Minimally Invasive Therapy for Urinary Incontinence and Pelvic Organ Prolapse (Current Clinical Urology) 2014th

4. Transobturator Tape

Saad Juma 

(1)

Incontinence Research Institute, 320 Santa Fe Dr., Suite 300, Encinitas, CA 92024, USA

Saad Juma

Email: urodawk@gmail.com

Abstract

Stress urinary incontinence (SUI) is the most common form of urinary incontinence and is estimated to affect more than 13 million adult women in the United States (Am J Obstet Gynecol, 189, 1275–82, 2003). Burch colposuspension and pubovaginal sling have been the most popular surgical treatments for female SUI. The cure rate for the retropubic open suspension (including Burch colposuspension) at 12–23 months is 82 %, and at 24 months and beyond is 73–76 %. For slings at the midurethra (transvaginal/retropubic technique), the estimated cure/dry rate is 81–84 %. The tension-free vaginal tape (TVT) procedure was introduced by Ulmsten in 1996. In an attempt to minimize the complications associated with the TVT technique, Delorme in 2001 devised and first described the Transobturator tape (TOT) technique. In the original description of the TOT by Delorme, the tunneler needle is advanced through the skin overlying the obturator fossa towards the vaginal incision (outside-in). In 2003 de Leval described an inside-out (TVT-O) technique where the tunneler needle is advanced through the vaginal incision towards the skin overlying the obturator fossa (inside-out).

Stress urinary incontinence (SUI) is the most common form of urinary incontinence and is estimated to affect more than 13 million adult women in the United States [1]. Burch colposuspension and pubovaginal sling have been the most popular surgical treatments for female SUI. The cure rate for the retropubic open suspension (including Burch colposuspension) at 12–23 months is 82 %, and at 24 months and beyond is 73–76 %. For slings at the midurethra (transvaginal/retropubic technique), the estimated cure/dry rate is 81–84 % [2].

The tension-free vaginal tape (TVT) procedure was introduced by Ulmsten in 1996 [3]. In an attempt to minimize the complications associated with the TVT technique, Delorme in 2001 devised and first described the Transobturator tape (TOT) technique [45]. In the original description of the TOT by Delorme the tunneler needle is advanced through the skin overlying the obturator fossa towards the vaginal incision (outside-in). In 2003 de Leval described an inside-out (TVT-O) technique where the tunneler needle is advanced through the vaginal incision towards the skin overlying the obturator fossa (inside-out) [6].

The TOT is a midurethral sling. It reproduces the natural suspension of the urethra while preserving the retropubic space. It replaces the pubourethral ligament, providing continence by creating functional kinking of the midurethra during increase intra-abdominal pressure and the associated rotational descent of the bladder neck and proximal urethra [7]. The TOT is a tension-free sling as the resting urethral angle is not changed by the procedure, nor is it necessary to correct urethral hypermobility [8]. This approach is more anatomically correct and poses no significant impact on voiding function [9]. Patients who undergo the TOT procedure have significantly lower rates of de novo urgency/urge incontinence than those who undergo other midurethral sling procedures as demonstrated by Botros and Juma in 2007 [1011].

In 2005 Delmas demonstrated that the anatomical course of the TOT avoids major neurovascular structures, and the anatomical structures crossed by the tape are muscles and fascia. It avoids femoral and obturator vessels in the thigh and pudendal vessels in the perineum [12]. Because of the nature of the procedure, major hemorrhage and bowel perforation are not reported in the TOT procedure [1314].

In 2006, Achtari demonstrated the course of the dorsal nerve of the clitoris (DNC) and the obturator canal in cadavers relative to the path of the tape in transobturator inside-out (TVT-O) and transobturator outside-in (TOT) procedures. The DNC passes beneath the pubic bone at a distance of 14.3 ± 4.7 mm of the midline. Given the course of the DNC along the medial aspect of the ischiopubic ramus, he concluded the outside-in (TOT) technique may be safer [15]. Further, Hinoul in 2007 concluded that the inside-out (TVT-O) tape trajectory is subject to wider variability than was originally postulated based on a study of the trajectory of the tape study in six fresh cadavers [16]. In 2007 Zahn demonstrated in cadavers that TOTs placed by the inside-out (TVT-O) technique were significantly closer to the obturator canal than with the outside-in (TOT) method, and the greater proximity of the inside-out method was noted in all dissections. This leads the authors to conclude the outside-in (TOT) technique results in the mesh being placed farther from the obturator canal and closer to the ischiopubic ramus, theoretically reducing the risk of neurovascular injury [17].

