transobturator tape

Aboubakr Elnashar

The surgical management of female SUI has

been deeply changed when Ulmsten described

a new concept in 1995: the mid-uretheral

support without tension (TVT).

In 2001, Delorme described a new approach

(TOT) eliminating the complications related to

the penetration of the retro-pubic space

Aboubakr Elnashar

TVT procedures use a vertical, retropubic route.

This intrapelvic route exposes the patient to a number of complications:

bladder perforation

injuries to blood vessels or GIT

Aboubakr Elnashar

•TVT: By placing a prolene tape around the

midurethera without tension Restores

the pubourethral ligaments & the

suburetheral vaginal wall Dynamic

kinking of the midurthera at stress (Rezapour et

al, 2001)

•Corrects the central & lateral fascial

defects of the anterior compartment of the

vagina (Ursula et al,2000)

Aboubakr Elnashar

TOT: The tape is placed under the mid-

urethera (as in TVT) between the two

obturator foramen, creating a real

hammock supporting the urethera

(uretheral suspension in TVT)

(Delorme,2001).

It is purely perineal & transverse

The position of TOT is similar to that of

natural hammock supporting the

urethera

Aboubakr Elnashar

1.Anticoagulant therapy (stop 14 d or replace

with low dose heparin)

2.Urinary tract infection

3.No sexual intercourse, heavy

lifting or exercise for 1mo

Aboubakr Elnashar

1. Genuine SI.

2. SI with Intrinsic sphincter deficiency (urethral p

<20 cm H2O).

3. Mixed I (urge & stress).

4. Recurrent SI (previous traditional surgical

procedure had failed).

Aboubakr Elnashar

1. Pregnancy

2. Women with plan for future pregnancy

(prolene mesh will not stretch

significantly). Incontinence may recur.

3. Motor urge incontinence & significant

detrusor instability (Ulmsten,2001)

Aboubakr Elnashar

TVT: Ursula et al,2000: 8.7% in 1762 patients

1. Bladder perforation: 5.4%. The most frequent

complication

2. De novo urgency or urge incontinence: 5.1%

3. Retropubic haematoma: 0.8%

Aboubakr Elnashar

4. Rare complications

a. Anterior vaginal wall laceration

b. Retained plastic sheath

c. Obturator nerve irritation

d. Vaginal wound infection

Most of these complications are related to the

penetration of the retropubic space

Aboubakr Elnashar

TOT:

Although the complications are uncommon, they must

be kept in mind in order to adopt an appropriate strategy

to prevent their development

I. Costa et al (2004) 183 women

Intraoperative: 2.2% (Up to 15% in TVT (Lebert et al, 2001)

No vascular, nerve or bowel injury

Bladder perforation: 1

Uretheral perforation: 2

Lateral vaginal perforation: 1

All these complications disappeared with use of the index finger

into the vaginal incision. Aboubakr Elnashar

Postoperative:

1. De nevo urgency: 5% (from 0-20% in TVT, Peschers et

al, 2000)

2. Voiding disorders: 3.3% (7 women)

{excessive tension of the tape}

Treatment:

immediate release of the tape in 3 (surgical 2,

uretheral dilatation with Hegar 1)

Temporary intermittent self-catheterization in 4

Aboubakr Elnashar

3. Vaginal extrusion of the tape: {silicon part

of the tape}.

Obtape not contain silicon

At 1 year

80.5% were completely cured

7.5% were improved

Aboubakr Elnashar

II. Krauth et al,2005: 604 women

Operative: very few

0.5% vesical perforations,

0.3% vaginal perforations,

no urethral wounds,

0.8% 200-300 ml haemorrhages,

2 perineal haematomas (0.33%).

Aboubakr Elnashar

Post-operative:

1.5% transient retentions,

2.3% transient pain,

2.5% urinary infections,

1.3% transient dysuria.

Aboubakr Elnashar

After 3 mo

5.2%: de novo symptoms.

After one year:

Satisfaction rate: 85.5%

1.5%: de novo dysuria & urgency.

Aboubakr Elnashar

III. But (2005):

Vaginal wall erosion 6.7%: 6 weeks after surgery

(Monarc)

The greater prevalence of vginal wall erosion

demand a search for the mechanism.

Treatment:

The periuretheral portion of the tape was removed &

a new Prolene tape was placed through the

retropubic space.

Follow up after 3 months: No signs of erosion.

Aboubakr Elnashar

Long term safety is not known, particularly in

relation to

changes in the synthetic material changes in

bladder & uretheral behaviour

as voiding disorders & bladder instability

(Delorme,2004)

Aboubakr Elnashar

I. De Tayrac et al (2004): 31 TVT & 30 TOT

TOT TVT P

Operative time

Bladder injury

Urinary retention

Cure

Improvement

Failure

15 min

0.0

13.3

90%

3.3%

6.7%

27 min

9.7%

25.8%

83.9%

9.7%

6.5%

S

S

S

NS

NS

NS

Aboubakr Elnashar

After 1-year:

No vaginal erosion occurred in either of the

groups.

No differences were found in bladder outlet

obstruction after TVT and T.O.T.

CONCLUSION: T.O.T. appears to be equally

efficient as TVT for treatment of SUI.

Aboubakr Elnashar

II. Mellier et al (2004): 94 TOT & 99 TVT

TOT TVT P

Hgic complications

Bladder injuries

Uretheral injuries

Cure rate

2%

0.0

0.9%

95%

10%

10%

0.0%

90%

S

S

NS

NS

Aboubakr Elnashar

In conclusion:

Obturator approach shows identical urinary

results to the retropubic approach.

Major hemorrhage and bowel perforation

are excluded in the TOT procedure.

Thus simplicity, safety and continence result

mean that the obturator approach is the

best method of suburethral tape insertion

for the treatment of USI.

Aboubakr Elnashar

1.TOT is a safe, effective technique for the

treatment of female SUI.

2.The easy technique, the short learning

curve & the very high grade of satisfaction

of the patient show that this approach is

based upon effective anatomical &

physiological criteria.

Aboubakr Elnashar

E-mail: elnashar53@hotmail.com Aboubakr Elnashar