Transobturator Tape Insertion Research Articles

Efficacy of urodynamic studies in predicting long-term outcomes of the transobturator tape: do they augment clinical assessment?

IntroductionSome controversy exists regarding necessity for urodynamic evaluation prior to surgical management of stress urinary incontinence (SUI). We aimed to interrogate the role of pre and post-operative urodynamic studies versus clinical assessment in predicting long-term patient reported outcomes of transobturator tape (TOT) placement.Material and methodsA 100 patient cohort of women post TOT insertion for stress/mixed urinary incontinence 2005–2010, under a single surgeon, was identified. Results of pre and post-operative clinical assessment and urodynamic studies were retrospectively evaluated. Long-term patient reported outcome measures (PROMs) were assessed using the International Consultation on Incontinence Questionnaire (ICIQ) Short Form, Patient Global Impression of Severity (PGI-S) and Patient Global Impression of Improvement (PGI-I) questionnaires. The role of urodynamic studies in predicting postoperative voiding dysfunction, and long-term procedure outcomes was analysed. Statistical correlations were performed using SPSS.ResultsQuestionnaire response rate was 76/100 (76%) at mean follow-up 9.4 years (7.25–12.75). Mean ICIQ score was 6.32 (1–20). No significant correlations between preoperative pDet QMax and postoperative uroflow/duration of intermittent self catheterisation (ISC), or between preoperative leak-point pressures and outcome were observed. Postoperative urodynamic tests did not reliably predict long-term success in SUI cure. Preoperative clinical urgency was a more reliable predictor of long-term clinical urgency than urodynamic detrusor overactivity. Whilst patients with mixed urinary incontinence at long-term follow-up tended to have the highest (worst) overall ICIQ-SF and ICIQ quality of life score, no studied variables on preoperative CMG were significantly correlated with long-term PROMs.ConclusionsWhilst urodynamic studies provide important baseline bladder function data, prior to mid-urethral sling placement, this study finds no specific value of either pre or postoperative urodynamics in predicting long-term patient reported outcomes of transobturator tape placement.

Impact of transobturator vaginal tape on female stress urinary incontinence and sexual function

ObjectiveTo evaluate the effect of vaginal transobturator tape (TOT) on female stress urinary incontinence (SUI) and sexual function. Patients and methodsIn all, 145 patients with SUI underwent TOT repair using the ‘outside–in’ technique. All patients had been sexually active in the previous 6months. Patients were evaluated by history, routine laboratory investigations, cough stress test, abdominopelvic ultrasonography, and full urodynamic studies. The preoperative data assessed included: age, parity, body mass index, menopausal status, and Stamey grade of SUI. The intraoperative data assessed included: operative time, blood loss, and hospital stay; intra- and postoperative complications were also assessed. At 2weeks after discharge, patients were followed-up with a routine examination and cough stress test. After 6months’ patients were assessed by urodynamic studies, maximum urinary flow rate, post-void residual urine volume. The following questionnaires were completed before and at 6months after TOT insertion: International Consultation of Incontinence Questionnaire-Short Form (ICIQ-SF), Urogenital Distress Inventory-Short Form (UDI-6), and Female Sexual Function Index (FSFI). ResultsAll sociodemographic data of the 145 patients were collected. According to ICIQ-SF scores, 122 patients were cured, 19 had improved, and four failed. There were significant improvements in the UDI-6 and FSFI scores, indicating that the women had significant improvement in their sexual life. There were six cases of urinary tract infection, five cases had a fever, and eight patients complained of groin or thigh pain postoperatively. ConclusionsCorrection of SUI using TOT appears to have a positive effect on female sexual function.

Neurogenic bladder in spinal cord injury patients.

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury.

Infected Multilocular Urethral Diverticulum Complicating Midurethral Transobturator Tape Procedure: A Case Report

The tension-free vaginal tape (TVT) and transobturator tape (TOT) procedures are now the most commonly performed operations for stress urinary incontinence (SUI) in the UK. The majority of reports in the literature relate to the success of TVT in treating SUI. However, there are little data regarding the associated complications. The occurrence of urethral diverticulum following a TVT is rare. The condition frequently presents with non-specific and non-classical symptoms and this leads to incorrect and delayed diagnosis. Reviewing the English literature, we could find three cases of urethral diverticula after a TVT procedure but we could not find any case of urethral diverticulum post TOT insertion. We report a case of a multilocular infected urethral diverticulum 5 years following TOT operation and we describe the management. J Clin Gynecol Obstet. 2014;3(4):138-140 doi: http://dx.doi.org/10.14740/jcgo260w