This minimally invasive midurethral sling technique (TOT) has become the standard procedure for the surgical treatment of SUI. Several studies in the literature have confirmed the feasibility, safety, and efficacy of this operation, [5111820].

Indications and Contraindications

This minimally invasive midurethral sling technique has become the most commonly performed surgical procedure for the management of female SUI. The TOT is indicated in the treatment of patients with SUI due to urethral hypermobility or mixed urinary incontinence with predominant stress component. The TOT may be performed in conjunction with pelvic organ prolapse (POP) repair and/or hysterectomy. The role of TOT in SUI due to intrinsic sphincter deficiency (ISD) is controversial. It may be used in the majority of patient with ISD and urethral hypermobility [11]. However, patients with stem pipe urethra (ISD and fixed urethra) are better served with a midurethral retropubic sling or pubovaginal sling.

The TOT is not indicated for patients with urge urinary incontinence (UUI) or mixed incontinence with predominant urge component. Patients, who undergo urethral diverticulectomy, urethral reconstruction, or repair of urethrovaginal fistula, should not have a mesh sling placed during the same procedure though a later sling may be considered once the repair has healed. Great caution should be exercised in patient with Parkinson’s disease, Multiple Sclerosis, and Myasthenia Gravis because of the increased functional urethral resistance due to detrusor sphincter dyssynergia or pseudo-dyssynergia.

Transobturator Tape

In evaluating the efficacy of a surgical procedure in the treatment of patients with SUI, dry rates are the ideal outcome and a precise end point. However, dry rates do not equate with, nor are they necessary for patient satisfaction. Patient satisfaction rate is as important outcome measure as it encompasses patient overall perception of outcome and not merely dry rates. The functional efficacy and patient satisfaction with the outcome of TOT in the treatment of patient with SUI have been demonstrated in several retrospective as well as prospective randomized controlled trials. In 2007, Juma reported 90 % subjective resolution of SUI in 130 women who underwent the TOT procedure at a mean follow-up of 16.85 ± 4.68 months [11]. Several series have reported similar success rates for the TOT procedure in the treatment of SUI [18192122]. de Tayrac reported a 1-year cure rate of 84 % with the TOT procedure, and in a series of 117 patients with a median follow-up of 16.3 months, Spinosa reported subjective complete and partial satisfaction rates of 92.3 % and 4.2 %, respectively [18]. Abdel-Fattah in 2011, demonstrated that TOTs have good patient-reported and objective success rates at 1 year of follow-up in women with previous failed incontinence surgery [23].

Several studies have demonstrated the subjective and objective cure rate of TOT is similar to pubovaginal and midurethral retropubic slings. In a study of 104 women with SUI, the condition was “cured” in 81.8 % of cases in the TVT group and 83.7 % in the TOT group, and improvement occurred in 10.9 % and 10.2 % of cases, respectively [24]. In a study comparing the retropubic and the TOT slings, a total of 597 women were randomly assigned to a study group; 565 (94.6 %) completed the 12-month assessment. The rates of objectively assessed treatment success were 80.8 % in the retropubic-sling group and 77.7 % in the transobturator-sling group. The rates of subjectively assessed success were 62.2 % and 55.8 %, respectively [25]. In a review and meta-analysis of 12 randomized controlled trials that compared TOT with TVT, and 15 that compared TVT-O vs. TVT for treating SUI; the subjective and objective cure of TOT was similar to TVT. For TVT-O, the subjective and objective cure was also similar to TVT [26]. Another study demonstrated that the cure rate for TVT, TVT-O, and TOT in three groups of women were 90.9 %, 92.3 %, and 91.1 %, respectively [27]. In a study comparing the TOT and TVT-O techniques and involving 341 women who completed 1-year follow-up, the patient-reported success rate was 80 % with no statistically significant differences between the groups. The objective cure rate was 91 % with no statistically significant difference between the groups [28].

In the author’s opinion, the TOT is effective in the majority of patients with ISD. The reason for success of the TOT in patients with low VLPP is due to the fact that not all these patients have a fixed urethra. In fact most of these patients have some degree of urethral mobility albeit less than that seen in patients with higher VLPP. The placement of a transobturator midurethral sling will correct the problem in the majority of these patients. Such a benefit cannot be achieved with similar success in patients with fixed urethra. In a series of 130 patients, we demonstrated the functional results and patient satisfaction of the TOT procedure in patients with VLPP ≤ 60 cmH2O are comparable to the results of the procedure in patients with VLPP > 60 cmH2O [11]. In another study, Valsalva leak point pressure, maximum urethral closure pressure, and urodynamic stress incontinence were the only urodynamic variables consistently associated with objective failure on multivariate analysis. It is the author’s opinion that patients with low Valsalva leak point pressure, and low maximum urethral closure pressure have a higher failure rate irrespective of the technique used. This was demonstrated in a study by Nager of the value of these urodynamic parameters, where no specific cut point was determined for predicting failure for Valsalva leak point pressure or maximum urethral closure pressure. The lowest quartile (Valsalva leak point pressure less than 86 cmH2O, maximum urethral closure pressure less than 45 cmH2O) conferred an almost twofold increased odds of objective failure 1 year after transobturator or retropubic midurethral sling [29]. In yet another study, multivariate analysis demonstrated a low maximal urethral closure pressure of <30 cmH2O was the only independent predictor of failure in patients who had previously failed incontinence surgery [23]. In a study of 145 subjects to compare TOT with TVT in patients with low maximum urethral closure pressure. A cut-off point of 42 cmH2O for preoperative maximum urethral closure pressure was identified as predictor of success in the entire cohort. In this study though, subjects with maximum urethral closure pressure of 42 cm or less H2O, the TOT subjects were nearly six times more likely to fail than TVT subjects [30].

One of the important and not well-recognized advantages of the TOT as compared to other midurethral sling procedures is the lower rate of de novo urgency/urge incontinence. The low incidence of de novo urgency/urge incontinence observed in our series [11] is consistent with what has been reported by others including a review and meta-analysis of 12 randomized controlled trials [18263132]. Roumeguere reported only 2.5 % de novo urgency [30], and Spinosa reported 0.85 % de novo urge incontinence [18]. Morey reported lower incidence of de novo urgency after TOT (1.3 %) compared to retropubic midurethral slings (6 %) [31]. In another study of 276 subjects with urodynamic stress or mixed urinary incontinence who underwent retropubic midurethral slings or transobturator slings, de novo subjective urge incontinence differed significantly between the TOT and the other two retropubic midurethral slings. Fourteen to sixteen percent of patients with preoperative urge incontinence who underwent TVT or other retropubic midurethral slings had worsening of their urge incontinence symptoms while only 6 % of the TOT group did (P = 0.02). There was no difference in rates of resolution of detrusor overactivity among the groups (40 % vs. 48 % vs. 32 %, P = 0.39) or de novo detrusor overactivity (32 % vs. 22 % vs. 22 %, P = 0.64) at 3 months. The authors concluded patients who undergo transobturator procedures have significantly lower rates of de novo urge incontinence than those who undergo midurethral sling procedures. Rates of resolution of detrusor overactivity, urge incontinence, and de novo detrusor overactivity do not differ between groups [10]. The lower incidence of de novo urgency/urge incontinence may be explained by two factors. In the transobturator approach, the path of the tape, crossing the obturator foramen, muscle, and fascia, reproduces the natural suburethral suspension by reinforcing the rotational pivot point, restoring continence while sparing the retropubic space. Sparing the retropubic space may preserve any periurethral nerve fibers that may be associated with urethral function and stability. Second, the TOT is associated with a lower risk of urethral obstruction as compared to other midurethral sling procedures [11].

