodynamic study, advised for pelvic floor exercises and prescribed anti-cholinergic medication in case of mixed incontinence. Monarc® tape was used. Procedures were performed or supervised by the same consultant, under general anaesthetics and followed the same technique as described by Delorme1. Vaginal pack was not used routinely and cystoscopy was performed if only otherwise indicated.
Total number of 136 patients had the procedure. The age range was between 31 and 81 years, with mean age of 54 years. TOT was the primary continence procedure, apart from five, two of those removed their previous tape for having vaginal erosion and developed recurrent stress incontinence thereafter, another one had colpo-suspension and the last two had peri-urethral injections. Of total, 73(53.7%) had TOT as a sole surgery and the others had additional procedures at the same time.
Out of the 136 patients seen after 2 to 3 months at gynaecology outpatient clinic, 12 failed to attend the appointment. Of the rest, 95(76.6%) reported subjective cure, 27 (21.8%) felt improvement in their condition with less leaking episodes; both groups were satisfied with the operation. Only 2 (1.6%) felt worsening in their symptoms. One patient of the last group had the procedure repeated after about a year. Those who had the tape as a second procedure were either improved or cured.
There were 25 cases developed post-operative complications (Table -1). All of those who developed de novo urgency were older than 67 year old, had no evidence of bladder overactivity pre-operatively. They were given anti-cholinergic, local HRT medications and only one needed seeing a continence advisor to manage urgency.
Post-operative urine retention developed in six cases, only one had reduced urinary flow rate pre-operatively and four of them had concomitant anterior repair operation. Two patients needed catheterisation for 7-10 days, and other two were given a cholinergic medication. Only one had incomplete emptying at the follow-up appointment.
For the patients who developed tape erosion, five of them were cured by the tape, and one did not attend the follow up appointment. One needed removing the tape after one year, two had the exposed parts excised and there was spontaneous healing in the other two cases.
TOT tape has been introduced initially, to minimise the intra-operative complications associated with TVT particularly bladder, vascular, bowel injuries and voiding difficulties and that has been shown in many reports, with maintaining similar success rates and minimal intervention. However, it has been blamed for increased risk of vaginal injuries/erosions and groin pain.
There has been a variable rate of short term cure (up to one year) reported in literature, ranging between 70%2 to 98%1. However, many reported similar rate of patients’ satisfaction of more than 85%3, 4, 5 as a short term response. This wide range of cure is attributed to different levels of surgical experience, use of different types of TOT tapes, patient characteristics, doing the procedure alone or combined with other prolapse repairs, as a primary or secondary continence options and variable follow-up time frames.
In our study, no bladder, urethral injuries or bleeding were recorded, the incidence of vaginal erosion came less than the rate of other reports6, 7, 8. Rate of tape erosion has been reported in literature to range from 1.1- 20%9, 10. The factor that was most found to be related to tape erosion is its material and manufacture, causing sub-clinical infection or rubbing with vaginal epithelium, as it is the case in Uratape® and Obtape®, while surgical experience has little influence, although checking for vaginal lacerations at time of insertion should be a routine step. Other reported risk factors for delayed wound healing are; hypo-estrogenised vaginal tissue, obesity, steroids use, diabetes, previous continence surgery and previous impaired healing after sling surgery11. In our series, erosion presented as an early postoperative complication and late after one year. However, it did not affect operation outcome and all patients were cured. It was managed conservatively first and only excised or removed when that option failed or it was symptomatic.
One of the favoured features of TOT over TVT tape is the wider angle of insertion (45o) to the vertical and horizontal planes contributing to less postoperative voiding difficulties. We had a comparable rate of urinary retention to other reports2, 12. Four of those cases had anterior repair too, which results in more tissue dissection and oedema. De novo urgency was encountered less frequently than in other reports2, 8, 12. It has been observed, both in our study and that by Falconer et al13 that age and hormonal status facilitates an altered metabolism of collagen which is induced by the intravaginal slingplasty.
TOT is a simple, safe, quick and effective procedure for treating stress urinary incontinence, with comparable success rates to its counterpart, the retropubic tape, with less potential for serious and bothersome complications. However, risk factors for failure or adverse outcomes are still understudied and development of predictive models would allow more accurate preoperative counseling and more satisfaction rate.
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