Infected Multilocular Urethral Diverticulum Complicating Midurethral Transobturator Tape Procedure: A Case Report

The tension-free vaginal tape (TVT) and transobturator tape (TOT) procedures are now the most commonly performed operations for stress urinary incontinence (SUI) in the UK. The majority of reports in the literature relate to the success of TVT in treating SUI. However, there are little data regarding the associated complications. The occurrence of urethral diverticulum following a TVT is rare. The condition frequently presents with non-specific and non-classical symptoms and this leads to incorrect and delayed diagnosis. Reviewing the English literature, we could find three cases of urethral diverticula after a TVT procedure but we could not find any case of urethral diverticulum post TOT insertion. We report a case of a multilocular infected urethral diverticulum 5 years following TOT operation and we describe the management.

Outcome of the Laparoscopic Two-Team Sling Procedure, Tension-Free Vaginal Tape Insertion, and Transobturator Tape Insertion in Women With Recurrent Stress Urinary Incontinence

ObjectiveAlthough the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures. MethodsThis retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications. ResultsForty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction. ConclusionThe laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.

Correlation of three validated questionnaires for assessment of outcomes following surgical treatment of stress urinary incontinence in women

ObjectivesTo assess the correlation between women's responses to the “Patient Global Impression of Improvement” questionnaire (PGI-I) and changes in women's quality of life and sexual function following surgical treatment of stress urinary incontinence (SUI). Study designAncillary analysis of data from a prospective randomised surgical trial: 299 women underwent transobturator tape insertion as a sole procedure and completed the King's Health Questionnaire (KHQ) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) at baseline and at 12-month follow-up in addition to PGI-I at 12 months. Spearman's correlation coefficient was used to evaluate the degree of association between PGI-I responses and the changes in total KHQ and PISQ-12 scores. Kruskal–Wallis tests were performed to compare the 7-point scale PGI-I responses in terms of changes in KHQ and PISQ-12 scores. ResultsThere was a significant positive correlation between PGI-I responses and changes in the total KHQ scores (r=0.48, p<0.001). The changes in the total KHQ score became larger (i.e., more positive) as the PGI-I responses became more positive. There were statistically significant differences across the PGI-I groups with respect to the changes in total KHQ scores (p<0.001). “Very much improved/Much improved” responses on PGI-I were associated with median (IQR) improvement in KHQ scores of 46 (32, 60) and 35 (18, 49) points respectively. An 18-point improvement in total KHQ score was required to clearly indicate a “better” response on PGI-I. There was a statistically significant, but weak, positive correlation between PGI-I responses and the changes in the total PISQ-12 score (r=0.17, p=0.019). ConclusionThe Patient Global Impression of Improvement Questionnaire strongly correlates with changes in Kings Health Questionnaire scores following surgery for SUI and can reliably predict improvement and deterioration in women's quality of life. CondensationThe Patient Global Impression of Improvement Questionnaire strongly correlates with, and can predict changes in, Kings Health Questionnaire scores following surgery for stress urinary incontinence.

Evaluation of holmium laser for managing mesh/suture complications of continence surgery

• To evaluate transurethral endoscopic excision using the holmium laser (TEEH) for the management of lower urinary tract mesh or suture complications of continence intervention. • To compare the outcomes, complications and recurrence rates of TEEH with the published results from studies using other techniques. • A retrospective review of six patients who underwent TEEH for eroded mid-urethral tape or suture into the urethra or bladder. • Patients with urethral and bladder exposure of mesh or suture material managed by TEEH were identified from the operating records, electronic data records and the Holmium Laser Registry at our institution. • Outcome variables included resolution of the presenting symptoms and continence status, recurrent mesh or suture exposure, and symptoms or other morbidity, including haematoma, urinary sepsis, voiding dysfunction and recurrent stress incontinence. • A literature review on the available evidence on holmium laser for lower urinary tract complications of continence surgery was undertaken. • Between September 2006 and March 2010, six women underwent TEEH. All presented with bladder storage symptoms and/or haematuria with recurrent cystitis. The interval between surgery and the diagnosis of erosion was 1-13 years. • Four women had previously undergone retropubic mid-urethral tape, one colposuspension and one a suprapubic arc procedure followed by a transobturator tape insertion. • Complete excision with TEEH was achieved in all cases. • Two women had postoperative haematuria, which resolved after 2 weeks. There were no other immediate complications. • Four patients had recurrent erosion at follow-up. Two of them were symptomatic, requiring repeat TEEH. One was asymptomatic and managed expectantly. In one case, recurrent mesh erosion occurred at the bladder neck in the submucosal layer. This was considered unsuitable for further TEEH. A laparotomy and open excision was undertaken. • TEEH is a minimally invasive technique, with minimal morbidity and complications, compared to open vaginal or abdominal excision of mesh or suture exposure into the lower urinary tract. Open urethrotomy involves risks of damage to the continence (sphincter) mechanism, with subsequent stress incontinence. In addition, anterior wall scarring may lead to dyspareunia, vaginal pain, urethral stricture and/or fistula. When mesh erosion involves the bladder, transabdominal open or laparoscopic excision may be required. • Although the recurrence rates in our series are high, the majority of them were managed easily by repeat TEEH, with minimal morbidity or expectantly if asymptomatic. • In selected patients, TEEH is an acceptable novel technique for the first-line management of this complication of continence interventions, although longer or pooled prospective studies evaluating TEEH are now required.