The TOT and the transabdominal midurethral slings appear equally efficacious in eliminating the need for incontinence pad use. However, signs of obstructive voiding are reported less often after TOT than TVT procedureswhether done as the only procedure or combined with pelvic prolapse repair procedures [2631]. Obstructive voiding dysfunction is the most commonly reported complication of TVT midurethral sling placement. Because the TOT is positioned horizontally across the urethra, it provides less chance for static urethral kinking and the associated urethral obstruction that may follow. In a series of 104 women, urinary obstruction rates (temporary and permanent) in the TVT group were approximately twice those in the TOT group [24]. In yet another series of 597 women, the rates of voiding dysfunction requiring surgery were 2.7 % in those who received retropubic slings and 0 % in those who received transobturator slings (P = 0.004) [25].

The TVT midurethral sling is associated with serious though rare complications including intestinal perforation, vascular injury, and obturator nerve injury, and even death [26273335]. The transobturator sling procedure spares the retropubic space and thus eliminates the risk of major bowelneural and vascular complications which have been reported with the TVT. Several series and meta-analysis that compared TOT with TVT, demonstrated that adverse events such as bladder injuries and hematoma were less with TOT than TVT [262736]. Bladder perforation is uncommon and resolves spontaneously with catheter drainage. We believe the presence of a distended bladder in the presence of a moderate to large cystocele increases the likelihood of this adverse event. Ensuring an empty bladder during needle passage particularly in the presence of a moderate to large cystocele will eliminate this adverse event [11]. In one study, two cases of retropubic hematoma have been reported with the TOT [37]. The authors suggest a technical error in passing the needle through the obturator internus muscle and into the retropubic space as the potential etiology.

The rate of vaginal extrusion of the tape in our series [11] is consistent with the rate of vaginal extrusion reported by other large series [18] and lower than reported with smaller series [3839]. This difference between large and small series may be related to differences in technique and patient selection and will need further evaluation. All extrusions in our series occurred in otherwise healthy women. There was no difference in the vaginal estrogen status in patients with and without extrusion. Management with estrogen vaginal cream did not result in resolution of extrusion and delayed the treatment of what is otherwise a simple to manage adverse outcome. Based on these results, we recommend early and limited excision of the extruded portion of the tape with primary closure of the incision in the majority of patients. The patient continence status in our series was not adversely affected by this approach [11].

In conclusion, the TOT has equal efficacy to other midurethral sling procedures in the treatment of patients with urodynamic demonstrated SUI. No significant difference was demonstrated in the functional outcome and patient satisfaction rates in the majority of patients with low VLPP. The incidence of de novo urgency/urge incontinence and obstructive voiding dysfunction is lower than other midurethral sling procedures. Serious adverse events are rare with this technique. The earlier report by Juma is supported by recent meta-analysis and prospective studies [26294041].

Technique

The procedure may be performed as the sole procedure or in combination with pelvic prolapse repair (cystocele repair, enterocele repair, rectocele repair, sacrospinous suspension) and/or hysterectomy. Hysterectomy, apical repair (enterocele repair and sacrospinous suspension), and cystocele repair should be performed prior to the TOT procedure to allow for proper adjustment of tension of the sling without further manipulation of the tissue once the sling is in position. If the patient is to undergo POP repair, an enema the night before surgery and liquid diet is advised to minimize the risk of postoperative constipation which may jeopardize the repair. Cephalosporin or Quinilone antibiotic prophylaxis (within the first 24 h of surgery) is given starting within 1 h of surgery.

The procedure can be performed under general, spinal, or local anesthesia with intravenous sedation. In one study comparing local vs. general anesthesia, the operative times were identical in the two groups, but the time spent in the recovery room was significantly longer in the general anesthesia group. Patients undergoing local anesthesia experienced less pain than did those undergoing general anesthesia. No significant differences were observed for the rates of complications [42]. Our experience in over 200 cases done under local anesthesia is consistent with the results of this study. The patient is positioned in the modified lithotomy position. In patients with artificial hip prosthesis, the rotation of the pelvis may be different on the side of the prosthesis even though the leg position is similar on both sides. This may result in the wider portion of the ischiopubic ramus being in the path of the tunneler needle on the side of the hip prosthesis. The lower abdomen, external genitalia, vaginal canal, and the proximal thighs should be prepped and draped in the usual sterile manner. The pubic hair should be clipped below the level of the clitoris to avoid entrapment of hair by the advancing tape. When intravenous sedation with local anesthesia is used, the anterior vaginal wall is infiltrated with 0.25 % Bupivacaine (Marcaine) from the midurethra to the bladder neck proximally, and from the urethra in the midline to the endopelvic fascia bilaterally. The anticipated path of the transobturator needle is likewise infiltrated with Bupivacaine (Marcaine).

