Results of tension free vaginal tape (TVT) versus tension free tape obturator (inside-outside TVT-O) in the surgical treatment of female stress urinary incontinence Rosita Aniuliene, Prof. of Lithuanian University of Health Science, Lithuania President of Lithuanian Association of Urogynecology

KAUNO MEDICINOS UNIVERSITETO AKUŠERIJOS IR GINEKOLOGIJOS KLINIKA

Surgical treatment of SUI Laparoscopic colposuspension Open retropubic colposuspension Suburethral slings Tension free vaginal tape Transobturator foramen tape Anterior vaginal repair (anterior colporraphy) Needle suspension

Cochrane DB, NICE guidelines, ICS guidelines Open retropubic colposuspension may be more likely to cure stress incontinence compared with anterior vaginal repair at 1-5 years. Complication rates are similar to those with other surgical procedures, but are higher than with non-surgical treatments. Suburethral slings, tension free vaginal tape (TVT), transobturator foramen procedures (TOT, TVT-O), and needle suspension may be as effective as open retropubic colposuspension in curing stress incontinence over 5 years. Complications of tension free vaginal tape include bladder perforation. Laparascopic colposuspension seems to be as effective over 5 years as open retropubic colposuspension or tension free vaginal tape. Cochrane DB, NICE guidelines, ICS guidelines

TVT golden standard by proving same effectiveness as colposuspension TVT became golden standard for SUI surgery in women after proving the same effectiveness as colposuspension. The study by Ward and Hilton was a milestone for TVT.

TVT – golden standard in SUI surgery Reference: Nilsson CG et al, Int Urogynecol J 2008: 19: 1043-1047

Analysis of TVT operation at the Obstetrics and Gynaecology Clinic of LUHS

Objectives Estimate the results and complications of TVT and TVT-O procedures

Study design A prospective study using a standardized preoperative and postoperative protocol

Material TVT operation TVT-O operation TVT Exact operation 114 women were operated and followed up during study period: 25 02 2000 – 01 07 2006 TVT-O operation 307 women were operated and followed up during study period: 20 03 2006 – 01 05 2011 TVT Exact operation 16 women were operated and followed up during study period: 03 01 2011 – 01 04 2011

Inclusion criteria All patients had typical medical history of stress incontinence The degree of the incontinence was 2-3 according to Ingelman-Sundberg scale Patients with urge symptoms were treated preoperatively with anticholinergics and HRT

Methods A medical history and urinary diary was taken of the duration and the severity of the stress incontinence A gynecological examination was performed A stress provocative test was performed in the supine and standing positions with a comfortably filled bladder (300ml) before and post operation A quality of life evaluation was undertaken

Methods II Urodynamic evaluation was performed by clinical indications for 30% of patients Foley catheter was left for 24 h after TVT operation and 6 h after TVT-O operation. The postoperative evaluation included operation time, complications, hospital stay and postoperative evaluation after 1 year was carried out.

Patients characteristics TVT (n=114) T VT Exact (n=16) TVT-O (n=307) Age ± SD 51 ± 10,1 50 ± 8,9 49 ± 9,5 POP Q system: Stage 1 Stage 2 26 14 51 22 2 29 Follow up period (months) 12 BMI, kg/m2 27,9 ± 4,0 28,5±3,5 28,2 ± 3,8 Number of birth 2,6 ±1,1 2,1 ±1,1 2,5 ± 1,2 Birth weight > 3500g 49 ± 1,2 9 ± 1,1 61 ± 1,3 Menopause (1-30 years) 48 5 57 Irritated bladder symptoms 6 1 10 Urinary incontinence period 6,5 ± 3,1 4,8 ± 2,7 7,5 ± 2,4 Hysterectomy in the past 15 Operated incontinence in the past 16 45

TVT and TVT-O procedures register data Register parameters TVT (n=114) TVT Exact (n=16) TVT-O (n=307) P Effectiveness of procedure 94,6% 100% NS Duration of procedure 27 ± 7,1 20 ± 11,1 19 ± 5,6 P<0,05 Hospital stay (days) 4,0 ± 1,6 4,5 ± 1,5 1,5 ± 0,5 Anesthesia: General 13 (11,4%) 2 (0,6%) Local 2 (1,8%) Lumbar 95 (83,3%) 1 (6,3%) 22 (7,1%) Intravenous 4 (3,5%) 15 (93,7%) 283 (92,6%) Bladder drainage: interrupted catheterization 18 (15,8%) 6 (37,5%) 10 (3,2%)

Postoperative complications TVT (n=114) TVT Exact (n=16) TVT-O (n=307) P No 81 (71,0%) 8 (50%) 283 (92,2%) P<0,05 Suprapubic hematoma 1 (0,8%) 1 (6,3%) NS Wound bleeding in vagina 2 (1,8%) 3 (0,9%) Bladder perforation Postoperative urinary retention 18 (15,8%) 6 (37,5%) 10 (3,2%) Symptoms of irritated bladder 6 (5,3%) Infection of urinary tract 5 (4,4%) 2 (0,6%) Temperature >380 C

Procedures combined with TVT (n=35) Anterior suturing of vagina 25 (22,1%) ( colporrhaphia anterior ) Mesh for cystocele repair 2 (1,7%) Posterior suturing of vagina 4 (3,5%) ( colpoperineoplastic ) Diathermoconisation 2 (1,7%) Hysteroscopy, D/C 2 (1,7%)

Procedures combined with TVT-O (n=78) Anterior suturing of vagina 41 (13,3%) ( colporrhaphia anterior ) Posterior suturing of vagina 22 (7,1%) ( colpoperineoplastic ) Vaginal hysterectomy 6 (1,9%) Hysteroscopy, D/C 3 (0,9%) Abdominal hysterectomy 1 (6,3%) Diathermoconisation 1 (6,3%) Polypectomy (urethral) 1 (6,3%) Lipomectomy (perineal) 1 (6,3%) Sphincterorrhaphy 1 (6,3%) Laparascopy adnexectomy 1 (6,3%)

Procedures combined with TVT Exact (n=3) Anterior suturing of vagina 1 (6,3%) ( colporrhaphia anterior ) Posterior suturing of vagina 1 (6,3%) ( colpoperineoplastic ) Polypectomy of cervix 1 (6,3%)

Conclusions TVT and TVT-O operations are very effective procedures while curing female stress incontinence after 12 months of follow-up. TVT-O procedure has a shorter operation time and hospital stay. TVT-O had lower complications rate that TVT procedure. TVT Exact operation had 50% complications, but effectiveness after 2 months was 100%.

References

Thank you for your attention