Tension-free vaginal tape sling for recurrent stress incontinence after transobturator tape sling failure

The transobturator tape (TOT) sling is a new minimally invasive technique to treat stress urinary incontinence (SUI). Short-term follow-up studies show high success rates; however, as with any surgical treatment of SUI, failures are known to occur. The treatment of recurrent or persistent stress urinary incontinence after a TOT sling is therefore a new dilemma as well. In this paper, we describe the successful use of a retropubic tension-free vaginal tape (TVT) sling in five patients after failed TOT sling. We present case series of five patients who had TOT slings placed for stress incontinence that failed and subsequently had TVT slings placed for persistent SUI. The TVT slings were placed under local/regional anesthesia without removal of the TOT sling. Retrospective chart review of office and hospital charts was completed, and both objective and subjective data were collected. Five patients had TVT slings placed 6–30 weeks after early failure of TOT slings that were placed for stress urinary incontinence. Postoperatively, all patients with urodynamic testing showed evidence of intrinsic sphincter deficiency; however, all maintained urethral mobility of 30°. All five patients had successful treatment of their incontinence with the retropubic tension-free sling procedure with a mean follow-up of 17 months. Recurrent or persistent stress urinary incontinence after TOT sling may be treated with TVT sling without removal of the TOT sling. Further studies with larger numbers and longer-term follow-up is warranted.     

Tension-free vaginal tape and associated procedures: a case control study

OBJECTIVES: We compare objective and subjective cure rates after tension-free vaginal tape procedures performed alone or in conjunction with vaginal procedures. METHODS: One hundred eighty-six women underwent a tension-free vaginal tape procedure for stress or mixed urinary incontinence. One hundred women treated with tension-free vaginal tape alone (group 1) were compared with 40 women treated with tension-free vaginal tape and concomitant vaginal hysterectomy (group 2), and 46 patients treated with tension-free vaginal tape and pelvic floor reconstruction (group 3). Patient outcomes, surgical difficulties and complications are reported. Postoperative voiding diaries, standing stress-test results, and patient satisfaction were compared. RESULTS: There were no significant differences among the three groups in terms of age, menopausal status, BMI, previous incontinence surgery, or the type and degree of incontinence. Parity was significantly higher in the group treated with tension-free vaginal tape and pelvic floor reconstruction ( p=0.04 ). The overall perioperative complication rate was 15.6%. Women treated with tension-free vaginal tape and hysterectomy (group 2), and those treated with tension-free vaginal tape and pelvic floor reconstruction (group 3) had a significantly higher incidence of bladder injury (17.9% and 13%, respectively, versus 5% in group 1; p=0.05 ). Estimated blood loss and the frequencies of postoperative urgency and voiding disorders did differ significantly between women treated with tension-free vaginal tape alone and those who underwent associated procedures. The mean follow-up time was 24.5+/-2.6 months. No difference in the objective cure rate was found between the tension-free vaginal tape group and the other two groups (93% versus 97.5% and 91.1%; p=0.3 ). No difference in the subjective cure rate was found between the tension-free vaginal tape group and the groups undergoing associated procedures (72% versus 72.5% and 68.8%; p=0.4). CONCLUSION: Pelvic floor defects, benign uterine disorders and stress urinary incontinence can be safely treated with tension-free vaginal tape and vaginal procedures during the same surgical procedure.     

Tension-free vaginal tape bowel perforation

A 73-year-old para 3 white female with posthysterectomy pelvic organ prolapse and stress urinary incontinence underwent pelvic reconstructive surgery and placement of tension-free vaginal tape. On postoperative day 4, she underwent exploratory laparotomy for small bowel obstruction. She was found to have an injury to the small bowel secondary to a through-and-through perforation by tension-free vaginal tape. The entire tape was removed. Partial small bowel resection and primary anastomosis were performed. Her subsequent recovery was uneventful.     

