Tension-free Vaginal Tape Operation Research Articles

Re: Kulseng‐Hanssen S, Husby H, Schiotz HA. 2007. The tension free vaginal tape operation for women with mixed incontinence: Do preoperative variables predict the outcome? Neurourol Urodynam 26:115–21

Re: Kulseng‐Hanssen S, Husby H, Schiotz HA. 2007. The tension free vaginal tape operation for women with mixed incontinence: Do preoperative variables predict the outcome? Neurourol Urodynam 26:115–21

A short-term follow-up comparison of two trans-obturator tape procedures

The objective of the study was to compare the clinical outcomes at the short-term follow-ups of two novel transobturator mid-urethral sling procedures – the transobturator tape (TOT) procedure and the tension-free vaginal tape (TVT)-obturator procedure. The study cohort consisted two groups of 40 women with urodynamically proven stress urinary incontinence (SUI). The patients in one group underwent the TOT procedure, performed according to Delorme (Prog Urol 11:1306–1313, 2001); those in the second group underwent the TVT-obturator operation, performed according to de Leval (Eur Urol 44:724–730, 2003). Intra-operative diagnostic cystoscopy was not performed with either the TVT-obturator or the TOT procedures. The average follow-up was 12 months. The two patient groups were similar in terms of demographic and therapeutic criteria, except for patient age, which was significantly younger in the TVT-obturator group. Previously reported TVT-related operative complications, such as bladder penetration, intra-operative bleeding, field infection and post-operative pelvic floor relaxation, were not observed in patients of either group. Bowel and urethral injuries were also not recorded. The therapeutic failure rates were 10% for the TOT procedure and 5% for the TVT-obturator procedure. Urinary frequency and urgency post-operatively were reported in 25% of the TOT patients and 19% of the TVT-obturator patients, pelvic or vaginal pain affected 10% of the TOT and 5% of the TVT-obturator patients, while post-operative voiding difficulty was experienced by 12.5% of the TOT and 7.5% of the TVT-obturator patients. None of the above-mentioned differences between the two patient groups were of statistical significance. The TVT-obturator and TOT procedures, both minimally invasive, novel, mid-urethral sling procedures, seem to be safe, easy-to-perform and effective in treating female SUI. The patients of both study groups suffered less intra- and post-operative surgical complications than previously been reported in connection with the TVT operation. The TVT-obturator patients had fewer therapeutic failures, less post-operative urinary frequency and urgency, less pelvic pain and less voiding difficulty. All of these findings, however, had no statistical significance; consequently, long-term comparative data collection will be required before solid conclusions can be drawn on the superiority of either of these two operative techniques.

Effect of tension-free vaginal tape position on the resolution of irritative bladder symptoms in women with mixed incontinence

The aim of this study was to determine whether the position of the tension-free vaginal tape (TVT) has an effect on the resolution of irritative symptoms in women undergoing the TVT operation. Initial audit suggested that more distally placed tapes were more likely to result in the resolution of irritative symptoms. An appropriately powered study was designed to test this theory. Seventy-seven women with urodynamic evidence of detrusor overactivity and urodynamic stress incontinence underwent a transperineal ultrasound scan to ascertain the position of the tape after a TVT. The tape was categorised as proximal, middle or distal urethra. The resolution of irritative symptoms was assessed compared to the TVT position. Forty-five women had distal tapes, 30 had mid-urethral tapes and two had proximal tapes. Women with the TVT placed on the distal urethra were no more likely to experience resolution of their irritative symptoms than women with tapes on the mid-urethra (p > 0.05). Placement of the TVT on any one part of the urethra is not more likely to result in resolution of irritative bladder symptoms.

Exploration on time of indwelling urinary catheter after tension-free vaginal tape operation

目的 探讨无张力性尿道中段悬吊术(TVT)术后留置导尿不同时间对预防和减少尿潴留的影响.方法 2003年11月-2006年6月我院TVT手术患者86例,随机分为实验组与对照组,实验组于术后24 h拔除尿管.对照组于术后2 h拔除尿管,观察拔除尿管后首次自行排尿时间、拔除尿管4～6 h排尿后B超下测定的残余尿量及尿路感染发生率.结果 实验组拔除尿管首次自行排尿时间在1.3～3.7 h,对照组拔除尿管首次自行排尿时间在1.6～3.8 h,2组无显著性差异(P＞0.05).实验组B超下测定的残余尿量＜100 ml 43例,≥100 ml 1例.对照组B超下测定的残余尿量＜100 ml 36例,≥100 ml 6例,2组有显著性差异(P＜0.05).实验组有1例尿路感染发生,占2.27%,对照组无尿路感染发生.结论 无张力性尿道中段悬吊术(TVT)术后24 h拔除尿管可预防和减少术后尿潴留的发生。

