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Tension Free Vaginal Tape
(TVT) Procedure for Female Stress Incontinence:
Qatar Experience
Farid I., Aboud I., Al Blushi
M.A., Al Mansoori Z.S.
Department of Obsterics and Gynecology, Women’s
Hospital
Hamad Medical Corporation, Doha, Qatar
  Abstract:
A
retrospective study was conducted on the records
of 44 women who had received tension-free
vaginal tape as a primary or secondary
procedure for the treatment of stress urinary
incontinence. Intra-operative complications were
uncommon, operative time and hospital stays were
short and late postoperative complications were
few. 36 (81.8%) women became dry, six cases
(13.6%) are satisfied and two patients (4.5%)
are still complaining of stress incontinence.
The tension free vaginal tape procedure
appeared to be an effective, minimally invasive
method for treating female stress urinary
incontinence.
 Introduction:
Stress urinary incontinence (SUI) affects 10-20%
of the general population(1).
In the last century more than 150 different
surgical procedures to correct this condition
were reported, reflecting that the exact
mechanism behind incontinence is not completely
understood and that there is no reference
standard treatment(2).
Recently several new surgical procedures have
been developed using a variety of slings. The
tension-free vaginal tape (TVT) is a relatively
new procedure that uses a synthetic
polypropylene mesh sling placed in the
mid-urethral position. Published data suggests a
good success rate from a minimally invasive
procedure that can be performed under local or
regional anesthesia with low morbidity(3).
We report our
experience of using the TVT procedure in the
Women’s Hospital Hamad Medical Corporation,
Qatar, and assess the results and potential
complications in treating female stress
incontinence.
Patients
and Methods:
Using a datasheet developed by the third author
the records were reviewed retrospectively of 44
women (age 47.2±7.8; parity 5.4±2.5; BMI
32.9±5.5) who received TVT from January 1999 to
March 2004. Twenty-nine cases (65.9%) were
Qatari, and 15 cases (33.1%) were non-Qatari
(Table 1). Analysis of the data was
by SPSS software v.11.
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Table 1:
Patient Characters
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Eighteen (40.9%) had symptoms of urinary stress
incontinence only; nine (20.5%) had mixed
symptoms of stress incontinence and urgency;
nine (20.5%) had stress incontinence with a
degree of genital prolapse; six (7.5%) had
problems such as dysfunctional uterine bleeding
and infertility in addition to stress
incontinence (Table 2).
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Table 1: Patient Characters
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In more than half the cases (62.8%) the TVT was
secondary to vaginal repair and/or hysterectomy;
hysteroscopy; microwave endometrial ablation,
laparoscopy or combined procedures to correct a
secondary complaint. From operative reports
various variables were collected such as
surgeon, type of anaesthesia, unusual vaginal
bleeding, total procedure time and
complications.
The TVT procedures were carried out as described
by Ulmstem (4),
with most patients under regional anesthesia.
The TVT set consisted of a polypropylene mesh
tape fixed to 6 mm needles connected to an
introducer (Ethicon, Inc., Sommerville, NJ,
USA). Some surgeons used cystoscopy after each
retropubic pass of the TVT needle, others once
after needle insertion on both sides. The tape
was adjusted with the patient coughing at a
bladder volume of 300 ml., to allow a few drops
of urine to escape from the urethral meatus. A
Foley’s catheter was inserted in every patient.
The day after the procedure the catheter was
removed if the residual urine was below 100 ml.
and the patient was discharged at the end of the
working day. Otherwise the catheter was kept in
and the residual urine re-checked the following
day for possible patient discharge.
The course in the
outpatient clinic after surgery was reviewed
using patient files and surgeons’ notes. The
final outcome was classified subjectively as
“cured”, “satisfied” or ”failed”.
Results:
The overall mean follow-up period was 15.2
months (Range: 3-54). Nearly all (97.7%) of the
TVT procedures were done under regional
anesthesia and the mean operative time was 42 ±
11.7 minutes for the TVT procedures only; this
is statistically significantly less than the
time taken when TVT was done with other
procedures (59±15.3 min; p < 001).
The mean total blood loss during surgery
was 100 ±17.5 ml; two patients had blood losses
of 350 ml. but no patient required blood
transfusion. Bladder perforation was recorded in
one case when the surgeon felt during cystoscopy
that the tape was closer to the bladder wall on
one side. The introducer was removed, urine came
out from the suprapubic site of the introducer
which was repositioned again and the procedure
was completed. One patient had a stomach injury
during laparoscopy done for tubal ligation in
addition to TVT.
Three cases (9.1%) had urinary retention with
residual urine >100 ml. All had additional
vaginal repair with TVT. Two of these women
developed retention on the third day after the
procedure and the Foley’s catheter was
reinserted for 24 hours, with a suprapubic
catheter added in one. The third case developed
urinary retention on the fourth day after
surgery and was managed with a suprapubic
catheter.
One patient had a haematoma of the right rectus
sheath measuring 7.2 cm in mean diameter (by
ultrasound) that was managed conservatively. One
woman (2.3%) who underwent TVT and vaginal
hysterectomy developed a fever (> 38
oC)
for three days that responded to intravenous
antibiotics. One case (2.3%) had urgency
incontinence and painful micturation after TVT
but recovered after a Foley’s catheter had been
kept in for 48 hours. The overall mean hospital
stay was 3.3±1.2 days (including two nights).
Twenty-seven women
(61.4%) completed 12 months of follow up; five
cases (11%) were followed for more than 24
months. One woman was followed for 54 months; 42
months after surgery she complained of
superficial dyspareunea and part of the TVT tape
could be felt by digital vaginal examination.
This part (2 cm long) was removed under general
anesthesia and the patient remained continent.
Data from the final
follow up visits found that 37 women (84.1%) had
no complaint; two cases (4.5%) developed de novo
urge; in two women (4.5%) there was an episode
of UTI in the first visit after surgery. Ten
cases that had presented with voiding problems
with their stress incontinence became free of
symptom. In seven of 9 cases (77.8%) presented
with some degree of genital prolapse in addition
to their SI became subjectively dry, one case
(11%) was satisfied, and another patient (11%)
has persistent SI. From 18 women who presented
with only stress incontinence, 14 (77.8%) became
dry, and four (22.2%) cases were satisfied. The
overall evaluation of patient continence after
TVT, showed that 36 (81.8%) women became dry,
six cases (13.6%) are satisfied and two patients
(4.5%) are still complaining of stress
incontinence.
Discussion:
The results of this study are comparable to
other studies documenting the TVT procedure; the
objective cure rate for GSI was 81.8% and was
consistent with rates reported by other studies (4-10).
Boustead 2002(3),
reviewed the results from 16 studies; the mean
overall objective cure rate in 1339 patients was
88%, with a further 9% improved, and a failure
rate of 6%. He found also that few studies(11-13)had
reported both subjective and objective outcomes
and both of them were similar. Although the
results of TVT and colposuspension are
comparable, however, the apparent advantage in
the short term is obvious, being, short
operative time, local anesthesia, and short
hospital stay. In this study, nine cases (20.4%)
were discharged home 24 hours after surgery,
another nine cases (20.4%) went home 48 hours
after surgery and 42 (95.4%) cases could void
freely after removal of the catheter the day
after the procedure.
In 2001 Wang and
Chen(14)
in their study showed that subjective and
objective cure rates were not significantly
different when TVT was done under local or
regional anesthesia but women in the epidural
group had a significantly greater incidence of
urinary obstruction (time to spontaneous
voiding, and post-voiding residual). This may
explain why, in this study, Foley’s catheter was
kept in place for the first 24 hours after the
procedure.
Although the TVT
procedure was originally designed to treat women
with GSI, Rezapoura and Ulmesten(15)
proposed that TVT surgery could be also used to
resolve female mixed urinary incontinence
without affecting the success rate. In this
study; ten cases (22.7%) had an urge component
to their stress incontinence and nine of them
(90%) became free of both symptoms after
surgery. Other studies(9,11,12,16,17,18),
showed improvement in 43-75 % of cases. However,
in this study, do novo urgency was present in
two patients (4.5%) which is consistent with
previously published reports of 0-5.9 %(11,17,19).