Randomised prospective single‐blinded study comparing ‘inside‐out’ versus ‘outside‐in’ transobturator tapes in the management of urodynamic stress incontinence: 1‐year outcomes from the E‐TOT study

To compare the 'inside-out' versus 'outside-in' routes for transobturator tape insertion for urodynamic stress incontinence, and to identify independent risk factors for failure at 1 year. Prospective single-blinded randomised trial. Tertiary urogynaecology centre. A cohort of 341 women undergoing transobturator tape procedures between April 2005 and April 2007. Women were randomised to tension-free vaginal tape-obturator (TVT)-O for the 'inside-out' route (n = 170) and transobturator tape (TOT)-ARIS for the 'outside-in' route (n = 171). Participants completed validated symptom-severity, quality-of-life and sexual-function questionnaires before and after surgery. In addition, they completed the patient global impression of improvement questionnaire (PGI-I) and standard 1-hour pad test postoperatively. The primary outcome was the patient-reported success rate reported on the PGI-I scale. Secondary outcomes included objective cure rate and improvement in King's Health Questionnaire scores. A total of 341 women were recruited: 171 women to the 'outside-in' (TOT-ARIS) group and 170 to the 'inside-out' (TVT-O) group; 299 completed the 1-year follow up. The patient-reported success rate was 80% with no statistically significant differences between the groups ('outside-in' 77.6% versus 'inside-out' 81.2%; OR 1.25; 95% CI 0.71, 2.20; P = 0.54). The objective cure rate was 91% with no statistically significant difference between the groups ('outside-in' 88% versus 'inside-out' 94%; OR 2.21; 95% CI 0.85, 5.75; P = 0.157). Previous incontinence surgery (OR 1.41; 95% CI 1.18, 1.91; P = 0.029) and preoperative urgency incontinence (OR 1.78; 95% CI 1.21, 3.91, P = 0.048) were significant risk factors for failure of transobturator tape at the 1-year follow up. There are no significant differences in patient reported and objective cure rates between 'inside-out' and 'outside-in' transobturator tapes. Quality of life and sexual function significantly improved following surgery. Both previous incontinence surgery and preoperative urgency incontinence are associated with significantly lower patient-reported cure rates.

A Prospective Study of Surgeon and Patient-Perceived Outcome following Transobturator Tape Insertion for Treatment of Urodynamic Stress Incontinence

Introduction: Transobturator tape (TOT) placement for stress incontinence (USI) is recommended following failure of conservative therapy. The literature shows that in the short-term efficacy is comparable to tension-free vaginal tape (TVT) and open colposuspension (OC). The study aim was to report a large consecutive cohort undergoing TOT insertion by a single surgeon specifically for both surgeon- and patient-perceived outcome. Patients and methods: Over 4 years at our institution 98 women underwent TOT insertion by a single surgeon. All women had preoperative urodynamics, 79% had type I and 21% type IIa USI. Perioperative and outpatient follow-up data were prospectively collected. Patient-perceived outcome was assessed using a mailed validated questionnaire. Results: Results are similar to other published series. Median operative time was 19 min (15–30) and blood loss 21 mls (15–60). Self-catheterisation was necessary for 13 patients. Vaginal perforation occurred in two patients. At follow-up (mean 7.1 months) 86/93 (92%) patients were dry and 23 (26%) women reported urinary symptoms. 80 (81%) women responded to the questionnaire (mean 18 months) and 54 (68%) describing complete cure. Conclusions: This large single-surgeon series confirms the safety and efficacy of TOT and illustrates the difference between surgeon and patient-perceived outcome. Results obtained are comparable to previously published series for TOT, TVT and OC.