The effect of spinal anaesthesia on urethral function

This study was to assess the effect of spinal anaesthesia on urethral retro-resistance pressure (URP), cough pressures and tendency to leak. The population consisted of 32 women undergoing a tension-free vaginal tape (TVT) operation under a spinal anaesthetic. URP, cough pressures and an assessment of the degree of leak were performed before the spinal anaesthetic was placed. A standard anaesthetic technique was used, and measurements were repeated after the spinal anaesthetic was inserted. The degree of leak was assessed on a five-point scale with 350 ml in the bladder. The cough pressures and URP values were averaged over three or more measurements. The mean URP value fell from 75.0 to 54.0 cm/H2O (p = 0.0003) after the spinal was inserted. There was a non-significant fall in mean cough pressure from 85.0 to 67.5 cm/H2O (p = 0.06). The degree of leakage increased (p = 0.005). Spinal anaesthesia causes a fall in the resistance in the urethra but does not cause a significant fall in the pressure generated by a cough. Women are more likely to leak after coughing during the TVT operation under spinal anaesthesia than they are before the spinal is inserted. The cough test under spinal anaesthesia does not mimic the result of coughing without a spinal.

Long‐term results of tension‐free vaginal tape for female urinary incontinence: Follow up over 6 years

To describe the long-term outcome of using tension-free vaginal tape (TVT) with and without associated procedures. A questionnaire was mailed to a population of 61 women who had undergone TVT surgery more than 6 years ago. Of this population, 41 (80%) had suffered from stress urinary incontinence (SUI). The questionnaire included questions about urinary symptoms, satisfaction and quality of life. The questionnaire was answered by 51 of the 61 women. Mean follow up was 83 months. The women with SUI had a persistent cure rate of 80% with a satisfaction rate of 97%. The cure rate after 6 years was 37% in women with mixed incontinence. Concomitant hysterectomy (relative risks = 0.87) and body mass index (BMI) do not alter the long-term results of TVT procedure. Peroperative bladder injury is not associated with an increased risk of long-term lower urinary tract symptoms (LUTS) or with a decreased satisfaction rate (relative risks = 0.85). Concomitant hysterectomy, increased BMI and bladder injury do not alter good long-term results of TVT.

Results of tension-free vaginal tape procedure in patients with or without colporrhaphy

We investigated the clinical results and the ultrasonic morphological characteristics of tension-free vaginal tape (TVT) surgery combined with anterior or posterior colporrhaphy in relation to the results after TVT procedure without prolapse repair. Seventy-two women with stress incontinence and other pelvic floor defects underwent the tension-free vaginal tape procedure in conjunction with anterior or posterior colporrhaphy. Another 212 patients with stress incontinence without genital prolapse underwent TVT procedure alone. The study was designed as a prospective investigation. The follow-up was performed 3 months after surgery. The protocol included a standardized questionnaire, gynecological examination, stress test and pad test. The position of the tape was evaluated by introital ultrasound. No differences were found when comparing the groups of patients in terms of complication rates, the rates of improvement or cure of stress incontinence and patient satisfaction. Also, no differences in the characteristics of the tape were identified on ultrasound examination. Additional colporrhaphy does not influence clinical and morphological outcome after TVT and can easily be performed in conjunction with the TVT procedure.

Factors predictive of post-TVT voiding dysfunction

In this study we assessed the incidence of voiding dysfunction in women 6 months after undergoing a tension-free vaginal tape (TVT) procedure. Logistic regression was then used to look for significantly associated factors from a range of patient, urodynamic and surgical variables. From a group of 267 women we identified 22 (8%) who needed to perform daily intermittent self-catheterisation (ISC) as a result of the TVT surgery. When potential predictive factors were examined individually there were three that appeared to be associated with the need to use ISC: menopausal status,previous incontinence surgery and the centile score for average voiding flow rate (as derived from a volume--flow rate nomogram). Following multivariate logistic regression this flow rate centile score showed the strongest association with post-TVT voiding dysfunction, the likelihood of needing ISC increasing as the centile score fell. This factor has not previously been described but is readily assessed pre-operatively and may be useful in case selection for TVT.

The Incontinence Outcome Questionnaire: an instrument for assessing patient-reported outcomes after surgery for stress urinary incontinence

The aim of this study is to develop and psychometrically test a questionnaire (Incontinence Outcome Questionnaire, IOQ) for assessing quality of life (QOL) after surgery for stress urinary incontinence that can be used as a single measurement after the intervention. A total of 171 patients who underwent the tension-free vaginal tape (TVT/TVT-O) operation for stress urinary incontinence completed the King s Health Questionnaire (KHQ), the Short Form-12 (SF-12) and the IOQ. The internal consistency, internal and external validity and responsiveness of the IOQ were tested. The IOQ-QOL subscale showed good internal consistency (Cronbach's alpha=0.83) and significant correlations with the KHQ and the SF-12 scales (r=0.30-0.56). Partial correlations with objective parameters showed a significant relation for the IOQ-QOL subscale with objective continence/incontinence. The results of our study suggest that the IOQ is a valid and reliable instrument for assessing QOL after incontinence surgery and can be used if baseline or pre-operative data are unavailable.

Re: Kulseng‐Hanssen S, Husby H, Schiotz HA. 2006. The tension free vaginal tape operation for women with mixed incontinence: Do preoperative variables predict the outcome? Neurourol Urodyam 26:115–121

Re: Kulseng‐Hanssen S, Husby H, Schiotz HA. 2006. The tension free vaginal tape operation for women with mixed incontinence: Do preoperative variables predict the outcome? Neurourol Urodyam 26:115–121

Economic impact of tension-free vaginal tape surgery for urinary incontinence in an ambulatory regimen compared with hospital admission

To determine the cost per patient of a tension-free vaginal tape procedure involving major ambulatory surgery (MAS) compared with inpatient surgery in 2002 and 2003, and to analyse the medical care given following each procedure in a public hospital in Spain. The method used was activity-based costing, which involves designing a protocol of processes of caring for the patient with the help of professionals and subsequently calculating the cost of each process; this system was applied retrospectively to patients cared for in 2002 and 2003. In addition, the clinical histories of these patients were reviewed in order to evaluate complementary care given by the emergency service and admissions to hospital immediately following surgery. The relation between these events and each sample group was analysed by means of a non-parametric test and CIs for a 95% level of significance were obtained in order to make the calculations more robust. The mean cost for the patients in the ambulatory group was 42.43% lower than that for the hospitalized patients. Whereas 5.5% of the ambulatory patients subsequently required admission and a further 7.3% required complementary medical care, 19.2% of the patients who had been hospitalized for the surgery required complementary medical care and 1.4% were readmitted after intervention. In spite of these results, there was no dependence between these variables according to the chi(2) test. MAS produced better results in terms of minimizing costs; under our conditions it was less costly but was of equal efficacy to the surgical intervention.

The value of cystoscopy and bladder biopsy taken at the time of tension-free vaginal tape insertion

SummaryThe primary aim of this study was to determine if a cystoscopy performed at the time of a tension-free vaginal tape (TVT) insertion is useful in finding unexpected pathology. A secondary outcome measure was to assess whether a bladder biopsy and cystoscopy performed during the TVT operation provide useful information about the outcome of surgery. The findings in 100 consecutive women were reviewed. A total of 42 women demonstrated mixed detrusor overactivity (DO) and urodynamic stress incontinence (USI); 32 women had abnormal biopsies. Women with DO were no more likely to have abnormal bladder biopsies than women without DO (p > 0.05). An abnormal bladder biopsy or cystoscopy failed to predict postoperative irritable symptoms (p > 0.05). The presence of preoperative DO correctly predicted postoperative irritable symptoms (p < 0.01). Cystoscopic abnormalities were noted in 14 women including one carcinoma, and one case of dysplasia was discovered on biopsy. In five women, the cystoscopy showed a bladder perforation. Cystoscopy should be performed in all women undergoing continence procedures.

Surgical treatment of urinary stress incontinence nowadays

There are various surgical methods for the treatment of female urinary stress incontinence. According to the opinion of American Association of Urologists, anterior colpoplasty is supposed to be the least effective for the long-term treatment out of four surgical treatment categories (anterior colpoplasty, suburethral sling, colposuspension, and long-needle sling). Nowadays, the open retropubic colposuspension (Burch operation) is considered the most effective and long-term treatment of the female urinary stress incontinence. A first-year postsurgical effectiveness is 85–90% for this operation. Tension-free vaginal tape (suburethral sling) operations are considered as much effective as the above-mentioned surgeries and tend to be very perspective. However, these operations require to be evaluated for their long-term systematic results.

Ovarian Vein Thrombosis Presenting with Persistent Fever After Laparoscopic Hysterectomy

In this paper, we describe a case of ovarian vein thrombosis following laparoscopic hysterectomy and obturator tension-free vaginal tape surgery. Clinical presentation included spiking fever and lower abdominal pain. The diagnosis was made using computed tomography scanning with contrast material. Therapy consisted of broad-spectrum intravenous antibiotics and subcutaneous low-molecular-weight heparin. This is a rare case of ovarian vein thrombosis following laparoscopic hysterectomy. We believe that such a thrombotic complication should be considered when evaluating a patient with spiking fevers and abdominal pain, even after minimally invasive procedures, such as laparoscopic hysterectomy. (J GYNECOL SURG 22:163)

Quality of life and continence 1 year after the tension-free vaginal tape operation

The purpose of this study was to evaluate changes in condition-specific and generic quality of life (QOL) and continence rates 1 year after the tension-free vaginal tape (TVT) operation for stress urinary incontinence. A total of 99 patients undergoing the TVT operation underwent clinical and urodynamic assessment and completed the German language King's Health Questionnaire (KHQ) and the Short Form 36 (SF-36) before and 3 and 12 months after surgery. Overall, 72 TVTs were performed as isolated procedure and 27 in combination with other operations. Data were analyzed with the Chi-square test, analyses of variance, and the Tukey test. Overall, the objective continence rate was 80% at 1 year and did not differ significantly between patients with or without concomitant surgery. Significant and clinically relevant (>10 points) improvements were seen in all domains of the KHQ except General Health perception. The SF-36 showed statistically significant but not clinically significant improvement. The TVT operation is associated with improved condition-specific QOL in women with stress urinary incontinence. The condition-specific KHQ is more appropriate than the generic SF-36 for evaluating treatment results in women treated for incontinence.

TVT-Obturator: Short-Term Data on an Operative Procedure for the Cure of Female Stress Urinary Incontinence Performed on 300 Patients

ObjectivesTo evaluate the short-term therapeutic results of a novel minimally invasive anti-incontinence operative procedure—the tension-free vaginal tape (TVT)-obturator. MethodsWith this prospective, observational, and consecutive patient series, TVT-obturator surgery was performed, according to de Leval (2003), by the same surgeon on 300 patients with urodynamically proven stress urinary incontinence. Follow-up lasted 4–24 mo. ResultsThe demographic and therapeutic aspects of the patient group data were evaluated. The TVT-obturator required neither bladder catheterization nor intraoperative diagnostic cystoscopy. Half of the 18 (6%) patients with postoperative voiding difficulties had postoperative urethral bladder catheterization for 1–4 d, whereas the other 9 patients underwent a tape loosening procedure in theater under anesthesia. The early therapeutic failure rate for the TVT-obturator procedure was 2.7% (8 patients). Six of the latter patients underwent an interval TVT operation with satisfactory results. Neither bowel nor urethral injuries were recorded, and no evidence of bladder penetration was observed. With the TVT-obturator, no intraoperative bleedings, postoperative field infections, or postoperative pelvic floor relaxations were noted. ConclusionsUse of the TVT-obturator, a novel midurethral sling, seems to reduce the incidence of some of the operative complications associated with the TVT, primarily bladder penetration and postoperative outlet obstruction. The early therapeutic results and the cost-effectiveness of the novel TVT-obturator appear similar to those reported for common TVT surgery. However, long-term comparative data collection will be required to enable drawing solid conclusions regarding the appropriate position of this operative technique within the spectrum of anti-incontinence operations.

The tension free vaginal tape operation for women with mixed incontinence: Do preoperative variables predict the outcome?

The aims of our study were (1) to investigate subjective and objective outcomes after tension free vaginal tape (TVT) operations in mixed incontinent women, (2) to detect if preoperative subjective and objective variables predict the outcome, and (3) to evaluate whether the surgical outcome is different for women who preoperatively find stress incontinence, urge incontinence, or urge and stress incontinence equally the predominant bother. A prospective cohort study was performed on 450 mixed incontinent women. A short-form disease-specific validated questionnaire, 24-hr pad test, standardized stress test, residual urine, and maximum urinary flow were used before and after a TVT operation. "Cure" was defined as a condition where the women were very satisfied with the TVT operation and had negative stress- and 24 hr pad tests. Preoperatively 69% had stress incontinence, 7% urge incontinence, and 24% urge and stress incontinence equally as the predominant bother. Cure rates were 80%, 52%, and 60%, respectively, in these groups. Postoperatively 43% of the women had no urge incontinence, while 49% were less, and only 8% were more bothered by urge incontinence. A higher preoperative urge incontinence index was correlated with significantly higher postoperative bother for all indices and leakage during 24-hr pad test. Mixed incontinent women with predominant stress incontinence had a better cure rate than those with predominant urge incontinence and those who were equally bothered by urge and stress incontinence. This point needs to be addressed when informing mixed incontinent women before a TVT operation.

Frequency of de novo urgency in 463 women who had undergone the tension-free vaginal tape (TVT) procedure for genuine stress urinary incontinence—A long-term follow-up

Background To determine risk factors for the appearance of de novo urgency symptoms, and subsequent accompanying problems, after the tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence. Method A structured preoperative analysis of the incontinence symptoms was made. A mailed questionnaire was distributed to 970 women that underwent the TVT procedure between 1995 and 2001. Average follow-up was 5.2 years (range 2–8 years). The questionnaire included specific questions on current urinary symptoms and incontinence. The disease-specific quality of life instruments IIQ-7 and UDI-6 were used to compare women with, and those without de novo urgency. Results Seven hundred and sixty women (78.3%) responded and 463 of those were identified as genuine stress incontinence preoperatively. De novo urgency occurred in 67 (14.5%) of the women. The frequency was similar irrespective of duration since the TVT procedure. The women that reported de novo urgency symptoms were compared with those without symptoms. Risk factors for occurrence of de novo urgency symptoms were older age (64.7 years versus 60.9 years; p = 0.01), parity (2.6 versus 2.3; p = 0.05), history of cesarean section (9.5% versus 2.5%; odds ratio 5.4), and history of recurrent urinary infections (29.7% versus 18.8%; odds ratio 1.6, but non-significant. De novo urgency had a severe impact on quality of life, as compared to the remaining study population. Conclusion Old age, parity and history of cesarean section were risk factors for de novo urgency after TVT surgery. Postoperative de novo urgency symptoms are as bothersome for the patient as the preoperative stress urinary incontinence.

Tension‐free vaginal tape surgery for stress urinary incontinencne: A prospective multicentered study in Japan

To report the prospective multicentered study of the tension-free vaginal tape (TVT) procedure for stress urinary incontinence. One hundred and fifty-one women with stress urinary incontinence were operated on by the TVT procedure and were followed up at 3, 12, and 24 months after surgery. Patients' age and body mass index (BMI) averaged 57 years and 23.9, respectively. Forty-nine women were classified as type I, 46 women type II and 56 women type III (McGuire's classification). Local anesthesia was used in the operations on 137 women (91%) and epidural or general anesthesia was used in 14 (9%). Surgical outcomes were analyzed with Kaplan-Meier survival curves. The subjective and objective cumulative cure rates 24 months later were 92% and 77%, respectively (P > 0.05). The TVT operation for women with type III (62%) resulted in a significantly lower cure rate compared to those with type I or with type II (83%) (P < 0.001). Post-operatively a urethral catheter was indwelt one day in 77 women (51%), two days in 14 (9%) and 3-7 days in 60 (40%). Surgical complications were encountered in 43 women (28%). The most frequent was bladder perforation in 24 women followed by postoperative difficulty in urination and de novo urgency. The TVT surgery was promising for the treatment of stress incontinence because of minimal surgical invasiveness and satisfactory surgical results. Women with type III incontinence resulted in fewer satisfactory outcomes than those with type I or II incontinence.

Treatment for Unsuccessful Tension-Free Vaginal Tape Operation by Shortening Pre-Implanted Tape

We studied the efficacy of shortening the pre-implanted suburethral tape in patients with recurrent urodynamic stress incontinence after a TVT operation. A total of 14 women, including 6 with ISD, were treated for recurrent urodynamic stress incontinence after the initial TVT operation by performing the shortening procedure under local anesthesia. Urodynamics, a 1-hour pad test, introital ultrasonography of the urethra and a cotton swab test were done before the procedure and 1 year postoperatively. All 14 patients completed the shortening procedure. Mean patient age was 47.2 years (range 43 to 66). Mean time between initial TVT and the shortening procedure was 4 months (range 3 to 14). Ten patients (71.4%) were objectively cured and treatment failed in 4 (2 with ISD and 2 with a fixed urethra). Mean operative time was 17 minutes (range 10 to 25). No intraoperative surgical complications were observed. The 1-hour pad test showed a decrease from a median of 9.0 gm to 1.0. Median postoperative hospital stay was 1 day (range 1 to 4). Spontaneous voiding with adequate post-void residual urine was noted in all patients before discharge home. Shortening a pre-implanted TVT tape for the treatment of recurrent urodynamic stress incontinence is a safe, effective and minimally invasive option requiring only a short hospital stay. However, ISD and an immobile urethra seem to be risk factors for failure. Long-term followup is needed to determine if this surgery achieves long-lasting results.