International Journal of Surgery (2007) 5, 3e10 www.theijs.com Transobturator tension free vaginal tapes: Are they the way forward in the surgical treatment of urodynamic stress incontinence? M. Abdel-fattah*, I. Ramsay Urogynaecology Unit, Southern General Hospital, South Glasgow University Hospitals, 1345 Govan Road, Glasgow G51 4TF, UK KEYWORDS Urodynamic stress incontinence; Transobturator tapes; TVT Abstract Objectives: The transobturator approach for sub-urethral tension free vaginal tapes had gained wide popularity in surgical treatment of urodynamic stress incontinence over the last few years. This study aims to survey the practice and preferences of urogynaecologists and urologists worldwide as regards the transobturator tapes. Material and methods: Seven hundred and twenty surgeons worldwide were surveyed via postal/email questionnaire about their views and practice regarding the transobturator tape procedures (TOTs). They were asked about their technique and tape material preference and their reasons for choosing them. They were also asked about every detail of the procedure. Results: Adjusted response rate was 68%. Of the responding surgeons, 97% were well awareofthetotsandonly44.3%undertakethem.while34.16%ofthesurgeons thought that TOTs are the way forward in the treatment of USI, 14.84% surgeons disagreed and the majority (51%) are yet to decide. With regards to technique of TOTs, most surgeons (38%) would prefer to use both techniques, while 34% use IneOut technique only and 28% use OuteIn technique only. The vast majority (72%) use polypropylene mesh tapes due to better tissue incorporation and proven safety records. A few surgeons deviate from the originally described TOTs; 13.6% use a catheter guide to deviate the bladder and urethra during the trochar insertion and 31.41% use routine cystoscopy as part of the procedure. Conclusion: Whilst one-third of the responding surgeons think that the transobturator approach for tension free vaginal tapes is the way forward for the management of USI, the majority are awaiting studies with longer-term results. The variation from the originally described TOT procedures seems to be inherited from the TVTä procedure. ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. * Corresponding author. Tel.: þ44 01412012818. E-mail address: msakr99@aol.com (M. Abdel-fattah). 1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2005.12.002
4 M. Abdel-fattah, I. Ramsay Introduction Sub-urethral sling procedures have been used for the treatment of urinary incontinence in women since the beginning of the 20th century. 1 Prior to 1990, slings were not generally used as a first linetreatment; however, the advent of tension free vaginal tape e TVTä e procedure 2 has revolutionised the treatment of urodynamic stress incontinence (USI) and reinstated the interest in sub-urethral slings. TVTä had been originally described as a minimal invasive procedure that can be done under local anaesthesia and sedation with minimal hospital stay and minimal operative/postoperative morbidity. Evidence of high efficacy from an early case series led to a wide spread take-up of TVTä and an estimated 700,000 patients have been treated with this procedure worldwide. 3 There are, however, concerns over the safety of the TVTä, most of which are related to the penetration of the retro-pubic space, with damage to bladder, 4 bowel, 5 major blood vessels 6,7 and the ilioinguinal nerve 8 all having been described. Whilst wishing to avoid these complications, yet keeping the principle of a minimally invasive procedure to reinforce the structures supporting the urethra, Delorme in 2001 9 described the transobturator tape. In this technique, a 2-cm incision is made through the vagina over the mid-urethra and a bilateral para-urethral tunnel created out to the obturator foramen on either side. A trochar is then passed from the genitofemoral fold at the level of the clitoris, through the obturator foramen from outside to in and brought round through the vaginal incision. A multi-filament micro-porous tape is then fed through the trochar and brought through the obturator foramen. The procedure is repeated on the contra lateral side and the tape left under no tension under the urethra. In 2003, De Leval 10 described a modification to the surgical technique, which allows the passage of a trochar and tape from inside to out. Several small studies have shown similar short term success rate to TVTä with lower surgical morbidity rates, 11,12 however, the long-term safety of this type of procedure is not known. This study aims to explore the views and practice of Urologists, Urogynaecologists and Gynaecologists (with special interest in Urogynaecology) undertaking sub-urethral vaginal tape procedures for the management of urodynamic stress incontinence (USI), regarding what they think is the best surgical approach, best tape material, and their specific surgical technique. Materials and methods This is a survey based study; questionnaires were sent to 720 surgeons worldwide, randomly selected from the members of both International Continence Society (ICS) and International Urogynaecology Association (IUGA). More than 2000 surgeons worldwide are currently on the register of both ICS and IUGA; the questionnaires and covering letter were sent by post and/or email. This is a self-designed anonymous questionnaire, where respondents were asked to identify themselves as gynaecologists or urologists and the type of institution in which they worked. They were asked if they carry out TVTä procedures and whether they think that transobturator tension free vaginal tapes (TOTs) are the way forward in surgical treatment of USI and to justify their answer. Those who carried out TOTs were asked about their level of experience, expressed by the number of procedures performed annually. They were then asked about the technique and the tape they prefer and to justify their answer. The questionnaire then went on to explore every detail of the TOT surgical procedure including the pre- and postoperative management (Appendix 1). Results Four hundred and thirty-three replies were received (response rate 60%). The response rate was adjusted to 68% after excluding 83 wrong email addresses. This included 2 replies from surgeons who did not perform sub-urethral tape procedures leaving 431 replies for analysis, which included a good representation of gynaecologists, urologists, general hospitals, teaching/university hospitals and tertiary referral centres (Table 1). More than twothirds of the surgeons in this survey (n ¼ 308, 71.46%) stated that they carry out TVTä procedures, 64 surgeons (14.84%) rarely carry out TVTä and 59 surgeons (13.7%) have stopped doing TVTä at all. Table 1 Demography of the responding surgeons n ¼ 431 % Gynaecologist 358 83.1 Urologist 73 16.9 DGH 210 48.7 Teaching/University Hospital 167 38.8 Regional Referral Centre 46 10.1 8 2.4
Transobturator tension free vaginal tapes 5 Figure 1 of USI? Is TOT the way forward in the management One-third of the responding surgeons (n ¼ 148, 34.16%) thought that TOTs are the way forward in the treatment of USI, 64 surgeons (14.84%) disagreed, whilst the majority, 219 surgeons (51%) had yet to decide (Fig. 1). More than half of the responding surgeons did not carry out TOTs (n ¼ 240, 55.7%) and their main reasons are shown in Fig. 2. One hundred and ninety-one surgeons (44.3%) stated that they perform TOTs for the management of USI and their main reasons are shown in Fig. 3. These surgeons were then asked about their experience with TOTs; the majority (n ¼ 103, 54%) perform 50e 100 procedures per annum, while 64 surgeons (33.5%) perform <50/year and the rest (n ¼ 24, 12.5%) carry out >100/year. The surgeons where divided regarding their technique and tape material preference (Figs. 4 and 5, respectively) and the main reasons for their preference are shown in Figs. 6 and 7, respectively. The vast majority of the surgeons (n ¼ 190, 99.5%) carry out pre-operative urodynamic studies. The majority of the surgeons (n ¼ 160, 84%) carry out TOTs in day surgery units compared to 100 (52.3%) surgeons who perform the procedure as inpatients. Three surgeons (1.6%) carried out TOTs in the outpatient department. Most surgeons (n ¼ 148, 77.5%) use general anaesthesia, compared with 92 (48%) surgeons who use a regional block, 63 surgeons (33%) use local anaesthesia and sedation, and 15 surgeons (7.8%) use local anaesthesia only. A few surgeons deviate from the originally described procedures 9,10 ; 26 surgeons (13.6%) use a catheter guide to deviate the bladder and urethra during the trochar insertion and 60 (31.41%) use routine cystoscopy as part of the procedure. Thirty-two surgeons (16.7%) use a routine cough stress test and 17 surgeons (9%) use a dilator to check the urethra at the end of the procedure. The use of a catheter at the completion of the operation was controversial with the majority (n ¼ 143, 74.9%) not employing one routinely, 45 (23.5%) routinely inserting a urethral catheter and 3 surgeons (1.6%) routinely using a suprapubic catheter. The majority of the surgeons (n ¼ 125, 65.4%) use a post-void residual bladder volume of <100 ml as acceptable for discharge, 33 (17.3%) use a residual of between 100 and 200 ml, 21 (11%) use a voided volume equal to or greater than twice the voided volume, and 12 (6.3%) use other criteria. Seventy percentage of the surgeons use bladder scan and 7.5% use real time ultrasound to estimate the post-voiding residual urine volume, compared to 22.5% using ineout catheterisation. The majority of the surgeons (82.8%) follow up on their patients, usually up to 12 weeks. Discussion Delancey s theory 13 on pelvic support for the bladder and urethra helps to explain the mechanism of TOT = Not convinced with the procedure 250 200 211 Awaiting longer term sturdy result Lack of training 150 Did not know about it 100 50 69 47 65 40 Not NICE approved 0 7 Figure 2 Reasons for not performing TOTs. NICE ¼ National Institute of Clinical Excellence in UK.
