Clinical Review

Tradition is yielding to new technology’s advantages, time-tested though they are not—yet

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Even as we scramble to gather definitive evidence on the immediate and long-term benefits of new technologies, they are supplanting tradition in the surgical treatment of incontinence and prolapse. Surgeons have been swift to adopt synthetic mesh and the new generation of needle suspension procedures, which offer the double advantage of a shorter operative time and shorter postoperative recovery. Yet, we lack well-designed randomized prospective clinical studies on whether outcomes and complication rates are better than traditional therapies such as vaginal colporrhaphy and paravaginal repair.

There hasn’t been time.

These innovations came onto the market in rapid succession, accompanied by aggressive corporate promotion, physician interest, and, in turn, pressure from patients. Improved reimbursement for quicker, easier procedures also entices many physicians to become “early adopters.” (Recent addition of the CPT code for mesh/graft use in prolapse surgery [CPT 57267], increases reimbursement over traditional procedures.)

It is important to keep a cautious but open mind. Given the blind needle techniques and use of biomaterial grafts and synthetic meshes, these procedures may not be for every surgeon or every patient. As always, astute clinical judgment and critical analysis of the data and anecdotal experience are recommended.

Transobturator sling

The needle-guided synthetic mesh midurethral sling was rapidly adopted as the treatment of choice for stress urinary incontinence due to urethral hypermobility and intrinsic sphincter deficiency, soon after it was described in 1995.1

With the transvaginal tape (TVT) procedure, the learning curve was shorter and so were hospital stays and recovery, compared with abdominal Burch colposuspension and traditional bladder neck slings. Furthermore, cost efficiency improved,2 and the persistent cure rate was 85% from 2 to 8 years.3

However, needle passage through the retropubic space can cause vascular, bowel, or bladder injury, even in the hands of experienced surgeons. An August 2005 French survey4 of 92 surgeons who performed 12,280 TVT procedures reported these complications: perioperative bladder injuries, 901 (7.34%); cases of complete postoperative urinary retention requiring catheterization, 809 (6.59%); vaginal mesh exposure, 26 (0.21%); retropubic or vulvovaginal hematoma, 39 (0.32%); and major organ injuries, 10 (0.08%).

The transobturator (TOT) approach, introduced in 2003,5 is simpler, with fewer complications. The sling is placed in a similar manner in the midurethral position, but the insertion points overlie the obturator space in the genitofemoral crease lateral to the vagina. A needle passing through the obturator membrane exits the vaginal incision without entering the retropubic space, theoretically averting risk of bowel, bladder, and major blood vessel injury.

Although the TOT is thought to be safer in this regard, complications including urinary retention, obturator hematoma and nerve injury, and urethral injury/erosion have been reported.6

A variety of TOT sling kits are available, none with proven superiority.

In a recent randomized, prospective trial in which 61 women had TVT or TOT, there were no bladder injuries in the TOT group, and 9.7% (n=3) in the TVT group (P>.05). The postoperative urinary retention rate was 25.8% (n=8) in the TVT group and 13.3% (n=4) in the TOT group (P>.05). Cure rates (83.9% vs 90%), improvement (9.7% vs 3.3%), and failure (6.5% vs 6.7%) were similar.7

The transobturator suburethral sling is encouraging, although it is unclear whether it is effective in patients with intrinsic sphincter deficiency, especially with a fixed or lead-pipe urethra. We need studies to determine how to match the right procedure to the right patient.

Which sling for which patients?

My indications for TOT vs. TVT, which are based on personal experience and available data, may change as data accumulate (TABLE). Indications are often surgeon-specific, depending on clinical experience.

In our review of 210 TOT slings over a 16-month period at 2 centers, we found a cure rate of 88% and an improvement rate of 1.9%. The complication rate was 24%; intraoperative and postoperative complications were all minor and mostly self-limited8: 1 cystotomy, 1 urethral injury, 2 hematomas, 1 erosion, 16 complaints of transient groin pain, 5 cases of urinary retention requiring reoperation, and 23 cases of de novo urge incontinence.

TABLE

Transvaginal vs transobturator sling

INDICATIONSADVANTAGES
Transvaginal (retropubic)
Physically active patientAvoids groin discomfort with activity
Thin, young patientLong term data available
Limited urethral hypermobility/internal sphincter dysfunctionData supports use/dynamic backboard
Transobturator
Elderly patientLess postop voiding dysfunction
Significant overactive bladder/urge incontinenceLess urethral obstruction
Previous retropubic surgeryLess risk of retropubic complication
ObesityLess risk of needle-passage complication
Inexperience with TVTLess risk of periop complications

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