Tension-free vaginal tape,suprapubic arc sling,and transobturator tape in the treatment of mixed urinary incontinence in women

We evaluated the outcome at least 6 months after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling, or transobturator tape (TOT) procedure in women with mixed urinary incontinence and identified factors predicting the outcome in these patients. A total of 144 women, 29 to 77 years old (mean age 57.3), were included in the study; TVT (n = 72), SPARC (n = 22), and TOT (n = 50). The mean follow-up time was 10.9 months (range 6 to 52). There were no significant differences in the three groups in terms of the cure rate for stress urinary incontinence (SUI; TVT, 95.8%; SPARC, 90.0%; TOT, 94.0%; P = 0.625) and urinary incontinence (UUI; TVT, 81.9%; SPARC, 86.4%; TOT, 82.0%; P = 0.965). In the multivariate model, there is no influencing factor for treatment failure of SUI, while maximum urethral closure pressure (MUCP) and the diagnosis of uninhibited detrusor contraction during cystometry were independent risk factors for treatment failure of UUI. Decreasing MUCP was associated with an increased likelihood of treatment failure of UUI [odds ratio (OR), 0.974; 95% confidence interval (CI), 0.950–0.998; P = 0.034]. In the same model, uninhibited detrusor contraction was associated with 3.4-fold risk of treatment failure of UUI (OR, 3.351; 95% CI, 1.031–10.887; P = 0.044). Our findings suggest that low MUCP and the presence of uninhibited detrusor contraction during cystometry should be considered to be at high risk of treatment failure of UUI after surgery in these patients.     

Sling removal after the Vesica sling and tension-free vaginal tape (TVT) procedures

PURPOSE: We describe our experience of sling removal performed after either the Vesica sling procedure (due to vaginal erosion or at the time of reoperation for recurrent stress incontinence) or the tension-free vaginal tape (TVT) procedure (due to persistent urinary retention). MATERIALS AND METHODS: From May 1997 to December 2002, we performed 19 Vesica sling procedures and 66 TVT procedures for the treatment of urodynamic stress incontinence. In the former procedures, four patients (21%) developed vaginal erosion and underwent total or partial removal of sling material (Hemashield made from bovine-collagen-injected woven polyester). In another three patients, stress incontinence recurred 2-4 years after the Vesica sling procedure, and they underwent total sling removal and the TVT procedure. Before using the urethral pull-down process (UPDP) in TVT procedures, 2 out of 23 patients (8.7%) developed persistent urinary retention and underwent either sling release alone or partial sling removal concomitant with a second TVT procedure. After the introduction of the UPDP, no patient developed urinary retention. RESULTS: Three patients in whom total sling removal was performed due to vaginal erosion after a Vesica sling procedure developed recurrent stress incontinence. One patient who underwent partial sling removal remained continent, but vaginal erosion recurred 2 years later. Patients who had total sling removal and TVT procedures due to recurrent stress incontinence after Vesica sling procedure became continent with an uneventful postoperative course. One patient who underwent transvaginal release of TVT tape (polypropylene mesh) due to urinary retention after the TVT procedure developed recurrent stress incontinence, and the other who underwent partial removal of TVT tape and a second TVT procedure had resolution of urinary retention without recurrence of stress incontinence. CONCLUSION: Prompt and total sling removal should be recommended for vaginal erosion after the Vesica sling procedure. In patients with urinary retention after the TVT procedure, partial removal of TVT tape and a second TVT procedure using the UPDP to prevent overtightness may be a preferable choice to attain both continence and resolution of urinary retention.     

Tension-free vaginal tape versus transobturator tape for treatment of female stress urinary incontinence

Objectives  

The transobturator tape (TOT) is based on a similar principle as the tension-free vaginal tape (TVT), but introduced through the obturator foramen. The aim of this study was to compare these slings as surgical procedures for the treatment of stress urinary incontinence (SUI) in women.     

Tension-free vaginal tape: a prospective subjective and objective outcome analysis

The purpose of this prospective study was to describe the effects of the tension-free vaginal tape (TVT) procedure on subjective and objective outcomes. Eighty-seven women (aged 31–95 years) underwent a TVT procedure and were followed for up to 24 months using the Incontinence Impact Questionnaire (IIQ-7), Urogenital Distress Inventory (UDI-6), and a Patient Satisfaction Questionnaire. IIQ-7 scores improved from a mean 51.1 before surgery to 12.7 at 1 month (p<0.001) indicating reduced impact of incontinence on quality of life. UDI-6 scores declined from a mean 61.8 to 21.9 (p<0.001) indicating improvement in urinary symptoms. At 1 month, 91.2% of patients were satisfied. Improvements on all measures were maintained throughout follow-up. Urodynamic evaluation of 57 patients (mean: 15.0 months) showed that 91.2% had a negative stress test. Results indicate significant immediate and sustained improvement in incontinence impact and urinary symptoms, and a high rate of patient satisfaction and objective cure.Presented at American Urogynecologic Society Meeting, Hollywood, FL, September 2003     