Fistule vésico-vaginale après bandelette transobturatrice

The transobturator approach is gradually replacing the retropubic approach for the treatment of female stress urinary incontinence and suburethral tape. The major argument in favour of this approach is the decreased risk of bladder injury during insertion of the needles, which nevertheless remains a minor complication. Provided another more median approach is used in closer contact with the bone, followed by prolonged bladder catheterization for 24 to 48 hours, this complication has no consequences. However, the authors report a case of bladder injury during insertion of transobturator tape (TOT) in a patient with no particular history, attributable to the technique itself as it occurred during finger dissection towards the obturator membrane. This complication led to secondary formation of a vesicovaginal fistula after insertion of the tape, despite satisfactory repair of the bladder This case illustrates that TOT is not devoid of risks to the bladder; with sometimes even serious consequences. TOT should not be inserted when bladder suture is required. If a fistula is observed after insertion of TOT the tape should be completely removed as soon as possible, but correction of urinary incontinence may persist.

Trans-Obturator Tape for Incontinence: A 3-Year Follow-Up

Aim: To assess operative and functional outcomes, including morbidity, after using the trans-obturator tape for stress incontinence. Patients and Methods: The first 24 consecutive patients undergoing trans-obturator tape insertion in a single centre were included in this retrospective study. All patients were female with a mean age of 63 (range 40–83) years. Fifteen patients (62.5%) suffered from pure stress incontinence, and 9 patients (37.5%) had mixed incontinence. Of the latter, 2 patients also had nocturnal enuresis. Each patient was followed up for between 3 and 12 months postoperatively and again at 36 months. The patients were assessed by clinical examination, ultrasound for residual urinary volume, and subjective satisfaction which was assessed at 3 and 12 months. At 36 months, all patients completed a validated incontinence questionnaire (International Consultation on Incontinence Questionnaire: ICIQ) which assessed female lower urinary tract symptoms and their impact on the quality of life. Results: All operations were performed under epidural anaesthesia in day surgery, and the mean operative time was 20 (range 15–38) min. Nineteen patients (79.2%) showed significant improvement postoperatively, with 16 of those (66.6%) being completely cured of their incontinence. The remaining 5 patients (20.8%) were considered to have had failed procedures. There were no vascular, bladder, or urethral injuries. One patient had perforation of the vaginal fornix, and 3 patients developed vaginal erosion. Conclusions: The trans-obturator tape is a safe and effective treatment for stress incontinence and has a low morbidity after a 3-year follow-up period; however, it should only be performed by clinicians with the relevant surgical expertise and experience in treating female incontinence.

Lower Urinary Tract Injuries After Transobturator Tape Insertion by Different Routes: A Large Retrospective Study

Lower Urinary Tract Injuries After Transobturator Tape Insertion by Different Routes: A Large Retrospective Study

Lower urinary tract injuries after transobturator tape insertion by different routes: a large retrospective study

To identify the rate of, and risk factors for, lower urinary tract (LUT) injuries associated with the transobturator tension-free vaginal tape (TOT) procedure. Retrospective cohort study. Tertiary referral urogynaecology centre. 390 women who underwent transobturator suburethral tapes for management of urodynamic stress incontinence between July 2002 and January 2006. Early cases were identified from theatre records and a case note review performed. From May 2005 (n = 94), data from an ongoing prospective audit were reviewed. Data for LUT injuries with TOT procedures were examined and routes of insertion were compared using Fischer's exact test. Rate of LUT injuries associated with the TOT procedures. Assessment of factors increasing risk of LUT injury, and comparison of the 'outside-in' and 'inside-out' techniques. 241 women underwent TOT outside-in technique and 148 of them underwent inside-out technique. Four LUT injuries occurred (1%): two urethral injuries (0.5%) and two bladder injuries (0.5%). All LUT injuries occurred in the outside-in group, although this difference did not reach significance (P = 0.146). Bladder injuries occurred in women who underwent concomitant vaginal surgery, while urethral injuries occurred in women undergoing secondary procedures. LUT injury is an uncommon complication of the TOT procedures, and in our hands only occurred with the outside-in technique. Intraoperative cystoscopy should be considered only in selected cases.