TVT-O vs. TVT: reply to comments by Burton et al.

Abstract

Dear Editor, We are grateful to Burton et al. [1] for giving us the opportunity to further clarify a few points regarding our article [2]. Briefly, in both groups of TVT-O and TVT the same anaesthetic technique was used and consisted of a combination of loco-regional anaesthesia (lidocaine or bupivacaine applied paraurethrally and along the trocar path) with sedation (midazolam 2 mg). Only the time spent in the surgical procedure per se was considered for the analysis, excluding that required for the anaesthesia. All reasons for reoperations were clearly stated at the end of the result section [1]. In 15 TVT/SUI 1 patients, 12 reoperations were conducted for a postoperative bladder obstruction (partial section of the sling), while three patients required the drainage of a pelvic haematoma. The TVT-O/SUI 1 group had no reoperations at all. Four TVT/ SUI 2 patients required either the drainage of a pelvic haematoma (n=3) or the resection of the tape after a bladder perforation (n=1). In 17 TVT-O/SUI 2 cases, TVTO failed to cure the incontinence and the patients underwent a TVT procedure. Generally speaking, there was no significant difference in reoperation rates between the TVT and TVT-O groups or between the SUI 1 and SUI 2 groups, but important differences were found when the subgroups analysis was conducted according to the SUI severity. We believe that the TVT procedure is more “obstructive” with regard to urine outflow than the TVTO procedure and that patients with severe incontinence (SUI 2) could benefit more from TVT than from TVT-O. This is further confirmed by the high reoperation rate in the TVT-O/SUI 2 group (34%), which probably reflects the application of a less “obstructive” procedure on patients with severe incontinence. Early postoperative hematomas manifested in both SUI 1 (three cases; 3%) and SUI 2 patients (three cases; 3%), but all occurred after TVT and not TVT-O (six cases vs zero, p<0.05). These patients were managed with surgical haemostatic sutures via the vaginal approach without the need for blood transfusions [2]. We followed the approach proposed by Neuman et al. for the control of postoperative bleeding after TVT to prevent the sequelae of major blood loss when the serial postoperative evaluation showed the persistence of pubic pain [3]. Finally, we planned this randomized controlled trial to evaluate the mean values and percentages with an epidemiological characterization that could exactly represent the local gynaecologic reality existing in our hospital. The only two factors allowed to stratify patients were controlled during the recruitment process using an ad hoc developed chart. This allowed us to gather homogeneous groups while the recruitment was still ongoing, and to minimize bias for the factors examined. A posteriori, the analysis after Int Urogynecol J (2009) 20:371–372 DOI 10.1007/s00192-008-0795-4