The American Urological Association’s 2001 consensus statement identified two effective and long-lasting treatments for stress urinary incontinence: abdominal Burch colposuspension or vaginal slings. However, in the past, sling procedures were far from standardized. There were numerous variations in materials used (such as fascia from the patient, human or animal cadavers, or synthetics), attachment points, and methods of tensioning the sling. Many procedures required general anesthesia, a hospital stay, and a urinary catheter. Moreover, a significant number of patients experienced urinary retention following sling procedures.
However, the late 1990s marked a new era in the treatment of stress urinary incontinence with the introduction of tension-free vaginal tape (TVT). This procedure, performed under local anesthesia, involves a small incision and takes approximately 10 minutes. It quickly became the standard of care worldwide, with over a million procedures performed.
What does “tension-free” mean?
Tension-free slings are used to treat stress urinary incontinence caused by urethral hypermobility and intrinsic sphincter deficiency. In this procedure, a synthetic suburethral sling is placed retropubically without the use of suspension sutures. The sling remains in place due to friction between the mesh and tissue channels created by metallic needle guides. Over time, scar tissue secures the mesh. Since the sling is not attached to the pubic bone, ligaments, or rectus fascia, it is considered “tension-free.” This provides urethral support, preventing descent and enhancing the stabilization mechanism provided by the pubourethral ligaments and levator ani muscles.
Despite the relative safety of TVT slings, the blind passage of needles through two small incisions in the abdomen, just above the pubic bone, poses risks. The retropubic space, through which the needles must pass, is a muscular region with a dense venous plexus. There is a risk of injury to major blood vessels, the bladder, bowel, or pelvic nerves. While rare, these complications have been reported in the literature.
Transobturator Sling
In 1998, Nickel and colleagues in the Netherlands successfully performed a sling procedure on female dogs using a polypropylene tape passed through the obturator foramen and around the urethra. In 2001, Delorme introduced the transobturator sling (TOT) procedure in humans. Subsequently, Dargent and colleagues performed the procedure on 71 patients using a technique inspired by Delorme, achieving short-term results similar to TVT. Thousands of TOT procedures have since been performed in Europe and more recently in the United States.
Advantages of the Transobturator Approach:
- Safer, faster, and more effective
- Lower risk of bowel injury
- Lower risk of bladder injury
- Lower risk of major bleeding
- No retropubic needle passage
- No abdominal incisions
Two small incisions are made in the groin, and a small vaginal incision is made below the urethra. This allows the needle to be guided safely through the tissue, avoiding the need for blind passage through the retropubic space. The risk of injury to major blood vessels, bladder, or nerves is significantly reduced. The TOT sling is placed subfascially, avoiding contact with the bladder and reducing the risk of bladder irritation.
Clinical Outcomes and Complications
The TOT procedure was first described in the Netherlands in 1998 and has been performed thousands of times in Europe since then. In 2001, Delorme performed the first TOT procedure in a human. Subsequent studies comparing TOT and TVT have shown similar short-term outcomes. While complications are rare, they can include bleeding, infection, urinary retention, mesh erosion, and pain in the vagina or groin. The TOT procedure can be completed in approximately 10 minutes under local anesthesia with minimal risk. TOT is particularly beneficial for obese women and those with previous retropubic surgery.
For Treatment in Istanbul
For the diagnosis and treatment of stress urinary incontinence, overactive bladder, mixed incontinence, overflow incontinence, functional incontinence, reflex incontinence, and temporary urinary incontinence, you can contact Prof. Dr. Ateş Karateke in Istanbul.