A Foley catheter placed in the bladder and a weighted vaginal speculum on the posterior vaginal wall facilitate the vaginal dissection. An Allis clamp or two are applied to the anterior vaginal wall over the midurethra, and a short incision (1–2 cm) is made in the anterior vaginal wall over the midurethra (Fig. 4.1). The vaginal wall is then dissected in the submucosal plane on both sides of the midline. The dissection is extended laterally to the ischiopubic rami (Fig. 4.2). Two stab incisions are made in the Genitofemoral folds, one on either side of the midline. These stab incisions should be at the level of the clitoris and overlying the superior medial aspect of the obturator fossa just below the insertion of Adductor Longus tendon (Fig. 4.3a, b). The lateral and the inferior portions of the obturator fossa should be avoided to minimize the risk of nerve and/or vascular injuries. The tunneler needle is then advanced through the skin incision, subcutaneous tissue, the adductor muscles (below the Adductor Longus tendon), the obturator externus, obturator internus muscle, and the obturator fascia (Fig. 4.4). The needle is then rotated medially below the Levator Ani and around the posterior edge of the ischiopubic ramus towards the midurethra while a finger in the vaginal incision guides the needle into the vaginal incision and protects the urethra from the advancing needle (Fig. 4.5). Caution should be exercised as the needle is passed over the lateral fold in the vaginal wall (sulcus) to avoid a button hole in the vaginal wall. A woven polypropylene tape is used for the sling. Once the needle is in the vaginal incision, one free end of the tape is threaded or attached to the end of the needle, and the needle is pulled back until the free end of the tape exits through the skin incision over the Genitofemoral fold (Fig. 4.6). The procedure is repeated on the opposite side in a similar fashion so that the tape is positioned over the midurethra and its free ends exit through the incisions in the Genitofemoral folds (Fig. 4.7). The tape tension is adjusted to provide passive support to the urethra during Valsalva. We prefer to tension the sling mesh with the Foley catheter in the urethra and a spacer is placed between the urethra and the sling mesh (Fig. 4.8). Alternatively, the sling is adjusted so as to leave a visual separation (1 mm) between the tape and the urethral wall. A right angle clamp may be placed between the mesh and the urethral wall to adjust the tension as well (Fig. 4.9). Excessive tension is avoided to minimize the risk of postoperative urethral obstruction and prolonged need for catheterization. The excess tape is excised just below the level of the skin incision (Fig. 4.10), the vaginal incision and the two skin incisions are irrigated with antibiotic solution, and the vaginal incision is closed with 2-0 Polyglycolic suture while the skin incisions are closed with 2-Octyl Cyanoacrylate (Dermabond) topical skin adhesive.

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Fig. 4.1

An Allis clamp is applied to the anterior vaginal wall over the midurethra, and a short incision (1–2 cm) is made in the anterior vaginal wall over the midurethra

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Fig. 4.2

The vaginal wall is dissected in the submucosal plane on both sides of the midline and extended laterally to the ischiopubic rami

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Fig. 4.3

(ab) Two stab incisions are made in the Genitofemoral folds, one on either side of the midline at the level of the clitoris and overlying the superior medial aspect of the obturator fossa just below the insertion of Adductor Longus tendon

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Fig. 4.4

The tunneler needle is advanced through the skin incision, subcutaneous tissue, the adductor muscles (below the Adductor Longus tendon), the obturator externus, obturator internus muscle, and the obturator fascia

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Fig. 4.5

The needle is rotated medially below the Levator Ani and around the posterior edge of the ischiopubic ramus towards the midurethra while a finger in the vaginal incision guides the needle into the vaginal incision and protects the urethra from the advancing needle

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Fig. 4.6

Once the needle is in the vaginal incision, one free end of the tape is threaded or attached to the end of the needle, and the needle is pulled back until the free end of the tape exits through the skin incision over the Genitofemoral fold

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Fig. 4.7

The procedure is repeated on the opposite side in a similar fashion so that the tape is positioned over the midurethra and its free ends exit through the incisions in the Genitofemoral folds

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Fig. 4.8

Tension is placed on the sling mesh with the Foley catheter in the urethra, and a spacer is placed between the urethra and the sling mesh

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Fig. 4.9

A right angle clamp may be placed between the mesh and the urethral wall to adjust the tension

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Fig. 4.10

The excess tape is excised just below the level of the skin incision

Following technical landmarks are mandatory to ensure successful procedure: the vaginal incision must include all the thickness of the vaginal wall; the transobturator end point must be located at the level of the midurethra; the tunneling needle must have a close contact with the ischiopubic bone; the finger inside the vaginal incision protects the urethra [43]. The tape has a transverse course; it crosses the adductor muscles close to their pubic insertion and passes through the obturator foramen by crossing the obturator membrane, before reaching the middle plane of the perineum after having crossed the obturator internus muscle. The tape passes above the internal pudendal pedicle and then under the Levator Ani muscle, under the tendinous arch of the pelvic fascia and continues in the middle third of the urethrovaginal septum [12]. At the end of the procedure, cystoscopy is done to ensure patency of the ureters and to exclude bladder or urethral injuries [944]. Removal of the Foley catheter concludes the procedure.

In the recovery room, a voiding trial is done when the bladder is full. Patients who void successfully can be discharged without a catheter while those who don’t will require an indwelling catheter usually for 1–2 days. Self-catheterization can also be used as an alternate to indwelling catheter. The patient is discharged home with oral analgesics and antibiotic prophylaxis. The patient is instructed to remove the vaginal pack within 24 h. They can resume ambulation the same day, resume driving within 1 week, and may return to work after 2 weeks; however, they should avoid straining for 6 weeks. Postop care should include pelvic exam to rule out sling mesh extrusion which can be minimal and very difficult to recognize. Vaginal creams including estrogen cream are avoided in the first 6 weeks postop to reduce the risk of accidental manipulation of the vaginal incision in the healing phase.

Postoperative Adverse Outcome

Urinary Retention and Obstruction

Voiding dysfunction after midurethral sling procedures is uncommon. If a patient is unable to void 48 h postoperatively, and there is a concern that excessive tension may be the cause, early tape release is advisable before any tissue in growth has occurred. Ozel et al. reported on a method to adjust the transobturator midurethral sling under local anesthesia in the early postoperative period for postoperative voiding difficulty. Both patients had immediate resolution of their symptoms while maintaining urinary continence [45].

Extrusion

Extrusion refers to the vaginal exposure of the tape mesh through the vaginal mucosa. It could be at the incision site (central) or at the sulcus (lateral). Several theories regarding the tape extrusion has been proposed. It’s the author’s belief that the etiology may vary depending upon host (patient), technique (surgeon), device (tape) factors, or any combination thereof. Although several reports suggest that estrogen should be used as the primary method of treatment for all tape extrusion, we believe tape excision and primary closure in the office under local anesthesia is more effective in most cases.

Urethral and Vesical Erosion

Erosion of the tape into the urethra may result if the dissection in the vaginal incision is carried deep and close to the urethral wall. Erosion into the bladder may occur due to in advert passage of the introducer needle into the bladder during passage. The presence of cystocele may increase this risk. If the patient presents with history of recurrent UTI or irritative voiding symptoms, erosion should be suspected, and cystoscopy should be done. Urethral erosions may be repaired transvaginal with mesh removal, urethral repair with/without Martius flap. Placing another sling at the same time should be avoided because the risk of recurrent erosion is high. If erosion occurs in the bladder, a transvaginal repair with/without Martius flap may be done; however, a transvesical approach may be needed if the mesh is embedded in the bladder wall and there is excessive tissue ingrowth or stone formation. In an assessment of factors increasing risk of injury, and comparison of the “outside-in” and “inside-out” techniques, 241 women underwent TOT technique and 148 of them underwent TVT-O technique. Four injuries occurred (1 %): two urethral injuries (0.5 %) and two bladder injuries (0.5 %). All 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. They concluded that lower urinary tract injury is an uncommon complication of the TOT procedures and in their hands only occurred with the outside-in technique. Intraoperative cystoscopy should be considered only in selected cases [44].

