European/Canadian Results Favor TOT for Ease and Safety


PARIS — A randomized, multicenter trial and two retrospective studies presented at the annual congress of the European Association of Urology found outcomes were similar whether patients had the transvaginal or transobturator sling procedure for urinary stress incontinence.

The investigators agreed that their results favored the newer transobturator tape (TOT) procedure, as it is simpler than constructing midurethral synthetic slings with transvaginal tape (TVT). “Both are the same in my experience. The TOT is easier, and it is inherently safe,” Dr. Graeme H. Urwin of the United Kingdom said in a conclusion echoed by investigators from France and Canada.

“My sense is transobturator is a little easier to carry out, so it gave me a little confidence to recommend this,” said Dr. Sender Herschorn, professor of urology at the University of Toronto.

Less clear was whether some patients might present with conditions that would be better treated by TVT or TOT. Dr. Herschorn said he did “not know of any specific indications for one over the other.”

The French group is continuing to investigate this question. “There might be some specific indications for the retropubic route, but we don't have enough data to support this yet. We are going to do more work,” Dr. Emmanuel David-Montefiore of Hôpital Tenon, Paris, said in an interview.

Dr. David-Montefiore reported 3-month data from a multicenter trial in which 88 women with similar demographics and clinical histories were randomized: 42 to a retropubic route (TVT) and 46 to TOT. He said the same tape was used in both groups.

At 3 months, 89.3% of the retropubic cohort and 88.6% of the transobturator group were dry. Satisfaction rates were 90% and 92%. He also reported de novo pollakiuria in 10.7% of the retropubic patients vs. 5.7% of transobturator patients. De novo urgency occurred in 17.9% and 17.1%.

Average hospital stays and overall morbidity were similar between the two groups. Bladder injuries occurred only in retropubic patients, however: 9.5% vs. 0% of the transobturator patients. The retropubic cohort reportedly had more pain and longer operating times.

Dr. Herschorn reviewed outcomes of 40 women who underwent TVT and 35 in whom TOT was used. A majority of both groups had mixed incontinence, and half had prior surgeries for urinary stress incontinence.

The only statistically significant difference in outcomes was that 8 (20%) of the TVT group vs. 3 (9%) of the TOT cohort had urinary retention after the procedure. Dr. Herschorn reported that all voided within a month.

He also reported three perforations (two bladder and one urethral) with the TVT procedure. Although there were slightly more complications with TVT, he said the difference was not statistically significant.

Most patients who responded to a subjective questionnaire described their condition as cured or improved, regardless of the procedure used.

Dr. Urwin reviewed available case notes for 73 of 83 TVT patients and 126 of 131 TOT patients at York (England) District General Hospital. He reported that most had preoperative urodynamics and about two-thirds had pure urinary stress incontinence.

Operating times were similar, while use of regional anesthesia was significantly more common with TVT and general anesthesia was more common with TOT. A learning curve was observed, but it did not significantly affect the complication rate, which was described as low and similar between both groups.

Monarc Sling Keeps Providing Symptom Relief for 24 Months

Two years after being implanted with the Monarc transobturator sling, most evaluable patients in an international study had symptom relief and were satisfied with the results, according to a poster presentation at the meeting.

Dr. Dirk Deridder reported that the proportion of patients who had a negative cough test dropped from 94.5% before surgery to 12.4% of 105 patients available for testing at 24 months. Pad use also declined from 3.4 to 0.6 per day, and the average weight gain per pad fell from 68.7 g/hour to 9.4 g/hour.

“One pad a day is more a security pad than anything else,” said Dr. Deridder of the University Hospital KU Leuven (Belgium). The single-arm study enrolled 148 patients at 15 sites in Europe, Canada, and Australia between January 2003 and February 2004.

Dr. Deridder disclosed that the sling's maker, American Medical Systems (AMS) of Minnetonka, Minn., sponsored the study and that he is an AMS advisory board member.

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