Tensionless vaginal tape (TVT) was introduced in 1996 by Prof Ulf Ulmsten and P. Petros for management of stress urinary incontinence. The procedure was done via a retropubic method1. This method had a very high success rate but was associated with higher morbidity which includes voiding dysfunction, bladder injury, vascular injuries and bowel injuries2. Newer techniques were then sort to reduce the risk of bladder injury, urinary retention, voiding dysfunction and other morbidities.
In 1998, Nickel from Holland reported a successful sling procedure using a polyester ribbon passed through the obturator foramen and around the urethra for treatment of refractory urethral sphincter incompetence in female dogs3. In France in 2001, Emmanuel Delorme introduced this transobturator sling procedure in humans4. He then reported the use of ‘Uratape’ as a simple and effective procedure with a follow-up of one year for the treatment of female stress urinary incontinence. He found that this transobturator approach avoids the risks of bladder, intestinal and vascular injuries5. In this approach, the vaginal dissection is as per the retropubic approach. The transobturator approach involves trocar passage through the obturator membrane and obturator internus muscle from a groin incision below the adductor muscle insertion. The trocar will exit through the vaginal incision. Anatomical studies have shown that in this method, the synthetic sling is placed entirely outside the pelvis and also of the retropubic space, within the foremost extension of the ischiorectal fossa6.
The original transobturator tape (TOT) operation was described as an ‘outside-in’ technique with the tape being passed from the thigh into the vaginal incision (Uratape, Porges-Mentor, Le Plessis, Robinson, France). In 2003, De Leval, further modified the technique as an ‘inside-out’, approach, with a vaginal incision through the obturator foramen and out through the inner thigh as the TVT-Obturator (TVT-O, Ethicon)7.
Grise P et al reported on the initial short term results of using this technique. This study confirmed the optimal results in stress incontinence previously reported in other short-term studies. These results suggested that the transobturator tape procedure is a valuable alternative to the retropubic procedure, with a lower rate of complications8.
The TOT procedure was noted to have high objective and subjective cure rates and low complications rate, even at the beginning of the surgeon's learning curve. However, a more experienced surgeon could significantly improve the subjective cure rate and could also reduce postoperative the groin pain9.
The TOT techniques of either outside in or inside out was found to be equally efficient for the treatment of female urinary incontinence with maintenance of high cure rates for 3 years10.
Latthe P et. al. found evidence for the equivalent effectiveness of TOT and TVT-O when compared with each other is established over the short-term. Bladder injuries and voiding difficulties seem to be less with inside-out tapes on indirect comparison11. Spinosa et al on the other hand found that the safety margins were reduced with the inside-out technique, and the external pudendal vessels and the posterior branch of the obturator nerve were at greater risk of injury. He concluded that the two techniques are not equivalent, with a lower risk of injury to vascular and nerve structures with the outside-in technique12. Debodinance P reported that the two trans-obturator access routes are equally safe and do not require per-operative cystoscopic evaluation. The clinical results would appear to be equivalent, in terms of recovery, to the rates obtained with retropubic TVT13. Tommaselli et al found that vaginal injuries were more common with TOT than with TVT-O14.
Comparing TVT and TOT, Latthe et al, found that the subjective cure between TOT and TVT were similar15. Giacomo Novaraa et al found that the use of retropubic tapes was followed by objective cure rates slightly higher than TOT, but subjective cure rates were similar. TOT had a lower risk of bladder and vaginal perforations and storage LUTS than RT16. However adverse events such as bladder injuries and voiding difficulties were less common for the TOT. Mean operating time, length of stay, and postoperative pain scores were similar between the two groups. The incidence of groin or thigh pain was higher in TOT route. The incidence of mesh exposure were also higher for the TOT17,18. Long CY et al found that TOT has the advantages over TVT with shorter operative time and a relatively lower complication rate. For women with intrinsic sphincter deficiency, however, TVT appears to be a better option because it is more obstructive19.
In a patients who underwent a midurethral sling procedure with concomitant vaginal hysterectomy and apical compartment repair, were associated with a higher risk for objective and subjective failure20. This needs to be considered when counselling patients with prolapse and urinary stress incontinence undergoing prolapse repair and TOT/TVT.
In conclusions, TOT is a safe procedure. It has less risk of bladder perforation, voiding dysfunction, vascular injury when compared to the TVT procedure. The TOT procedure provides high objective and subjective long-term efficacy, a clinically meaningful improvement in patient quality of life, and an excellent safety profile. The efficacy is almost equivalent to the efficacy of the TVT. There is a higher risk of mesh exposure in TOT procedure as compared to the TVT. There were higher complaints of thigh and groin pain in TOT group. However there was no difference in effectiveness and complications between the two TOT techniques.