Tension-free vaginal tape: analysis of risk factors for failures

To investigate whether there are any demographic, clinical, or urodynamic variables associated with an increased risk of failure in women undergoing surgery with tension-free vaginal tape (TVT). We retrospectively analysed 325 consecutive patients who had been operated with the TVT procedure. Patients were assessed with a complete history, physical examination, and urodynamic testing. The operation was done under local or epidural anesthesia and any further surgical procedure was added as indicated. The postoperative evaluation included collection of data on intra- and postoperative complications and analysis of outcomes. The outcome of surgical treatment was evaluated subjectively and objectively. The Statistical Package for Social Sciences (SPSS, Chicago, Illinois, USA) was used for data analysis; P<0.05 was considered significant. The overall complication rate was 14%, voiding dysfunction being the most common. Three hundred and one women were available for the analysis of surgical outcome and the mean follow-up was 34+12 months (median 32 months). Subjectively, 269 women (89%) were cured by the procedure and 13 (4.3%) reported marked improvement. An objective cure was achieved in 263 (87%); 38 patients still having leakage while coughing during postoperative cystometry. Among the numerous presumed risk factors for failed antiincontinence surgery only urethral hypomobility and recurrent stress urinary incontinence were significantly associated with failure of the TVT procedure in our study. However, even in these complicated situations, the cure rate was more than 70%.     

Midurethral sling outcomes: tension-free vaginal tape versus Pelvilace

We sought to compare the complications and efficacy of tension-free vaginal tape (TVT) and Pelvilace. Chart reviews and telephone questionnaires documented complications, urinary symptoms [Urogenital Distress Inventory short form (UDI-6) and Patient Global Impression of Improvement (PGII)], and re-operations. Failure was defined as PGII >/= 4 (no change or worse) or reoperation for urinary incontinence. There were 91 TVT and 22 Pelvilace slings. The TVT group had lower rates of urinary retention beyond 1 week (8% vs. 43%, p < 0.001) and reoperation for retention (1% vs. 19%, p < 0.001). Median changes in UDI-6 scores were -33.3 for the TVT group and -29.6 for the Pelvilace group (p = 0.21). Median PGII scores were 1 for the TVT group and 2 for the Pelvilace group (p = 0.024). Ten percent of the TVT group and 24% of the Pelvilace group (p = 0.095) were failures. Urinary retention was more common after Pelvilace than TVT slings. Symptomatic outcomes and failure rates were similar.     

Tension-free vaginal tape: why an unusual concept is so successful

The surgical treatment of female stress urinary incontinence has been dramatically changed during the last 5 years, after Ulmsten introduced the tension-free vaginal tape procedure. This technique is based on a series of experimental investigations of the urethral closure mechanisms in women. The procedure is easy to learn, could be performed on an outpatient basis, and is recognized as a minimally invasive surgery. Despite these arguments, the most probable reason for its present success is the reproducibility of the results in the various published series. The success rate is estimated at between 85 and 95% for correction of genuine stress urinary incontinence. However, longer follow-up will be necessary to confirm these preliminary results, and probably to determine what are the most valuable prognostic factors.     

Tension-free vaginal tape exposure presenting as a recurrent sterile paraurethral abscess

We report a case of tension-free vaginal tape (TVT) exposure presenting as a recurrent sterile paraurethral abscess at 25 months and 40 months following successful continence surgery and describe the management of this problem.     

Tension-free vaginal tape for stress incontinence in women with detrusor overactivity

In this case report, we discuss two cases of the successful use of the tension-free vaginal tape (TVT) to treat women with detrusor overactivity (DO) but no evidence of urodynamic stress incontinence (USI). The use of the TVT for the treatment of DO has been evaluated in a small number of studies of women with mixed incontinence. There is no data in the literature concerning its use in women with DO only. Here, we briefly review the literature including the postulated mechanism by which stress leakage due to DO is cured by the TVT.     

