Study design, materials and methods
Design
A retrospective analysis of all trans-obturator tape operations for stress urinary incontinence performed between February 2014 and September 2020 in our facility.
Methodology
Data collected using medical records of 196 women whom underwent TVTO/TOT.
The following information were collected from patient records:
(1) whether the type of incontinence had been confirmed by objective urodynamic investigation.
(2) Whether conservative treatment had been tried prior to surgery.
(3) What information had been provided to the patient prior to obtaining consent.
(4) Any complications during and immediately after the operation.
(5) Any long-term complications.
(6) Patient Cure Rate.
Results
Results
Preoperative assessment showed 74/196 patients (38%) tried conservative management before surgery, 70/196 patients (36%) had urodynamics preoperatively and finally 196/196 patients (100%) were consented preoperatively explaining the procedure with full info about advantages and disadvantages.
Intraoperative assessment showed no reported cases of bladder perforation, nor injury to blood vessels, nor injury to nerves or bowels, nor vaginal wall perforation, nor urethral injury or hematoma formation Intraoperatively.
Post-operative assessment showed cure rate of 187 patients (95%), the other 9/196 (5%) failed to adhere to the follow up schedule. In the immediate postoperative period; 2 patients had urinary retention which was managed by urinary catheter for 24 hours and resolved,1 patient had lower limb paresthesia that resolved spontaneously and gradually over 72 hours. Out of the187 patients whom adhered to the Postoperative follow up; 2 developed Denovo Urgency (OAB) and 3/8 had Voiding Dysfunction (one of them underwent tape division). No reported cases of Mesh erosion or Urinary tract infection.
Interpretation of results
Since the introduction of MUS in the mid-1990s, the retropubic sling has become the gold standard for treatment of female SUI. This surgical procedure is associated with high subjective and objective SUI cure rates (80–90%) after > 11 years of follow-up.The original tension-free vaginal tape (TVT) sling, as described by Ulmsten et al, technique used a retropubic route for the insertion of the tape. Intra- and postoperative complications resulting from the penetration of the surgical device into pelvic organs (bladder and bowel), nerves, and vessels, have been reported. In an attempt to minimize the blind passage of the retropubic space and the subsequent risk of major bleeding and bladder injury, in 2001, Delorme proposed an outside-in transobturator (TOT) passage through the obturator foramen for sub urethral tape placement followed by an inside-out procedure (TVT-O) which was introduced in 2003 by De Leval.
The goal of this study is to evaluate the extent of compliance with the new NICE/European and American guidelines on the use of TVTO/TOT for stress incontinence, evaluate the clinical effectiveness of TVTO/TOT treatment of patients especially those with comorbidities in whom minimally invasive MUS is the surgical approach of choice, measure the outcomes of TVTO/TOT treatment of patients and to compare the outcome with the results of recognized controlled trials, assess the prevalence of intra- and post-operative complications on TVTO/TOT treatment such as intraoperative significant bleeding; bladder or urethral perforation; intraoperative Obturator complex injuries ; post-operative urinary retention; long term voiding dysfunction; de novo OAB ; aggravation of pre-existing urge incontinence; rejection of the tape or defective healing and /or mesh extrusion and finally to conclude with evidence that MUS has largely been regarded as the "gold standard" in treatment of stress urinary incontinence (SUI) with high success rate and safety profile.
Analysis of the results found :
Preoperative assessment showed 74/196 patients (38%) tried conservative management before surgery, 70/196 patients (36%) had urodynamics preoperatively and finally196/196 patients (100%) were consented preoperatively explaining the procedure with full info about advantages and disadvantages.
Intraoperative assessment showed no reported cases of bladder perforation, nor injury to blood vessels, nor injury to nerves or bowels, nor vaginal wall perforation, nor urethral injury or hematoma formation Intraoperatively.
Post-operative assessment showed cure rate of 187 patients (95%), the other 9/196 (5%) failed to adhere to the follow up schedule. In the immediate postoperative period; 2 patients had urinary retention which was managed by urinary catheter for 24 hours and resolved,1 patient had lower limb paresthesia that resolved spontaneously and gradually over 72 hours. Out of the187 patients whom adhered to the Postoperative follow up; 2 developed Denovo Urgency (OAB) and 3/8 had Voiding Dysfunction (one of them underwent tape division). No reported cases of Mesh erosion or Urinary tract infection.
Comparing the results to the to the international bench mark success rate and least complications rate , the study have proven positive outcome measures and in line with the expected management , success rates , safety ,risk adjusted outcome and least complications rate both short and long term.
The study concluded that MUS is safe, effective minimally invasive surgical technique with high success rate comparable and even superior to the more invasive morbid conventional methods such as Autologous facial slings and colposuspension especially for our patients with multiple medical and surgical comorbidities , hence should be continued to be the first surgical option and should be offered and recommended to our patients following adequate counselling and informed patient’s consent.