CODE: 12.2 - Comparison of the results of stress urinary incontinence treatment using trans vaginal (TVT) and trans obturator (TOT) approach
Article published in Urologia Polska 2006/59/Suplement 1.

authors

Zbigniew Wolski ¹, Magdalena Mikulska-Jovanović ¹, Aleksander Łapuć ¹, Zbigniew Trzepizur ², Marek Sosnowski ², Eugeniusz Miękoś ²

¹ Katedra i Klinika Urologii Collegium Medicum w Bydgoszczy, UMK w Toruniu
² Klinika Urologii i Rehabilitacji Urologicznej Uniwersytetu Medycznego w Łodzi

summary

Introduction. The new method of mid-urethral support, without tension - TVT - developed by Ulmsten in 1995 revolutionized the treatment of the stress urinary incontinence. Despite good efficacy, this method did not avoid the risk of complications. Most of these complications seem to be related to the preparation of the retro-pubic space. In 2001 Delorme presented a new surgical technique using foramen obturator approach (outside - inside) - TOT, aiming to reduce the risk of complication.

Objectives. The evaluation of the efficacy and safety of the treatment of the stress urinary incontinence using TVT and TOT.

Materials and methods. Between October 2003 and December 2005, 55 TOT procedures in women aged 44-78 were performed, using non-woven polypropylene tape - Obtape (Porges-Mentor) and the foramen obturator approach (Group I); between January 2000 to December 2003 43 TVT procedures in women aged 49-72 (group II) were performed. In group I ten (18.2%) patients were operated earlier due to urinary incontinence: in 7 patients anterior colporaphy, in 2 patients Miszczerska method were applied, and in 1 patient, an urethro-vaginal fistula appeared after the TVT procedure, which necessitated TVT tape removal and few repairing procedures. This did not bring the relief of symptoms of urinary incontinence in that woman. In group II 3 patients underwent anterior colporaphy earlier. In all patients the preoperative work-up included: clinical examination, cough and Boney test, urodynamic examination, abdominal ultrasound with evaluation of urinary tract and post voiding residual urine, and in a selected cases cystoscopy. During the TVT procedure in all patients a cystoscopy was performed. In TOT procedure, cystoscopy was not used. All patients were evaluated one, three and six months after the operation. By the first visit the cough test with a full bladder, gynecological examination with estimation of the healing of the anterior vagina wall, uroflowmetry and ultrasound with post void residual urine were performed.

Results. The mean follow up in group I was 11 months (2-26) and in group II 18,6 months (3-36). After TOT procedure 48 (87.2%) patients were completely cured and 3 (5.4%) improved. In 4 patients, the symptoms of urinary incontinence did not resolve (7,2%). After TVT 38 (88.37%) were completely cured and 2 (4.65%) were improved. The symptoms of urinary incontinence did not resolve in 3 (6.97%) patients. After TVT, bladder perforation was observed in 3 (6.97%) and vesico-vaginal fistula in 1 (2.32%) patient. The above mentioned complications were not observed after TOT procedures. Complete urinary retention occurred in 6 (13.95%) of the patients after TVT and in 2 (3.6%) after TOT. During the TOT procedure three perforation of the vaginal vault were observed after the insertion of the tunneler with the tape. This was immediately intraoperatively repaired, without removing the tape. De novo urgency developed in 5 (11.65%) patients in group II and in 2 (3.6%) in group I. One vaginal erosion occured 2 months after TOT procedure; the tape was removed with recurrence of incontinence. The Foley catheter, inserted during the procedure, was removed on the first postoperative day. The mean overall clinical stay was 4 days in I group and 3,7 days in II group. The average length of operating time of TOT procedure was 28 min., and TVT procedure 34 min. No vascular, bowel or nerve injury was observed in both groups.

Conclusions. 1. Both operating methods are effective in the treatment of stress urinary incontinence in women. 2. TVT surgical approach carries a greater risk of perioperative complications when comparing with TOT. 3. The advantage of both methods are short operating time and hospital stay. 4. A longer follow-up is required for the exact evaluation of the TOT method. 5. TOT seems to be safe even in patients treated ineffectively earlier due to urinary incontinence using an open retropubic procedure.