Tension-free vaginal tape evaluated using patient self-reports and urodynamic testing--a two-year follow-up

OBJECTIVE: Urinary incontinence entails both reduced quality of life for many women and considerable public expense. Compared with other methods aimed at alleviating incontinence, tension-free vaginal tape (TVT) is minimally invasive, can be performed under local anaesthesia and results in less morbidity and shorter hospitalization. The present study was carried out to evaluate early and late complications and as a 2-year follow-up after surgery. MATERIAL AND METHODS: In 1996-98, 75 women underwent TVT sling plasty; mean time for surgery was 39 min and for hospitalization 24 h. The procedure caused bladder perforation in 3 women, but this was detected by cystoscopy and immediately corrected. Postoperative retention occurred in 9 patients but was transient. RESULTS: After surgery 80% were cured, 9% showed improvement and 11% were failures. Two women exhibited vaginal erosion, and one of these had previously undergone radiation therapy. One sling caused obstruction and had to be cut. Improvements included less impact on social and physical activities and mental status and significant reduction of voiding frequency, leakage episodes and pad use. CONCLUSIONS: The TVT technique seems to provide results comparable with those obtained with Burch colposuspension, but it entails less risk of obstruction than previous slings techniques because it causes no compression of the urethra. TVT is effective in women with genuine stress incontinence due to urethral hypermobility and in elderly women with sphincter incompetence, although the outcome is better in the former.     

Tension-free vaginal tape and female stress incontinence: further evidence of effectiveness

OBJECTIVES: Female stress incontinence is a frequent and distressing event with subsequent impact on quality of life. The tension-free vaginal tape (TVT) technique is considered to fulfill the criteria for an ideal surgical procedure and we therefore reviewed our cases to further analyze its effectiveness. MATERIALS AND METHODS: 57 patients suffering from stress incontinence with grade 1-2 cystocele underwent the TVT operation. During follow-up (mean 22.2 months), the short- and long-term results were investigated. RESULTS: 91.3% of patients achieved complete resolution of previous stress incontinence in the early postoperative period. Early complications occurred in 8.7% of patients. Follow-up (mean 22.2 months) highlighted the stabilization of positive outcomes in 87.7% of cases. No postoperative modification of sexual habits and a significant improvement in quality of life were reported by all patients. CONCLUSION: The results of our study confirm that the TVT technique for stress incontinence is an easy to perform procedure which is safe, effective and long-lasting.     

Comparative analysis of urinary incontinence severity after autologous fascia pubovaginal sling, pubovaginal sling and tension-free vaginal tape

PURPOSE: Autologous fascia, Pelvicol implant and polypropylene are common materials used in suburethral anti-incontinence procedures. We explored the relative effectiveness of the autologous fascia pubovaginal sling, Pelvicol pubovaginal sling and Gynecare TVT on self-reported postoperative urinary incontinence. MATERIALS AND METHODS: The study was a mailed cross-sectional survey of health related quality of life 1 to 3 years after suburethral anti-incontinence surgery performed at our institution. The Incontinence Symptom Index was used to assess the presence and severity of urinary incontinence symptoms and the Incontinence Impact Questionnaire-7 was used to assess impairment. Regression models were developed to identify factors with an independent effect on the presence, severity and impairment of urinary incontinence symptoms. RESULTS: The questionnaire was returned by 69% of eligible respondents (173 of 250). Those with previous incontinence surgery (OR 11.0, 95% CI 2.3-51.4) and medical comorbidities (OR 1.6, 95% CI 1.1-2.2) were more likely to report urinary incontinence symptoms, ie incontinence symptom index greater than 0. Symptom severity, which was analyzed only in respondents with urinary incontinence symptoms, was greater in the Pelvicol than in the autologous fascia pubovaginal sling and TVT groups (each p <0.01). No significant difference was observed between the TVT and autologous fascia pubovaginal sling groups (p = 0.15). Also associated with higher urinary incontinence symptom severity scores were body mass index (p = 0.03), a history of incontinence surgery (p = 0.01) and lower education (p <0.01). Impairment from urinary incontinence, as assessed by the Incontinence Impact Questionnaire-7, was associated with body mass index, severe depression and current smoking (each p = 0.01) but not with surgical treatment group. CONCLUSIONS: Women who received an autologous fascia pubovaginal sling or TVT reported lower symptom severity scores than those who had a Pelvicol pubovaginal sling. Impairment was not associated with procedure type. These findings suggest better outcomes with autologous fascia pubovaginal sling and TVT. Randomized, controlled trials are needed to confirm these findings.