6 M. Abdel-fattah, I. Ramsay TOT = Less operative time Lower average blood loss 160 140 120 150 120 140 lower risk of bladder injury No blind entery to retropubic space 100 80 60 92 60 60 65 Lower risk of voiding dysfunction Cheaper 40 40 Easier 20 0 20 For patients with previous retropubic surgery Figure 3 Reasons for performing TOTs. action of the transobturator tape in the treatment of USI, where the position of the tape is similar to that of the natural hammock supporting the urethra. Unlike the TVTä, the purely perineal insertion of the transobturator tape minimises the risk of trauma to the internal organs: bladder, intestine, major vessels and nerves. A recent prospective randomised trial had shown TOT to be equally effective to TVTä in the management of USI with less operative morbidity. 14 TOT has also been recently described for the treatment of USI in men! 15 The relatively easy and safe insertion techniques and the low peri-operative morbidity described in the short to intermediate follow-up trials 11,12 have led to the increasing popularity of the transobturator sub-urethral tapes in the treatment of USI. Therefore, it was important to explore the thoughts of different surgeons dealing with these types of operations to find out their views about them and if they think TOT is the way forward in the management of female USI. The response rate was satisfactory and was mainly from urogynaecologists and this can be explained by the wider representation of urogynaecologists in both IUGA and ICS. The majority of the respondents (97%) were well aware of the transobturator approach, although it is arguable that a significant percentage of the non-respondents might have been un-aware of the procedure or indeed not interested in the sub-urethral Technique Preference No preference 38% In- out only 34% Out-In only 28% Figure 4 Transobturator technique preference among responding surgeons.
Transobturator tension free vaginal tapes 7 Tape Preference Monarc 27% 9% TVT-O 42% Ob-tape 22% Figure 5 Type of tape preference among responding surgeons. tension free slings and therefore did not respond. Unfortunately, geographical practice variation (according to country of origin) was not addressed in this survey. Comparable numbers of the surgeons (16%) were not convinced with the procedure, compared to those who have totally stopped TVTä in favour of TOTs (13.7%). Lower peri-operative morbidity and the suitability for women with previous vaginal surgery were the main reasons given for preferring the transobturator approach as it avoids the blind entry into the retro-pubic space. Most of the surgeons undertaking TOTs would prefer to use both techniques (OuteIn and IneOut) if they got the appropriate training and the vast majority use polypropylene mesh tapes due to their wider pores, better tissue incorporation and proven safety records. Most of those who mentioned using only a single technique stated that the main reason being the technique they first learned. Although it is supposed that the transobturator approach is less invasive and associated with lower postoperative pain, only a minority of the responding surgeons carried out TOTs as an outpatient procedure (1.6%) or performed the procedure under local anaesthesia (7.8%). Most of the cases are performed as day cases reflecting the minimal invasive and relatively safe profile of the procedure. Reassuringly, nearly all of the responding surgeons undertake routine pre-operative urodynamics. A few of them deviate from the originally described procedures and these variations were mainly in the use of catheter guide during the trochar insertion, routine cystoscopy and postoperative routine catheterisation; Reasons for Technique Preference 120 Number of Surgeons 100 80 60 40 20 99 73 25 15 0 Anatomically safer Less dissection/ Easier Less blood loss Figure 6 Reasons for technique preference among responding surgeons.
8 M. Abdel-fattah, I. Ramsay Reasons Of Tape Preference Cheaper Mono/ Multi filament Better tissue incorporation Wider pores More elastic 0 20 40 60 Number of Surgeons Proven safety NICE approved Figure 7 Reasons for tape preference among responding surgeons. variations which seem to be inherited from the TVTä procedure. Long-term follow-up studies are urgently needed to establish the safety, objective success rates, quality of life improvements and patient satisfaction rates of the transobturator tension free vaginal tapes in the management of USI. To date, only one randomised trial comparing the transobturator approach to TVTä has been published, 14 yet it involved a relatively small number of patients (30 patients in each arm) and was only up to 12 months of follow-up. The results were encouraging showing transobturator tape to be equally effective to TVTä with less operative morbidity, yet the paper was later withdrawn by the editor due to failure of the authors to obtain proper ethical approval for the trial. Numerous types of tapes are now being marketed without being rigorously evaluated in a course of well designed clinical trials, therefore causing a degree of uncertainty among the surgeons. Randomised trials comparing both InsideeOut and OutsideeIn approaches and also comparing various mesh types are urgently needed, if we are to provide evidence based practice in the management of USI. Conclusion Whilst one-third of the responding surgeons think that the transobturator approach for tension free vaginal tapes is the way forward for the management of USI, the majority are awaiting studies with long-term clinical trials. Appendix 1 Are Transobturator Tapes (TOTs) The Way Forward in Management of USI? Type of Surgeon: Gynaecologist Urologist Type of Hospital: DGH Teaching/ University Hospital Regional referral centre Do you do TVT -Gynaecare: Often Rarely Not at all Do you think Transobturator approach is the way forward: Why did you decide to do TOTs (if applicable): Less Operative time Lower average Blood Loss Lower risk of bladder injury No Blind entry to retropubic space Lower risk of Voiding Dysfunction Cheaper Easier (Please tick all that apply) Why did you decide to not do TOTs (if applicable): Not convinced with the procedure Awaiting longer term study results Lack of training Did not know about it Not NICE approved (Please tick all that apply)
Transobturator tension free vaginal tapes 9 If you do TOT please proceed (Please tick all that apply) Number of TOT per annum: Which Technique do you use: In Out Technique Only Out In Technique Only Both Which Technique Do You Prefer: In Out Technique Only Out In Technique Only No preference I prefer this technique because it is: Anatomically Safer Less dissection Easier Less Blood loss Which Tape Do You Prefer: TVT- O Ob-tape (mentor) Monarc I prefer this tape because it is: NICE approved Proven safety More elastic The way forward tape Do you always do pre-operative Urodynamics Type of operating theatre: Outpatient Day surgery unit In-patient Theatre Type of anaesthesia used: Local anaesthesia Local anaesthesia + Sedation General anaesthesia Regional anaesthesia **If Local anaesthesia is used: What is the volume used Do you routinely use Aqua dissection: /year mls Do you routinely use a Catheter Introducer to deviate the bladder whilst inserting the TOT needle: ** If yes: What is the size of catheter do you use Do you routinely Cystoscope: **If yes: After each needle insertion Only after both needle insertion Do you always do a cough stress test: **If yes; What volume is the bladder routinely filled to: Approximate volume Leak point volume seen on urodynamics Bladder capacity on urodynamics Other; Please specify.. mls. Do you routinely check the urethra after Tape adjustment **If yes: Size of dilator used References Hegar Fg Do you routinely insert a catheter at completion of the operation: **If yes: Urethral Supra-pubic Post-operatively; What post- voiding residual volume do you consider acceptable for patient discharge: < 100ml 100-200ml Voided volume twice the residual volume Other; Please specify.. Do you routinely follow patient post-operatively: **If yes: How long post-operative Weeks Month. Comments: Thanks for your time. 1. Bidmead J, Cardozo L. Sling techniques in the treatment of genuine stress incontinence. Br J Obstet Gynaecol 2000; 107(2):147e56. 2. Ulmsten U, Henrikson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anaesthesia for treatment of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:81e5. 3. Data on File. Somerville, NJ: Gynaecare Worldwide, A Division of Ethicon, Inc. 4. Ward KL, Hilton P, Browning J. A randomized trial of colposuspension and tension free vaginal tape for primary genuine stress incontinence. Neurourol Urodyn 2000;19:386e8. 5. Fourie T, Cohen PL. Delayed bowel erosion by tension free vaginal tape. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:362e4. 6. Zilbert AW, Farrell SA. External iliac artery laceration during tension free vaginal tape procedure. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:141e3. 7. Vierhout ME. Severe haemorrhage complicating tension free vaginal tape (TVT): case report. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:139e40. 8. Geis K, Dietl J. Ilioinguinal nerve entrapment after tension free vaginal tape procedure. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:136e8. 9. Delorme E. Transobturator urethral suspension minimal invasive procedure for treatment of stress urinary incontinence in women. Prog Urol 2001;11:1306e13. 10. De Leval J. Novel surgical technique for treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol 2003;44:724e30. 11. Costa P, Grise P, Droupy S, Monneins F, Assenmacher C, Ballanger P, et al. Surgical treatment of female stress
10 M. Abdel-fattah, I. Ramsay urinary incontinence with a trans-obturator-tape (TOT) Uratape: short term results of a prospective multicentric study. Eur Urol 2004;46:102e6. 12. Cindolo L, Salzano L, Rota G, Bellini S, D Afiero A. Tensionfree transobturator approach for female stress urinary incontinence. Minerva Urol Nefrol 2004;56:89e98. 13. Delancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1713e20. 14. De Tayrac R, Deffieux X, Droupy S, Chauveaud-Lambling A, Calvanese-Benamour L, Fernandez H. A prospective randomised trial comparing tension free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence. Am J Obstet Gynecol 2004;190:602e8. 15. Bauer W, Karik M, Schramek P. The self anchoring transobturator male sling to treat stress urinary incontinence in men: a new sling, a surgical approach and anatomical findings in a cadaveric study. BJU Int 2005;95:1364e6.