Trans-Obturator Tape Operation Using MONARC Technique (Outside-In Technique) --- Revisited Objective And Subjective Assessment

Abstract

Objective: This study was undertaken to describe and evaluate the outcome of trans-obturator tape (TOT) operation using Outside-In technique without cystoscopy. This procedure was carried out either solely or as a part of pelvic reconstructive surgery. Design: Retrospective cohort study with follow up objective and subjective assessment. Population: 84 women were presented with urodynamic stress incontinence at North Cumbria NHS Trust. They were treated with transoturator tape operation using outside-in technique between the years 2007 and 2008. Method: Eighty-four women underwent trans-obturator tape operation (outside-in technique) without cystoscopy. Diagnosis of stress urinary incontinence (SUI) was made by uro-dynamic studies. They were all operated only by a single surgeon. The mean length of follow-up was 6 months. Operative complications were recorded. The anatomic integrity of urethra, the anterior vaginal wall was objectively assessed at follow up visit. Subjective assessment was made during patient consultation. Objective failure was defined as persistence of urodynamic stress urinary incontinence. Subjectively, failure was defined mainly as persistence of stress incontinence symptoms. Other related symptoms are noted like voiding difficulties and sexual dysfunction. Results: In the study data eighty four women underwent a TOT operation. The mean age was 50 years (38-63). Pre-operatively, of those 84 patients, SUI was diagnosed in 62 patients while mixed urinary symptoms were present in 22 patients. Transobturator tape operation was carried out using MONARC subfacial hammock system in all women. Additional pelvic surgical procedures were performed according to the presence of other pelvic defects. No intraoperative complications were recorded. The estimated blood loss was 125 mL (range, 50-200 mL). None of the patient had suspected bladder or urethral injury intraoperatively. Transient urinary retention was observed in 8% (n= 7) of women in immediate postoperative period. Three women developed urinary tract infection in immediate postoperative period and in one woman urethral pus was noted which resolved with the help of oral antibiotics. Postoperative objective assessment was made with speculum examination and stress provocation tests like cough and valsalva manoeuvres. There was no stress incontinence on stress provocation tests. Two women developed de novo urge incontinence that was treated with anticholinergics. Two complained of worsening urge incontinence symptoms and none of the women having concurrent urge incontinence symptoms showed any improvement in their urge incontinence symptoms. The overall subjective success rate was 92% (n= 77). Six women judged themselves to be improved in terms of stress incontinence but were still wearing protection, although less, to avoid any urinary leakage. One woman gave history of prickling sensation in the vagina after the procedure at her follow-up visits, from 6 weeks to 9 months although she was reassured and that prickling sensation resolved at 9 month follow-up. Conclusion: Transobturator tape operation (outside-in technique) without cystoscopy seems an effective and safe treatment of urodynamic stress incontinence. It has a good subjective and objective outcome. A large study may be required to confirm the results.