QUEBEC CITY, Que: TOT offers a true alternative to mid-urethral slings in patients with mixed incontinence, Dr. J. Christian Winters told delegates here to Urogynecology Quebec 2007. What’s more, he noted, there is a decreased risk of voiding dysfunction with TOT and in selected patients, you can expect similar efficacy to retropubic MUS with decreased LUTS.
This ‘inside-out’ or ‘outside-in procedure,’ which requires no entry into the retropubic space, is associated with decreased incidence of bowel injury and bladder perforation, said Dr. Winters, who is professor and chairman, Louisiana State University Health Sciences Center, New Orleans, LA.
There is also less potential for major vascular injury. “The TOT procedure offers a true alternative in the ‘hostile’ retropubic space and the wider hammock of support approximates normal anatomy,” said Dr. Winters.
A 12-month followup of outcomes with retropubic tension free procedures show that they may be more effective than transobturator procedures, particularly in ISD patients, noted Dr. Winters. “The forces that are put on the urethra explain the theoretic rationale…” he said, adding that, “Both are highly effective for the hypermobile patient.”
In reviewing the literature, Dr. Winters highlighted the following:
* randomized trials looking at TOT versus TVT show there is no difference in clinical outcomes and US tape position; however, OR times and complications are decreased after TOT;
* a comparison of TOT with SPARC and Monarc in 276 patients showed that de novo subjective UUI differed significantly between patients in the Monarc group and those who received a retropubic sling;
* in the same group, 14-16% of patients with preoperative UUI who underwent TVT or SPARC had worsening of their UUI symptoms compared to only 6% in the Monarc group;
* a retrospective study of 90 TVT and 90 TOT patients showed that there were no major complications in either group although there was less short-term voiding dysfunction with TOT;
* in the same study, cure/improved rates for the TVT group were 91% and 7%, respectively, and for the TOT group, 95% and 4%, respectively; and
* when similar tensioning techniques are used, Monarc is less obstructing than TVT.
While there are fewer bladder injuries with TOT, there are more vaginal injuries, pointed out Dr. Winters. In his experience, he said, active patients are more apt to get thigh pain. “There are sub-groups of patients for whom the retropubic approach is better,” said Dr. Winters, adding that, “I do a TOT in very rare instances.”
“Why do we need an improvement in results with trans-obturator tapes?” asked Dr. Geoffrey Cundiff, professor and chair, department of obstetrics and gynecology, St. Paul’s Hospital, Vancouver. “Is it because of unhappiness about hitting the bladder?”
The only way you can reassure patients that the tape is in the right place (and not in the bladder) is to do a cystoscopy after the procedure, said Dr. Cundiff. (“If you’re doing any procedure for incontinence, you should be doing cystoscopy afterwards,” he pointed out.)
Despite these reservations about TOT, Dr. Cundiff conceded that, “a lot of work has gone into developing the procedure as a better alternative to retropubic techniques. I do think there is a place for TOT in patients in whom you want to stay out of the retropubic space. We shouldn’t use the same hammer for every nail.”
The hypothesized advantages of the trans-0bturator sling is that it has equal efficacy, less voiding dysfunction, safer passage and that cystoscopy is not necessary. But does it have equal efficacy? asked Dr. Cundiff.
He cited a prospective multicentre trial of TVT (42 patients) and TOT (46 patients) with a 10-month followup which showed that there was no difference in de novo urge incontinence, voiding dysfunction or quality of life improvement (Darai EI. Eur Urol, 2007 Mar; 51(3);795-802).
However, a retrospective case control study of Sparc versus Monarc (Dietz HP, Int Urogynecol J. Pelvic Floor Dysfunction, 2006; 17(6): 566-9) indicated that even though there was no difference in voiding dysfunction, there was a significant difference in cure and improvement and in patient satisfaction. What’s more, a prospective RCT of Sparc versus Monarc (Wang AD. Int Urogynecol J Pelvic Floor Dysfunc 2006; 17(5): 439-43) indicated that bladder injury is more common in TVT while thigh pain is more common in TOT.
Is TOT safer? Dr. Cundiff noted that “if you look at any procedure that’s new, the answer is always ‘yes’ because problems [associated with it] haven’t hit the literature yet.”
Dr. Cundiff’s review of the literature revealed reports of the following complications:
* vulvar hematoma following a transobturator sling (TVT-O);
* retropubic hematoma after transobturator sling procedure;
* obturator abscess after transobturator tape for stress urinary incontinence;
* prepubic and thigh abscess after successive placement of two suburethral slings;
* abscess of the thigh and psoas muscle after transobturator suburethral sling procedure;
* large thigh abscess after placement of synthetic transobturator sling;
* necrotizing fasciitis following unrecognized bladder injury during transobturator sling procedure;
* transobturator tape erosion associated with leg pain;
* vaginal erosion, sinus formation and ischiorectal abscess following transobturator tape: ObTape implantation
Dr. Cundiff noted that, “a lot of the erosion problems are with the OB tape, which is not an ideal mesh.”