Urinary Tract Infection

If a patient presents with recurrent UTI, it should raise the suspicion of urethral or bladder erosion, and cystoscopy should be considered once the acute infection is treated. A single episode of UTI should be treated with antibiotics in the usual fashion.

Dyspareunia

If a patient reports Dyspareunia postoperatively, proper evaluation to rule out mesh extrusion or granuloma formation should be sought and addressed accordingly. However, in the absence of specific reversible physical findings, proper evaluation of the potential etiology of female sexual dysfunction should be conducted and the necessary treatment recommended accordingly.

Urinary incontinence is a common condition that negatively impacts female sexuality. In one study, at 60-month follow-up, 52 patients (72 %) were objectively cured of SUI but only 44 patients (61 %) were satisfied. The mean cause of dissatisfaction was the development of sexual dysfunction resulting from Dyspareunia or incontinence during intercourse, which was found in 37.5 % [40]. Another study of 46 women who completed 12-month follow-up, 71 % of sexually active women showed an improvement in the total 12-item POP/Incontinence Sexual Function Questionnaire scores [23].

In yet another study of 133 patients who underwent TOT procedure, or a retropubic procedure, and who completed 12-month follow-up, data showed that after a midurethral sling procedure, female sexual function improves. The authors also found that a very relevant percentage of nonsexually active women reported renewed sexual activity after midurethral sling [46].

Recurrent Incontinence

If urinary incontinence persists beyond 3 months of surgery, complete evaluation including urodynamics should be done to elicit the etiology of persistent or recurrent incontinence. In the majority of cases, persistent detrusor overactivity/urge incontinence, or de novo urge incontinence is the etiology and conservative management should be considered first. In those who demonstrate urethral obstruction on urodynamic studies, initial trial at urethral dilation and if it fails, tape release should be considered. In those who have recurrent SUI, consideration should be given to proximal tape placement or migration as the possible etiology, and tape removal and replacement should be considered. If this is done, tape fixation will increase the likelihood of success. Alternatively, bulking agents may be used or otherwise in a lead pipe urethra consideration for midurethral retropubic sling should be given.

In one study done in 463 patients with SUI who were randomly allocated to treatment with a standard TOT procedure or to a TOT procedure with additional 2-point tape fixation. Two absorbable sutures parallel to the urethra were added to fix the tape and prevent displacement during tape tensioning. Objective clinical efficacy of the procedure at 12 months with fixation was significantly higher with 95.12 % cured or improved compared to 88.73 % cured or improved with the standard sling (P = 0.0169). Also, among patients with ISD they noted a significantly better outcome in the fixation group than in the control group, 95.1 % cured or improved vs. 73.8 % (P = 0.0011). The authors concluded tape fixation significantly increases the clinical efficacy of the transobturator sling, especially in patients with ISD [47].

De novo Urgency

In patients who develop de novo urgency/urge incontinence, obstruction should be ruled out. In the absence of obstruction, the majority of cases will resolve spontaneously. In those in whom it persists, it should be treated with behavioral modification with or without pharmacotherapy. If obstruction is suspected, urodynamic studies should be done, and urethrolysis should be considered if obstruction is diagnosed.

Leg pain

Based on cadaver studies, the outside-in (TOT) technique results in the mesh being placed farther from the obturator canal and closer to the ischiopubic ramus, theoretically reducing the risk of neurovascular injury [16]. In a study of TOT vs. TVT-O, severe postoperative thigh pain was twice as common in the inside-out group but this was not statistically significant [48]. In another study of 127 women, the TVT-O caused more transient leg pain than the TVT (26.4 % vs. 1.7 %, P = 0.0001) [49]. In the author’s experience, thigh pain is mild and transient, and responds well to nonsteroidal anti-inflammatory agents.

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