1. TVT PROCEDURE – TOT PROCEDURE

2. TOT helicoidal needle
TOT semi-circular needle
TVT needle

3. TOT POSITION OF THE MESH
The mesh is placed under the mid-urethra and the tips of the mesh come out from the body through the Obturator foramen.

4. TOT POSITION OF THE MESH

5. TYPES OF APPROACHES:
TOT – TransObturatorTape ( IN OUT technique)
TOT – TransObturatorTape ( OUT IN technique)

6. Step 1 out-in TOT PROCEDURE (most common)
2 cm anterior vaginal wall incision
Periurethral scissor dissection.
Step 1

7. Step 2 out-in TOT PROCEDURE Area of groin incision located
1 cm inferior to the Adductor
Longus Tendinous insertion,
at the level of clitoris.
Step 2

8. Step 3 out-in TOT PROCEDURE To guide the needle, the finger
is placed in the vaginal incision.
The needle is placed in the groin
incision and then passed through
it.
Step 3

9. Step 4 out-in TOT PROCEDURE
The needle passed through the groin incision, through the Obturator membrane and muscles and brought into the vaginal incision.
Step 4

10. Step 5 out-in TOT PROCEDURE
Once the needle is brought into the vaginal incision, it is connected to the tip of the mesh inserting the threads in the needle’s hole.
Step 5

11. Step 6 out-in TOT PROCEDURE
The needle with the attached thread of the mesh is then brought back through the groin incision.
Step 6

12. Step 7 out-in TOT PROCEDURE The needle and the mesh is
passed on the opposite side.
Tape is then adjusted with an
intra-operative cough test and
adjusted until no leakage occurs.
Step 7

13. Step 8 out-in TOT PROCEDURE Excess mesh is cut off at
the groin incisions and
these are closed with
steri-strips.
Vaginal incision is closed.
Step 8

14. TOT PROCEDURE IN-OUT
Exactly the same as TOT OUT-IN procedure but the introduction of the needle is made from the vaginal incision to the groin incision, instead of the contrary.
The needle used for this technique are semi-circular.

15. TVT PROCEDURE
The needles are passed from the vaginal incision lateral to the urethra, following the posterior wall of the pubis, and crossing the fascia and the rectus muscle until the needle appears at the lower abdominal wall.
The sling is adjusted and the excess mesh cut of.