tvt: long term results

Benha University Hospital, Egypt Aboubakr Elnashar

•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

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

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

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

• 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%

4. Rare complications

a. Anterior vaginal wall laceration

b. Retained plastic sheath

c. Obturator nerve irritation

d. Vaginal wound infection Aboubakr Elnashar

• Cochrane library, 2002: 682 women

•1 in 11 had a complication during TVT,

•Most commonly bladder perforation

•None had serious consequences

Aboubakr Elnashar

Ursula et al(2000) 1762 patients

Objective improvement: (Cough stress

test, pad test, urodynamics)

87.3%

Subjective improvement:

89.3%

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4 different groups of patients:

GSI, Recurrent, ISD, Mixed

Cure: Pad test < 10 g of urine/24 h,

Quality of life improved > 90%

Improvement:Pad test <15 g of urine/24 h,

Quality of life improvement >75%

Aboubakr Elnashar

1.Genuine SI

Nilsson et al, 2001:85 patients, follow-up 5 yrs

• Retropubic hematoma: 3.3%

Bladder perforation: 1.1%

Intraoperative bleeding >200ml: 3.3%

Postoperative voiding difficulties: 4.4%

UTI: 7.8%

Infection of operating site: 1.1%

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•Complete cure (no leak at all & no voiding problems): 84.6%

Significant improvement (leak occasionally): 10.6%

No significant decline in efficacy over an extended period

Failure rate: 4.8%

• De novo urge symptoms: 5.9%

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2.Recurrent SI

Rezapour & Ulmsten, 2000: 34 patients, Follow up for 5

yrs

• No significant intra-or postoperative complications

Bladder perforation: 1 patient

Post operative urinary retention: higher than that of

uncomplicated SI

• Cure rate: 82%

Significant improvement: 9%

Failure: 9%

• No long term complications

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3.SI with ISD (hypotonic urethera, Type 3

incontinence)

Difficult to cure

Rezapour et al,2001: 49 women, follow-up 4 yrs

• Bladder perforation: 1 patient

Small hematoma: 11%

Temporary postoperative voiding problems: 23%

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• Complete cure: 74% (equal or better

than traditional surgery)

Significant improvement: 12%

Failure: 14% (more than that in genuine

SI). The majority in >70 yrs, urethral p

<10 cm H2O & immobile urethra.

• No LT complications, No LT urinary

retention

Aboubakr Elnashar

4.Mixed ( urge & stress)

Rezapour & Ulmsten, 2001: 80 women, follow-up 4 yrs

Urge component may consist of:

1.detrusor instability with low bladder volume <200 ml (excluded & treated with anticholinergics),

2.uretheral relaxation or

3.uninhibited premature micturition reflex

• Postoperative voiding problems: 18%

Bladder perforation: 1 patient

Small heamatoma: 8% & Significant haematoma: 1patient (on anticoagulant)

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• Cure rate: 85%

Improvement: 4%

Failure: 11%

Urgency without incontinence: 25% of the cured & improved women

Aboubakr Elnashar

Provided that a urodynamic evaluation is done, TVT can be used in mixed I.

Not only the stress but also the urge I was cured or improved in 85%. ?

TVT:

1. Minimal vaginal dissection, the tape is placed tension-free around the mid urethra. So, the proximal part of the urethra & bladder neck which are densely innervated would be less compromised than in other sling operations

2.Causes only dynamic Kinking of the midurethera at stress & less likely to obstruct urine flow at micturition

Aboubakr Elnashar

•Cochrane library, 2002: 682 women

•Cure rates after TVT were similar to those

following open abdominal retropubic

suspension.

•No difference in: voiding dysfunction,

urge incontinence or

detrusor instability between

suburetheral slings & abdominal or needle suspensions Aboubakr Elnashar

•Ursula et al,2000

Contrary to Burch colposuspension in which a

continuous decline of success, no such

deterioration has been reported with TVT

TVT creates a new hammock under the

midurethera. The tape is invaded by fibroblast

during the course of time, thereby stabilizing its

position with time

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1. TVT cannot be expected to treat all types of

incontinence

2. TVT is effective, safe & long lasting, also in

previous operated patients

3. TVT can be used in ISD SUI, even with low

cure rate compared to GSI

Aboubakr Elnashar

4. TVT can be used in MSI to cure or

improve also urge symptoms

5. TVT results are comparable to traditional

surgery but simple & less invasive

6. TVT cure rate is about 90% lasting for 5

yrs, with few intra & postoperative

complications

Aboubakr Elnashar

E-mail: elnashar53@hotmail.com

Aboubakr Elnashar