In this study, three
cases (6.9%) had urinary retention as defined by
residual urine >100 ml 24 hours after the
procedure. This is similar to rates in other
studies (2.3-10%)(6,11,16,17,20,21).
In this study,
retention of urine started on day two (two
cases), and day four (one case), after surgery,
while in other studies, retention of urine
started on day one or day two after the
procedure, also the incidence in one study
reached 20%(22).
The difference in the rate of urinary retention
might be due to the difference in the definition
of urine retention used by different studies No
patient in this study required prolonged
catheterization or tape release which was
reported by one study(22)
that recommended tape release under local
anesthesia in case of retention for 48–72 hours
after surgery which allows easy mobilization of
the tape before it becomes fixed in place,
leaving 3–5 mm between the tape and the ventral
aspect of the urethra.
At follow up
complaints related to voiding difficulty were
made by two patients (4.5%) but these were not
sufficiently severe to necessitate specific
treatment.
In other studies(4,5,6,9,23,24)voiding
problems of short duration were reported in
3-10% of patients and were self-limiting.
During surgery there
was one case (2.5%) of uncomplicated bladder
injury, which was consistent with other reports
(0–6%) (15,16,20)
. Two cases had UTI in the first three months
after surgery, and responded to treatment with
oral antibiotics. This was noted also in other
studies (22)
but its significance was unclear.
Late complications
(> three months after surgery) included voiding
disorders in two patients (4.5%) and genital
prolapse in one patient although its
significance was unproven. Finally; one woman
had dyspareunea and part of the tape could be
felt on physical examination and was removed
under regional anesthesia. The patient was
followed for 12 months, remained continent, and
the tape could no longer be felt. In one study(22)
two cases of tape erosion through the vagina
were recoded after 12 months; part of the tape
was excised under local anesthesia and the
patients remained continent.
Conclusion:
The present study was the first to be done in
Qatar and reflects the clinical experience with
TVT procedure in the Women’s Hospital .Most of
the complications were few and could be managed
conservatively with a success rate comparable
with other studies; TVT procedures remain an
effective minimally invasive and safe technique
for treating female SUI.
Answer the question,
Did they have uorodynamics or not ? and if not
,Why did they not have it ?
Comments:
The answer is, according to the data collected
from the patients files, Uorodynamic study only
done for ten cases out of 44 patients (22.7%).
Other 7 patients refused the investigation and
two did not complete it.
The Uorodynamic study showed GSI in all seven
patients and in three of them showed mixed
urinary incontinence
Owing to that study being a retrospective one we
have no comment why Uorodynamic is not tried for
other patients. However, the complain of stress
incontinence was very clear preoperatively and
the relief of symptoms after the procedure was
objectively dependant on the patient
satisfaction.
References:
1. Knochel JP, Reed
G. Disorders of heat regulation. In: Narins RG,
ed. Maxwell & Kleeman’s clinical disorders of
fluid and electrolyte metabolism. 5th ed. New
York: McGraw-Hill, 1994: 1549-90.
1. Hunskaar S,
Arnold EP, Burgio K, et al. Epidemiology and
natural history of urinary incontinence.
Icontinence. Plymouth, UK: Health, 1999: 199.
2. Robert A, Jordan
R.S, Margerite L, et al. Complication of tension
-free vaginal tape surgery: a
multi-institutional review British journal
urology, 2004: 94: 110-113.
3. Boustead GB. The
tension-free vaginal tape for treating female
stress urinary incontinence. British journal
urology international, 2002: 89, 687-693.
4. Ulmsten
U,Henriksson L,Johnson P, et al. An ambulatory
surgical procedure under local anesthesia for
treatment of female urinary incontinence. Int
Urogynecol J Pelvic Floor Dysfunct : 1996; 7:
81-6.
5. Ulmsten U,
Falconer P, Johoson P, et al. A multicenter
study of tension-free vaginal tape (TVT) for
surgical treatment of stress incontinence. Int
Urogynecol J 1998; 9: 210-3.
6. Ulmsten U,
Johoson P, Rezapour M. A three-year follows up
of tension – free vaginal tape for surgical
treatment of female stress urinary incontinence.
Br J Obstet Gynaecol 1999; 106: 345-50.
7. AbramsP, blaivas
JG, Stanton SL, et al.The standardization of
terminology of lower urinary tract function.Br J
Obstet Gynaecol 1990; 97: 1-16.
8. Nilsson CG. IVS/TVT
- A new surgical procedure for treatment of
female stress Urinary incontinence. Finnish and
Scandina- vian Noedic Urogynecological
Association Meeting; February 7-8, 1997, Oslo,
Norway. Acta Obstet Gynecol Scand 1998; & 7 (
Suppl. 168 ): 33-7.
9. Wang AC, Lo TS.
Tension-free vaginal tape. A minimally invasive
solution to stress urinary incontinence in
women. J Reprod Med 1998; 43; 429-34.
10. Ward Kl, Hilton
P. Tesion–free vaginal tape: Initial
experiences. 23rd Annual Meeting of the
international Urogynecology Association.
November 18-21, Buenos Aires, Argentina. Int
urogynecol J 1998; 9: 319.
11. Moran PA, Ward
KL, Johnson D, et al. T ension-free vaginal tape
for primary genuine stress incontinence: A two
center follow-up study. BJU Int 2000; 86: 39-
42.
12. Petros PE. New
ambulatory surgical methods using an anatomical
classification of urinary dysfunction improve
stress, urge and abnormal emptying. Int
Urogynecol J Pelvic Floor Dysfunct 1997; 8:
270-78.
13. Haab F, Trockman
BA, Zimmern PE, et al. Results of pubova- ginal
sling for the treatment of intrinsic sphincteric
deficiency determined by questionnaire analysis
J Urol 1997; 158: 1738-41.
14. Petros P,
Ulmsten U. An integral theory in female urinary
incontinence. Experimental and clinical
considerations. Acta Obstet Gynecol Scand 1990;
69: 153.
15. Rezapour M,
Ulmsten U. Tension-free vaginal tape (TVT) in
women with mixed urinary incontinence – a long
term follow-up. Int Urogynecol J Pelvic Floor
Dysfunct 2001; 12 (Suppl): S15-S18.
16. Meschia M,
Pifarotti P, Bernasconi F et al. Tension-free
vaginal tape. Analysis of outcomes and
complications in 404 stress incontinence women
Int Urogynecol J Pelvic Floor Dysfunct 2001; 12
(Suppl. 2): S24-S27.
17. Nisson CG, Kuuva
N, Falconer C, et al. Long-term results of
tension-free vaginal tape (TVT) procedure for
surgical treatment of female stress urinary
incontinence. Int Urogynecol J Pelvic Floor
Dysfunct 2001; 12 (Supp, 2); S5-S8.
18. Black N,
Griffiths J, Pope ZC, et al. Impact of surgery
for stress incontinence on morbidity: Cohort
study. British Medical Journal, 1997; 315:
1493-1498.
19. Wang AC. An
assessment of the early surgical outcome and
urodynamic effects of the tension-free vaginal
tape (TVT). Int Urogynecol J Pelvic Floor
Dysfunct 2000; 11: 282-4.
20. Nilsson CG,
Kuuva N. The tension-free vaginal tape procedure
is successful in the majority of women with
indications for surgical treatmentof urinary
stress incontinence Br J Obstet Gynecol 2001;
108: 414-9.
21. Kuuva N, Nilsson
CG. A national-wide analysis of complica- tion
associated with the tension-free vaginal tape (TVT
procedure). Acta Obstet Gynecol Scand 2002; 81:
72-7.
22. Robert A, Jordan
R. Steinberg, et al. Complication of tension-
free vaginal tape surgery: a multi-
institutional review. BJU Int. 2004; 94: 110-13.
23. Nilsson CG. The
tension-free vaginal tape procedure (TVT) for
treating female urinary incontinence. Acta
Obstetrica Gynecologia Scandinavica,1998; 77:
168 ( suppl) 34-37.
24. Schiotz.
Tension-free vaginal tape-a new surgical
procedure for female stress incontinence 2000; J
Obstet Gynecol 20: 158-61. |
