Transobturator tape

1. Aboubakr Elnashar

2. The surgical management of female SUI has been deeply changed when Ulmsten described a new concept in 1995: the mid-uretheral support without tension (TVT).
In 2001, Delorme described a new approach (TOT) eliminating the complications related to the penetration of the retro-pubic space
Aboubakr Elnashar

3. TVT procedures use a vertical, retropubic route.
This intrapelvic route exposes the patient to a number of complications:
bladder perforation
injuries to blood vessels or GIT
Aboubakr Elnashar

4. •TVT: By placing a prolene tape around the midurethera without tension Restores the pubourethral ligaments & the suburetheral vaginal wall Dynamic kinking of the midurthera at stress (Rezapour et al, 2001)
•Corrects the central & lateral fascial defects of the anterior compartment of the vagina (Ursula et al,2000)
Aboubakr Elnashar

5. TOT: The tape is placed under the mid- urethera (as in TVT) between the two obturator foramen, creating a real hammock supporting the urethera (uretheral suspension in TVT) (Delorme,2001).
It is purely perineal & transverse
The position of TOT is similar to that of natural hammock supporting the urethera
Aboubakr Elnashar

6. 1.Anticoagulant therapy (stop 14 d or replace with low dose heparin)
2.Urinary tract infection
3.No sexual intercourse, heavy lifting or exercise for 1mo
Aboubakr Elnashar

7. 1.Genuine SI.
2.SI with Intrinsic sphincter deficiency (urethral p <20 cm H2O).
3.Mixed I (urge & stress).
4.Recurrent SI (previous traditional surgical procedure had failed).
Aboubakr Elnashar

8. 1.Pregnancy
2.Women with plan for future pregnancy (prolene mesh will not stretch significantly). Incontinence may recur.
3.Motor urge incontinence & significant detrusor instability (Ulmsten,2001)
Aboubakr Elnashar

9. TVT: Ursula et al,2000: 8.7% in 1762 patients
1. Bladder perforation: 5.4%. The most frequent complication
2. De novo urgency or urge incontinence: 5.1%
3. Retropubic haematoma: 0.8%
Aboubakr Elnashar

10. 4. Rare complications
a.Anterior vaginal wall laceration
b.Retained plastic sheath
c.Obturator nerve irritation
d.Vaginal wound infection Most of these complications are related to the penetration of the retropubic space
Aboubakr Elnashar

11. TOT:
Although the complications are uncommon, they must be kept in mind in order to adopt an appropriate strategy to prevent their development
I. Costa et al (2004) 183 women
Intraoperative: 2.2% (Up to 15% in TVT (Lebert et al, 2001)
No vascular, nerve or bowel injury
Bladder perforation: 1
Uretheral perforation: 2
Lateral vaginal perforation: 1
All these complications disappeared with use of the index finger into the vaginal incision.
Aboubakr Elnashar

12. Postoperative:
1. De nevo urgency: 5% (from 0-20% in TVT, Peschers et al, 2000)
2. Voiding disorders: 3.3% (7 women)
{excessive tension of the tape}
Treatment:
immediate release of the tape in 3 (surgical 2, uretheral dilatation with Hegar 1)
Temporary intermittent self-catheterization in 4
Aboubakr Elnashar

13. 3. Vaginal extrusion of the tape: {silicon part of the tape}.
Obtape not contain silicon
At 1 year
80.5% were completely cured
7.5% were improved
Aboubakr Elnashar

14. II. Krauth et al,2005: 604 women
Operative: very few
0.5% vesical perforations,
0.3% vaginal perforations,
no urethral wounds,
0.8% 200-300 ml haemorrhages,
2 perineal haematomas (0.33%).
Aboubakr Elnashar

15. Post-operative:
1.5% transient retentions,
2.3% transient pain,
2.5% urinary infections,
1.3% transient dysuria.
Aboubakr Elnashar

16. After 3 mo
5.2%: de novo symptoms.
After one year:
Satisfaction rate: 85.5%
1.5%: de novo dysuria & urgency.
Aboubakr Elnashar

17. III. But (2005):
Vaginal wall erosion 6.7%: 6 weeks after surgery
(Monarc)
The greater prevalence of vginal wall erosion demand a search for the mechanism.
Treatment:
The periuretheral portion of the tape was removed & a new Prolene tape was placed through the retropubic space.
Follow up after 3 months: No signs of erosion.
Aboubakr Elnashar

18. Long term safety is not known, particularly in relation to
changes in the synthetic material changes in bladder & uretheral behaviour
as voiding disorders & bladder instability (Delorme,2004)
Aboubakr Elnashar

19. I. De Tayrac et al (2004): 31 TVT & 30 TOT
TOT
TVT
P
Operative time
Bladder injury
Urinary retention
Cure
Improvement
Failure
15 min
0.0
13.3
90%
3.3%
6.7%
27 min
9.7%
25.8%
83.9%
9.7%
6.5%
S
S
S
NS
NS
NS
Aboubakr Elnashar

20. After 1-year:
No vaginal erosion occurred in either of the groups.
No differences were found in bladder outlet obstruction after TVT and T.O.T.
CONCLUSION: T.O.T. appears to be equally efficient as TVT for treatment of SUI.
Aboubakr Elnashar

21. II. Mellier et al (2004): 94 TOT & 99 TVT
TOT
TVT
P
Hgic complications
Bladder injuries
Uretheral injuries
Cure rate
2%
0.0
0.9%
95%
10%
10%
0.0%
90%
S
S
NS
NS
Aboubakr Elnashar

22. In conclusion:
Obturator approach shows identical urinary results to the retropubic approach.
Major hemorrhage and bowel perforation are excluded in the TOT procedure.
Thus simplicity, safety and continence result mean that the obturator approach is the best method of suburethral tape insertion for the treatment of USI.
Aboubakr Elnashar

23. 1.TOT is a safe, effective technique for the treatment of female SUI.
2.The easy technique, the short learning curve & the very high grade of satisfaction of the patient show that this approach is based upon effective anatomical & physiological criteria.
Aboubakr Elnashar

24. E-mail: elnashar53@hotmail.com
Aboubakr Elnashar