NEUROUROLOGY & FEMALE UROLOGY

Correlation of morphological alterations and functional impairment of the tension-free vaginal tape obturator procedure
Yang JM, Yang SH, Huang WC
Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China
J Urol. 2009; 181: 211-8

• Purpose: We explored the morphological features associated with functional impairment in patients undergoing the tension-free vaginal tape obturator procedure.
• Materials and Methods: We retrospectively reviewed the records of 98 women who underwent the tension-free vaginal tape obturator procedure alone or with concomitant pelvic surgery. Postoperative assessment included a symptom questionnaire, ultrasound cystourethrography and a cough stress test. During followup the measures of postoperative functional impairment included a positive cough stress test, new onset voiding dysfunction and the worsening or progression of urge symptoms.
• Results: Median follow-up was 22 months. During follow-up 11 women had a positive cough stress test, 22 had voiding dysfunction and 12 had worsening or new onset urge symptoms. Failure was associated with 4 variables on multiple logistic regression analysis, including absent urethral encroachment at rest (OR 16.63, 95% CI 1.87-147.85, p = 0.01), bladder neck funneling (OR 8.27, 95% CI 1.99-34.26, p < 0.01), a urethral location of less than the 50th percentile (OR 6.01, 95% CI 1.43-25.25, p = 0.01) and a resting tape angle of less than 165 degrees (OR 5.21, 95% CI 1.15-23.54, p = 0.03). A resting tape distance of less than 12.0 mm (OR 3.00, 95% CI 1.44-6.26, p < 0.01) and urethral encroachment at rest (OR 2.86, 95% CI 1.30-6.30, p < 0.01) were the variables predictive of postoperative voiding dysfunction. Bladder neck funneling was the only risk factor for postoperative urge symptoms (p < 0.01).
• Conclusions: The tension-free vaginal tape obturator procedure achieves its effectiveness in a process of biological reaction and mechanical interaction between the tape and urethra. When this mechanical interaction is too great or too little, there is functional impairment after the procedure.
  
  
• Editorial Comment
  The authors describe their experience and findings when examining a patient population who has undergone a transobturator tape procedure. Postoperative follow-up included questionnaire analysis, physical examination and ultrasound cystourethrography. The surgeons used transvaginal ultrasound at the time of surgery to assure that there was not indentation of the urethra on initial placement. Postoperatively, their success rate for stress urinary incontinence was approximately 90% with approximately 75% having resolved their urinary urge incontinence with a 3% de novo development of urinary urge incontinence. They found that urethral encroachment at rest and a distance between the tape and the symphisis pubis of < 12 mm were associated with obstructive voiding symptoms in their patient population.
  The authors publish an excellent manuscript describing their observations of the dynamic forces and reaction of the transobturator suburethral tape during Valhalla maneuvers. They further break down the movement of the tape and its’ effect on the urethra into 5 types. That they were able to identify urethral encroachment while the tape at rest as being significantly associated with obstructive voiding phenomenon definitely lends support to the consideration of using transvaginal ultrasound when evaluating for post-procedure urinary obstruction. We currently utilize fluorourodynamics as well temporal association of symptoms to diagnose postoperative urethral obstruction but will consider strongly the incorporation of transvaginal ultrasound in an effort to assist in this sometimes challenging patient population.

Dr. Steven P. Petrou
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu