VERSUS TVT-O FOR MINIMALLY INVASIVE SURGICAL CORRECTION OF STRESS URINARY
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VICENTE SOLA, JACK
PARDO, PAOLO RICCI, ENRIQUE GUILOFF, HUMBERTO CHIANG
Unit, Department of Obstetrics and Gynecology, and Department of Urology,
Las Condes Clinic, Santiago, Chile
The present work describes our experience in surgical correction of stress
urinary incontinence, comparing both the TVT and the TVT-O techniques.
Method: Between October 2001 and March 2004,
76 patients underwent the TVT procedure. Between January 2004 and January
2005, 98 surgical corrections of urinary incontinence were carried out
using the TVT-O technique.
Results: Median operative time was 28 minutes
for TVT and 7 minutes for TVT-O. Intraoperative complications for TVT
occurred in 4 patients (6.6%): urinary bladder perforation in 3 patients
(5%, p = 0.0228) and parietal peritoneum perforation in 1 case (1.6%).
No intraoperative complications took place during TVT-O. Immediate postoperative
complications: transient urinary retention in TVT, 2 cases (2.6%) and
overcorrection in TVT-O (1%) which was readjusted within 24 hours. There
were no late complications after TVT. There were 2 cases (2.04%) with
late complications in TVT-O. TVT and TVT-O resulted in correction of incontinence
in 100% of the patients.
Conclusion: TVT and TVT-O are two effective
techniques for the correction of stress urinary incontinence. TVT-O would
seem to be a technique much easier to perform resulting in less intraoperative
words: urinary incontinence, stress; suburethral sling; female;
tensionless vaginal tapes; transobturator tapes
Int Braz J Urol. 2007; 33: 246-53
number of techniques for the correction of stress urinary incontinence
have been described through the years. In 1996, Ulmsten published the
minimally invasive technique known as TVT (1). Many authors believe TVT
should be considered the gold standard for surgical correction of stress
urinary incontinence (2), by virtue of its efficiency featuring up to
81% and 16% complete and partial remission respectively (3). Nevertheless,
the technique entails the disadvantage of requiring intraoperative cystoscopy,
and consequently it is not free of risks such as bladder, urinary tract
and intestinal injury among others (4-7). In 2001, while in search of
a simplified version of the procedure, Delorme (8-10) described the TOT
technique (trans-obturator-tape). The main advantages of such technique
are more anatomical position of the tape than with TVT, the fact that
needles do not pass through the retropubic space, it entails less operative
blood loss, do not involve abdominal incisions, is associated with a decreased
risk of urinary bladder and intestinal injuries and does not require cystoscopy.
Thus, TOT merged as an easier to perform and faster to achieve surgical
technique when compared to TVT (11).
In 2003, Jean de Leval during an attempt
to further simplify the procedure, described TVT-O (12). The TVT-O procedure
is even closer to the concept of minimally invasive surgery than its predecessors
TVT and TOT. Dissection of the anterior vaginal wall involves only one
centimeter; the dissection of the paraurethral space is performed with
fine scissors; the use of a winged bendable guide helps in the introduction
of the needle; needles pass through only once and are withdrawn from the
inner side of a protective plastic sheath; cystoscopy is not needed. As
well as in the case of other kinds of TOT, the efficacy of such procedure
should be further assessed in the long term (13). Undoubtedly, techniques
involving polypropylene mesh tape within the medial urethra should be
considered as first choice for SUI (14,15).
The present work describes and compares
our experience with TVT and TVT-O techniques in surgical therapy of urinary
October 2001 and March 2004, 76 patients underwent a surgical procedure
with the classic TVT technique (1) at the Urogynecology and Vaginal Surgery
Unit, Department of Obstetrics and Gynecology, of Las Condes Clinic. When
we got to know the new technique TVT-O we decided to initiate and to compare
them in our surgery experiences.
Between April 2004 and January 2005, 98
surgical corrections of urinary incontinence were carried out through
the TVT-O technique (12).
Used TVT and TVT-O are system of Johnson
& Johnson Companies.
The data obtained for both surgical techniques
were pooled in previously designed databases, for prospective follow-up.
For patients undergoing TVT, the median
age was 53 years (range: 35 to 72), the median body weight was 64.8 kg
(range: 50 to 90 kg), the BMI was 27.6 (range: 23 to 32), and vaginal
parity was 2 (range: 2 to 5 deliveries).
For patients undergoing the TVT-O procedure,
the median age was 54 years (range: 38 to 74), body weight ranged between
53 and 82 kg (median 65 kg), the BMI was 27.5 (range: 23 to 33), and vaginal
parity was 2.6 (range: 0 to 5), Table-1. All patients underwent the urodynamics
test in order to classify in preoperative time the type of urinary incontinence
(according to the classification ICS 1999), which evidenced the following
in patients scheduled for TVT: Type II SUI in 71 (93%) patients (including
22 cases of mixed incontinence) and type III SUI or intrinsic sphincter
deficit in 5 cases (7%).
In patients scheduled for TVT-O, type II
SUI was found in 91 (93%) cases (including 9 cases of mixed incontinence),
type III SUI was found in 4 cases (4%) and type 0 SUI was evidenced in
3 cases (3%), Table-2.
There was a gynecological surgical procedure
associated to the procedure for correction of urinary incontinence in
61 cases (80.3%) for TVT and in 78 cases (79.6%) for TVT-O. The gynecological
surgical procedure took place in all cases during the period after TVT
All these procedures were initially carried
out under regional anesthesia, while in those cases requiring laparoscopy,
additional general anesthesia was used.
Only TVT cases were implemented with intraoperative
The Foley catheter was removed only once
the TVT or TVT-O procedure was completed, and after completing 24 hours
of the preoperative period in those cases involving complementary surgery.
One simple intravenous dose of 2 g Cephazoline
was used as prophylactic antibiotic therapy.
Rofecoxib 50 mg per os was administered
one hour prior surgery as analgesia for TVT alone or in association with
other surgical procedures, with further oral monodose every 24 hours.
The same dosing scheme was used for analgesia
in patients undergoing TVT-O, since November 2004, replacing Rofecoxib
for Valdecoxib 40 mg following the same above-mentioned prescription.
All patients received information prior
to surgery, which included details about the procedure, TVT or TVT-O respectively,
and concerning the concomitant surgical procedure when indicated. All
patients signed an informed consent.
All patients were controlled in an outpatient
basis between 7 and 14 days and 3 and 6 months after the procedure. Telephone
communication was maintained when needed.
Both patient populations displayed a normal
distribution upon comparison. The student “t” test for continuous
parametric variables was used. The statistical analysis was carried out
though the use of Excel (Microsoft Corporation) and Statview (SAS Institute,
were no significant differences between both groups upon comparing age
and body weight.
to Additional Gynecological Surgery
In the TVT group there were 21 cases with
two additional surgical procedures (34%) and 40 cases with one additional
surgical procedure (66%). Among the TVT-O treated patients there was one
additional surgical procedure in 66 patients (67%), two in 26 patients
(27%) and three in 6 patients (6%). Thirty cases required laparoscopic
As for TVT, vaginal plasty was the most
commonly associated surgery, followed by laparoscopic hysterectomy, vaginal
hysterectomy, laparoscopically assisted vaginal hysterectomy, laparoscopic
tubal sterilization, Gargiulo’s operation, adnexectomy and trachelectomy.
For TVT-O, the most commonly associated
additional surgical procedure was vaginal plasty, followed by vaginal
hysterectomy, laparoscopic hysterectomy, laparoscopic tubal sterilization
and partial vulvectomy.
Measured from the opening to the closing
of the vaginal mucosa):
Median operative time for TVT was 28 minutes
(range between 20 and 48 minutes), while for TVT-O it was 7 minutes, with
a range between 4 and 15 minutes.
Among patients treated with TVT, intraoperative
complications occurred in 4 cases (6.6%). Complications were: bladder
perforation in 3 cases (5%) and parietal peritoneum in 1 case (1.6%).
Complications were due to the TVT needle insertion procedure, and were
not related to the additional gynecological surgical procedure. Bladder
perforation cases involved the lateral anatomical bladder area, and the
location was corroborated with intraoperative cystoscopy. The needle was
reinserted and the procedure was completed easily. A Foley catheter was
placed for 4 days in one case and for 2 days in the remaining two cases.
All patients underwent complete recovery, with no further complications.
No additional interventions were needed in the case of parietal peritoneum
perforation, in which we observed it like a finding when we made a laparoscopic
surgery after anti-incontinence procedure.
TVT-O treated patients did not experience
complications during the operative act. There was no bladder no urinary
tract injuries (Table-3).
For both surgical techniques, intraoperative
blood loss was scarce (less than 80 mL).
Postoperative Complications (up to 7 days)
During the immediate postoperative period,
among TVT treated patients, there were two cases of dysfunctional voiding
(2 out of 76; 2.6%), due to transient urinary retention. Both cases recovered
after voiding through a Nelaton catheter in one occasion, with no need
of further interventions. Both cases did not have associated surgery.
There were complications in one case (1
out of 98; 1.02%), consisting of urinary retention due to overcorrection.
The case required surgical correction at the operating room within 24
hours of the first surgery. The sutures of the mucosa of the anterior
vaginal wall were removed (1 cm), and the tape was adjusted by means of
traction with Kelly clamps between the urethra and the polypropylene mesh.
The latter consisted of TVT-O associated with posterior colpoperineoplasty.
No hematomas or infections of the operative
area were observed in any of the cases (Table-4).
There was no need for additional pharmacological
therapy to the initially designed scheme for the management of postoperative
pain, since patients reported an adequate degree of pain control in all
For both approaches, all patients were asked
to be up immediately after the loss of the effect of anesthetics. Food
intake was resumed between 2 and 4 hours after surgery.
Discharge home occurred in both TVT and
TVT-O unassociated with additional surgeries, after confirming a second
spontaneous micturition. The median length of hospital stay was 48 hours
for TVT and 12 hours for TVT-O.
For both approaches, in those cases associated
with anterior or posterior colpoperineoplasty, discharge occurred at 24
hours. In those cases associated to hysterectomy, discharge occurred after
Postoperative Period Complications (more than 1 week)
There were no late complications for TVT,
while there were late complications in 2 cases among TVT-O patients (2
out of 98; 2.04%).
The first case consisted of polypropylene
mesh tape erosion into the mucosa of the anterior vaginal wall, measuring
1 cm2, which was evidenced 6 weeks after surgery. The complication required
sectioning the tape at the operating room, a procedure resulting free
of complications. Such case had needed TVT-O associated with anterior
and posterior colpoperineoplasty.
The second case consisted of a urinary retention
occurring 11 days after surgery, it was of sudden onset. Urinary infection
was ruled out and the retention corroborated to and evacuated with an
intermittent Nelaton catheter. Both sutures were removed from the mucosa
of the anterior vaginal wall with local anesthesia (lidocaine) in an outpatient
basis, and the position of the tape was adjusted through traction with
scissors. The latter case was a TVT-O procedure associated with labioplasty.
There were no new retention episodes and continence remained normal. There
was no fistula formation in any of the cases (Table-5).
of Urinary Incontinence
Urinary incontinence was successfully corrected
in 100% of TVT cases, including those with mixed incontinence. In 73 cases
(96%) there was cure (the incontinence absence after surgery was considered
cure), while in the remaining 3 (4%) the cure was partial or improvement
(incontinence urinary episodes less than once every two weeks). There
were no failures related to the technique.
Correction of the urinary incontinence was
successful in all 98 patients (100%) including those with immediate and
late postoperative complications. Among patients with type II SUI, two
cases presented de novo urge incontinence, which resolved spontaneously
30 and 45 days later respectively. Among those cases with mixed urinary
incontinence (9 cases), only one patient remained with micturition urge,
therefore she was treated with Detrusitol (Tolterodine) with a complete
response to therapy.
Cases of fault were not observed (urinary
incontinence episodes more of one per week), Table-6. The general comparison
between TVT and TVT-O is shown on Table-7.
All patients were followed in compliance
with the protocol, which is still under observance in 6 TVT-O cases.
great number of techniques have been described for the correction of stress
urinary incontinence. Lately, tension-free tape techniques, introduced
in 1996 with TVT, have undergone a significant development.
The TVT-O approach is easier to perform,
by virtue of the fact it does not require intraoperative cystoscopy. Needles
are passed from “outside to inside”, and thus remain far from
the bladder and the urinary tract, consequently decreasing the risk of
an eventual bladder perforation (p = 0.00228: statistically significant).
Furthermore, the use of guides enables an easy introduction towards the
obturators. All the above mentioned has resulted in the absence of intraoperative
complications across our experience with TVT-O compared to the TVT approach
(statistically significant difference).
When comparing postoperative complications
in our experience in both procedures was low, the difference between both
techniques in our experience is remarkable. Complications in TVT-treated
patients were two cases of transient urinary retention during the immediate
postoperative period, and were treated with Nelaton catheter evacuation,
not requiring additional interventions. In contrast, among TVT-O-treated
patients the complication was an overcorrection during the immediate postoperative
period, which required correction. For the same technique, during the
late postoperative period, there was one case of erosion to the anterior
vaginal wall due to tape exposition, and a case of urinary retention after
the 11th postoperative day, which required tape adjustment. Taking into
consideration this last case, we started leaving a looser tape under the
urethra, and obtained the same results for resolution of the incontinence,
preventing thus such complication from occurring again.
Both techniques are effective in correcting
stress urinary incontinence, with 100% success rate. For TVT, a partial
cure or improvement occurred only in 4% of the cases. When comparing only
cure rates there is a statistically significant difference between TVT
and TVT-O, favoring TVT-O.
In the present when we asked to these patients
(TVT and TVT-O) about quality of life, they respond that it has improved
remarkably. Nevertheless, we have initiated new protocols of pursuit and
we continued adding new patients to register if the cure rates stay in
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tape (TVT) in the treatment of urinary stress incontinence: 3 years
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Accepted after revision:
September 30, 2006
Dr. Vicente Solà Dalenz
Department of Obstetrics and Gynecology
Las Condes Clinic, Lo Fontecilla 441
Las Condes, Santiago, Chile.
Fax: + 56 2 210 4195
authors report on their experience with TVT and TVT-O in the surgical
treatment of female stress urinary incontinence. The two study populations
were relatively homogenous with regards to number, age, parity, and BMI.
The authors detected very high rates of surgical cure with both techniques
but noted a comparatively distinct ease of use with the TVT-O.
authors should be commended for adding to the world’s literature
their experience with the relatively new TVT-O technique. Highlights that
they have noted include the low rate of perioperative complications including
voiding dysfunction (urinary urge incontinence and urinary retention)
and vaginal tape erosion. It is hoped that in 3-5 years the authors consider
revisiting the study population and report on the durability rates of
this operation as well as potential appearance of any late complications.
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA