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Transobturator tape
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Aboubakr Elnashar
The surgical management of female SUI has
been deeply changed when Ulmsten described
a new concept in 1995: the mid-uretheral
support without tension (TVT).
In 2001, Delorme described a new approach
(TOT) eliminating the complications related to
the penetration of the retro-pubic space
Aboubakr Elnashar
TVT procedures use a vertical, retropubic route.
This intrapelvic route exposes the patient to a number of complications:
bladder perforation
injuries to blood vessels or GIT
Aboubakr Elnashar
•TVT: By placing a prolene tape around the
midurethera without tension Restores
the pubourethral ligaments & the
suburetheral vaginal wall Dynamic
kinking of the midurthera at stress (Rezapour et
al, 2001)
•Corrects the central & lateral fascial
defects of the anterior compartment of the
vagina (Ursula et al,2000)
Aboubakr Elnashar
TOT: The tape is placed under the mid-
urethera (as in TVT) between the two
obturator foramen, creating a real
hammock supporting the urethera
(uretheral suspension in TVT)
(Delorme,2001).
It is purely perineal & transverse
The position of TOT is similar to that of
natural hammock supporting the
urethera
Aboubakr Elnashar
1.Anticoagulant therapy (stop 14 d or replace
with low dose heparin)
2.Urinary tract infection
3.No sexual intercourse, heavy
lifting or exercise for 1mo
Aboubakr Elnashar
1. Genuine SI.
2. SI with Intrinsic sphincter deficiency (urethral p
<20 cm H2O).
3. Mixed I (urge & stress).
4. Recurrent SI (previous traditional surgical
procedure had failed).
Aboubakr Elnashar
1. Pregnancy
2. Women with plan for future pregnancy
(prolene mesh will not stretch
significantly). Incontinence may recur.
3. Motor urge incontinence & significant
detrusor instability (Ulmsten,2001)
Aboubakr Elnashar
TVT: Ursula et al,2000: 8.7% in 1762 patients
1. Bladder perforation: 5.4%. The most frequent
complication
2. De novo urgency or urge incontinence: 5.1%
3. Retropubic haematoma: 0.8%
Aboubakr Elnashar
4. Rare complications
a. Anterior vaginal wall laceration
b. Retained plastic sheath
c. Obturator nerve irritation
d. Vaginal wound infection
Most of these complications are related to the
penetration of the retropubic space
Aboubakr Elnashar
TOT:
Although the complications are uncommon, they must
be kept in mind in order to adopt an appropriate strategy
to prevent their development
I. Costa et al (2004) 183 women
Intraoperative: 2.2% (Up to 15% in TVT (Lebert et al, 2001)
No vascular, nerve or bowel injury
Bladder perforation: 1
Uretheral perforation: 2
Lateral vaginal perforation: 1
All these complications disappeared with use of the index finger
into the vaginal incision. Aboubakr Elnashar
Postoperative:
1. De nevo urgency: 5% (from 0-20% in TVT, Peschers et
al, 2000)
2. Voiding disorders: 3.3% (7 women)
{excessive tension of the tape}
Treatment:
immediate release of the tape in 3 (surgical 2,
uretheral dilatation with Hegar 1)
Temporary intermittent self-catheterization in 4
Aboubakr Elnashar
3. Vaginal extrusion of the tape: {silicon part
of the tape}.
Obtape not contain silicon
At 1 year
80.5% were completely cured
7.5% were improved
Aboubakr Elnashar
II. Krauth et al,2005: 604 women
Operative: very few
0.5% vesical perforations,
0.3% vaginal perforations,
no urethral wounds,
0.8% 200-300 ml haemorrhages,
2 perineal haematomas (0.33%).
Aboubakr Elnashar
Post-operative:
1.5% transient retentions,
2.3% transient pain,
2.5% urinary infections,
1.3% transient dysuria.
Aboubakr Elnashar
After 3 mo
5.2%: de novo symptoms.
After one year:
Satisfaction rate: 85.5%
1.5%: de novo dysuria & urgency.
Aboubakr Elnashar
III. But (2005):
Vaginal wall erosion 6.7%: 6 weeks after surgery
(Monarc)
The greater prevalence of vginal wall erosion
demand a search for the mechanism.
Treatment:
The periuretheral portion of the tape was removed &
a new Prolene tape was placed through the
retropubic space.
Follow up after 3 months: No signs of erosion.
Aboubakr Elnashar
Long term safety is not known, particularly in
relation to
changes in the synthetic material changes in
bladder & uretheral behaviour
as voiding disorders & bladder instability
(Delorme,2004)
Aboubakr Elnashar
I. De Tayrac et al (2004): 31 TVT & 30 TOT
TOT TVT P
Operative time
Bladder injury
Urinary retention
Cure
Improvement
Failure
15 min
0.0
13.3
90%
3.3%
6.7%
27 min
9.7%
25.8%
83.9%
9.7%
6.5%
S
S
S
NS
NS
NS
Aboubakr Elnashar
After 1-year:
No vaginal erosion occurred in either of the
groups.
No differences were found in bladder outlet
obstruction after TVT and T.O.T.
CONCLUSION: T.O.T. appears to be equally
efficient as TVT for treatment of SUI.
Aboubakr Elnashar
II. Mellier et al (2004): 94 TOT & 99 TVT
TOT TVT P
Hgic complications
Bladder injuries
Uretheral injuries
Cure rate
2%
0.0
0.9%
95%
10%
10%
0.0%
90%
S
S
NS
NS
Aboubakr Elnashar
In conclusion:
Obturator approach shows identical urinary
results to the retropubic approach.
Major hemorrhage and bowel perforation
are excluded in the TOT procedure.
Thus simplicity, safety and continence result
mean that the obturator approach is the
best method of suburethral tape insertion
for the treatment of USI.
Aboubakr Elnashar
1.TOT is a safe, effective technique for the
treatment of female SUI.
2.The easy technique, the short learning
curve & the very high grade of satisfaction
of the patient show that this approach is
based upon effective anatomical &
physiological criteria.
Aboubakr Elnashar
E-mail: [email protected] Aboubakr Elnashar