Synthetic Midurethral Slings and the Attractiveness of TOT
The helical passer can then be removed with a reverse rotation of the handle, and the plastic tube and tape can be pulled completely through the skin.
We repeat the technique on the other side, of course, and then ensure that the tape lies flat under the urethra without tension. I choose to set the tape using a “cough test.” This has been shown to be superior to empiric or visual setting in a study by Dr. Miles Murphy and colleagues at the University of Louisville (Ky.).
Because the inside-out technique offers safety advantages over the outside-in technique, I believe we have an obligation to at least inform patients that the option exists, even if we're having success with the original retropubic TVT or the outside-in procedure.
We also can look forward to seeing yet another generation of synthetic midurethral slings in the coming year or so. The new sling can be placed in either a hammock or a “U” configuration with only a single incision in the anterior vaginal wall. An instrument deploys the tape by pushing it into position, rather than by pulling it into position as the TVT and obturator procedures do. There is no exit site, so even less tissue is traumatized.
We'll need to demonstrate durability and acquire more robust data, but the preliminary data look promising.
EMILY BRANNAN, ILLUSTRATION
The Transobturator Tape Procedure
In the August edition of Master Class, Dr. Mickey Karram discussed the use of tension-free vaginal tape (TVT) for the treatment of symptomatic stress urinary incontinence. Although both the success rate and subsequent patient satisfaction with TVT have proved to be excellent, the risk of bladder perforation remains a concern. Because of this risk, I have continued to perform laparoscopic retropubic urethropexy (Burch procedure) for severe stress urinary incontinence.
In this edition of Master Class, the second-generation midurethral sling—known as the transobturator tape (TOT) procedure—will be discussed. This technique, when used in patients without internal sphincter deficiency and/or low urethral opening pressures, has proved to be not only efficacious, but safe as well. In my early experience, TOT has proved to be an easy procedure to master.
The TOT procedure can be performed via two distinct approaches. I have asked Dr. Peter Sand to present the “outside-in” technique. Dr. Sand is professor of obstetrics and gynecology at Northwestern University, Chicago. He is the director of Evanston Northwestern Healthcare's division of urogynecology and reconstructive pelvic surgery, as well as the director of the fellowship program in female pelvic medicine. Dr. Sand also directs the Evanston Continence Center.
Discussing the “inside-out” approach to TOT will be Dr. Vincent Lucente. Dr. Lucente is a clinical professor of obstetrics and gynecology at Temple University in Philadelphia. He is the chief of gynecology at St. Luke's Health Network in Allentown, Pa., and the medical director of the network's continence management center. Dr. Lucente is also the chief medical officer of the Institute for Female Pelvic Medicine and Reconstructive Surgery in Allentown, as well as chief of the Section of Female Pelvic Medicine and Reconstructive Surgery at Abington (Pa.) Memorial Hospital.