References:
1. Ulmsten U, Petros P. Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol 1995; 29: 75–82
2. Debodinance P, Delporte P, Engrand JB, Boulogne M. Tension-free vaginal tape (TVT) in the treatment of urinary stress incontinence: 3 years’ experience involving 256 operations. Eur J Obstet Gynecol Reprod Biol. 2002 Oct 10;105(1):49-58.
3. Nickel RF, Wiegand U, Brom WV. Evaluation of a trans pelvic sling procedure with and without colposuspension for treatment of female dogs with refractory urethral sphincter mechanism incompetence. Vet Surg. 1998; 27:94–104.
4. Delorme E. Transobturator urethral suspension: Mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol. 2001; 11:1306–13.
5. Delorme E, Droupy S, de Tayrac R, Delmas V Transobturator tape (Uratape). A new minimally invasive method in the treatment of urinary incontinence in women. Prog Urol. 2003 Sep; 13(4):656-9.
6. Spinosa JP, Dubuis P, Riederer B. Transobturator surgery for female stress incontinence: a comparative anatomical study of outside-in vs inside-out techniques. BJU Int 2007; 100: 1097–102
7. de Leval J. Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol. 2003 Dec; 44(6):724-30.
8. Grise P, Droupy S, Saussine C, Ballanger P, Monneins F, Hermieu JF, Serment G, Costa P. Transobturator tape sling for female stress incontinence with polypropylene tape and outside-in procedure: prospective study with 1 year of minimal follow-up and review of transobturator tape sling. Urology. 2006 Oct; 68(4):759-63.
9. Serati M, Bogani G, Braga A, Sorice P, Salvatore S, Uccella S, Ghezzi F. Is there a learning curve for the TVT-O procedure? A prospective single-surgeon study of 372 consecutive cases.Eur J Obstet Gynecol Reprod Biol. 2015 Mar; 186:85-90.
10. Park YJ, Kim DY. Randomized controlled study of MONARC® vs. tension-free vaginal tape obturator (TVT-O®) in the treatment of female urinary incontinence: comparison of 3-year cure rates. Korean J Urol. 2012 Apr; 53(4):258-62.
11. Latthe P, Singh P, Foon R, Toozs-Hobson P. Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials. BJU Int. 2010 Jul; 106(1):68-76.
12. Spinosa JP, Dubuis P, Riederer B. Transobturator surgery for female stress incontinence: a comparative anatomical study of outside-in vs inside-out techniques. BJU Int 2007; 100: 1097–102
13. Debodinance P. Trans-obturator urethral sling for the surgical correction of female stress urinary incontinence: outside-in (Monarc) versus inside-out (TVT-O). Are the two ways reassuring? Eur J Obstet Gynecol Reprod Biol. 2007 Aug; 133(2):232-8.
14. Tommaselli GA, Di Carlo C, Formisano C, Fabozzi A, Nappi C. Medium-term and long-term outcomes following placement of midurethral slings for stress urinary incontinence: a systematic review and metaanalysis. Int Urogynecol J. 2015 May 20. [Epub ahead of print]
15. Latthe PM, Foon R, Toozs-Hobson P. Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications. BJOG. 2007 May;114(5):522-31
16. Giacomo Novaraa Artibani W, Barber MD, Chapple CR, Costantini E, Ficarra V, Hilton P, Nilsson CG, Waltregny D. Updated Systematic Review and Meta-Analysis of the Comparative Data on Colposuspensions, Pubovaginal Slings, and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence . European Urology. Volume 58, Issue 2, August 2010, Pages 218–238
17. Barber MD Kleeman S, Karram MM, Paraiso MF, Walters MD, Vasavada S, Ellerkmann M. Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2008 Mar;111(3):611-21
18. Laurikainen E, Valpas A, Aukee P, Kivelä A, Rinne K, Takala T, Nilsson CG. Five-year results of a randomized trial comparing retropubic and transobturator midurethral slings for stress incontinence. Eur Urol. 2014 Jun;65(6):1109-14
19. Long CY, Hsu CS, Wu MP, Liu CM, Wang TN, Tsai EM. Comparison of tension-free vaginal tape and transobturator tape procedure for the treatment of stress urinary incontinence. Curr Opin Obstet Gynecol. 2009 Aug;21(4):342-7.
20. Athanasiou S, Grigoriadis T, Zacharakis D, Skampardonis N, Lourantou D, Antsaklis A. Seven years of objective and subjective outcomes of transobturator (TVT-O) vaginal tape: why do tapes fail? Int Urogynecol J. 2014 Feb;25(2):219-25.
Written by:
Balakrishnan SS, Department of O and G, Penang Medical College, Pulau Pinang, Malaysia; Department of O and G, Hospital Pulau Pinang, Pulau Pinang, Malaysia
The transobturator outside in suburethral sling insertion procedure - Abstract