UROLOGICAL SURVEY   ( Download pdf )

 

FEMALE UROLOGY

Tension-free vaginal tape for stress urinary incontinence: Is there a learning curve?
Groutz A, Gordon D, Wolman I, Jaffa AJ, David MP, Lessing JB
Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
Neurourol Urodynam. 2002; 21:470-2

  • Aim: To assess the learning curve characteristics of the first 30 tension-free vaginal tape (TVT) procedures carried out in our medical center and to evaluate its safety and short-term effectiveness.
  • Methods: A total of 30 incontinent women with urodynamically proven SUI were enrolled. None had undergone any previous anti-incontinence procedure. All were operated on by one surgeon, in accordance with the technique describe by Ulmsten et al. in 1996. Mean follow-up was 11.4 ± 3.6 months (range, 5-17 months).
  • Results: Five (17%) bladder perforations occurred at the beginning of the study, due to inadvertent insertion of the applicator. All perforations were identified by intraoperative cystoscopy. Five other patients (17%) had increased intraoperative bleeding (> 200 mL) necessitating vaginal tamponade. Blood transfusions were not required. Eight (27%) patients had immediate postoperative voiding difficulties, necessitating catheterization for 2-10 days, but none needed long-term catheterization. There was no local infection or rejection of the Prolene tape was found. All patients were subjectively cured of their stress incontinence; however, urodynamic evaluation revealed “asymptomatic genuine stress incontinence” in one patient. Sixteen of 21 patients (80%) with preoperative urge syndrome had persistent postoperative symptoms. No patient developed de novo urge incontinence.
  • Conclusion: The TVT operation is a new, minimally invasive surgical procedure with excellent short- and medium-term cure rates. However, there is a definite learning, curve, and we believe that the operation should only be performed by experienced surgeons.

  • Editorial Comment
    The authors present their experience regarding the initiation of tension-free vaginal tape (TVT) placement at their hospital for the treatment of stress urinary incontinence. They examined 30 incontinent women who had never had previous anti-incontinence surgery. The TVT placement was performed by one surgeon. Thirty patients were recruited in this study and analyzed in 3 groups of 10. The parameters examined included operative time, bladder injury, bleeding, hospitalization, and need for catheterization in each of the 3 groups. These parameters were then examined for statistical significance. In addition, the groups were stratified for age, parity, and the presence of preoperative urgency.
    This paper is important in view of the popularity of the TVT since its introduction by Ulmsten et al. in 1996 (1). As the popularity for this operation has increased, there has been an increase in pressure and desire on urologists and gynecologists to perform this at their respective hospitals to provide a full service for their patients. The question which each surgeon asks of himself prior to performance of a surgery, is how easy will this be to do, and how rapidly may I learn it so I may offer it in a successful and safe fashion to my patients. The 3 main complications examined in this paper were bladder injury, bleeding, and the need for catheterization postoperatively. Of note, was that the instance of bladder injury did diminish rapidly with increase in surgical experience. Bleeding did not alter between the 3 groups. The need for perioperative catheterization also did not change significantly with increase in surgical experience. In the patients who had urgency, it was noteworthy that 80% had persistent postoperative symptoms. This is in marked contrast to the classic thought of the resolution of urgency after an anti-incontinence operation, with two-thirds having the urgency resolve, one-third having the urgency continue, and less than 5% having de novo urinary urge incontinence (2).
    Several points of critique in this paper were that the paper did look at the learning curve of a single surgeon, but it was stated in the article that the urogynecological surgeon had been trained by Ulmsten to perform all of the operations. It was unclear to me whether the surgeon spent one day with Dr. Ulmsten, one month, or a residency. In addition, it would be more illuminating if the exact training could be delineated with regard to the number of cases, hands on training or solely observation. Also, there were 30 TVT procedures carried out, one of the procedures was aborted and converted to a Burch-retropubic suspension secondary to distorted anatomy attributed to previous pelvic surgeries. I was unsure whether this patient was included in the 30 patients. Another point of review is that 11 (37%) of the patients underwent concomitant surgical procedures. These ranged from laparoscopic procedures to pelvic relaxation repairs. The authors try to accommodate this and still use the TVT procedures in their series by commenting on the mean operating time for the TVT procedure outside of the concomitant surgical procedures. Unfortunately, the concomitant surgical procedures may have had a downstream effect on the overall incidence of bleeding, hospitalization, and post-operative catheterizations. I would have found the paper much more educational if the TVT procedures analyzed would have been without concomitant operations.
    Literature is now replete with commentary and descriptions of the tension-free transvaginal tape procedures. Any of the papers in the literature report fairly small series with a large number of multi-site authors with good results, thus indicating that perhaps the learning curve is rather rapid with the TVT procedure (3). Though the paper by Groutz et al. used patients who had never had anti-incontinence operations before, other papers have commented on the success of the TVT procedure for patients who have previously failed stress incontinence surgery (4).
    This paper is valuable for it helps guide the reader in the onset of the use of the TVT procedure, if that operation has not yet been added to his surgical armamentarium. It also guides the reader to counsel his patients that there may not be a significant diminution in urge incontinence after the anti-incontinence operation. Based on this paper, the surgeon can count on the incidence of bladder perforation diminishing with increased surgical experience but the challenge of perioperative hemorrhage remaining. In addition, emphasis is made that this operation should not be completed without intraoperative cystoscopy.

References
1. Ulmsten U, Henriksson L, Johnson P, Varhos G: An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int. Urogynecol J. 1996; 7:81-6.
2. McGuire E: Bladder instability and stress incontinence. Neurol Urodynam. 1988; 7:563-7.
3. Soulié M, Cuvillier X, Benaïssa A, Mouly P, Larroque JM, Bernstein J, et al.: The tension-free transvaginal tape procedure in the treatment of female urinary stress incontinence: A French prospective multicentre study. Eur Urol. 2001; 39:709-15.
4. Azam U, Frazer MI, Kozman EL, Ward K, Hilton P, Rane A: The tension-free vaginal tape procedure in women with previous failed stress incontinence surgery. J Urol. 2001; 166:554-6.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA