Hypothesis / aims of study
Transobturator tape (TOT), is a worldwide used tecnique for stress urinary incontinence with high cure rates. 5% to 20% surgical failure after procedures were reported. Next step for patients in whom the TOT procedure has failed remains unclear. Traditional treatment alternatives of recurrent incontinence after failure of TOT procedure includes colposuspansion, repeated sling surgery, injection of peri-urethral bulking agents, and artificial urinary sphincter. We compared the success rates of tape shorthening method and repeating of new sling material after failure of TOT. We evaluated the changes in continence status and satisfaction of patients who underwent tape shortening and repeating of sling material after failure of TOT procedure.
Study design, materials and methods
Nineteen patients were involved to our study after failure of TOT. Tape shortening (TS) was performed for 9 patients and repeating sling material (RT) for 10 patients. Evaluation before the procedures included detailed history ,physical examination, stress test, Q-type test, urinalysis, urine culture, ultrasonography and uroflowmetry. Maximum flow rate (Qmax), and postvoid residual (PVR) volume were checked.
Shortening of the tape and repeat TOT procedures were both performed under spinal anesthesia. The TOT procedure was performed as described by Delorme technique. Tape shorthening was performed via sagittal incision in the anterior vaginal wall, starting 1 cm below the external urethral meatus. A bilateral dissection was performed. The tape was identified and the tape was held by 2 forceps simetrically from the center of sling. Then using 1-0 Prolene, a figure-eight suture was done. We closed the vaginal incisions with 2-0 Vicryl.Evaluation of objective and subjective success rates of procedures were evaluated at the first year of surgery with stress test and Q-type test. Subjective outcome was evaluated using the validated condition-specific questionnaire: UISS (Urinary Incontinence Severity Score). Patient satisfaction was evaluated by one question from the questionnaire Are you satisfied with the operation or not?’’ Pain status after operations were assessed by utilizing average visual analogue Scale (VAS) (1-10)
The mean patient age was 56.6 (range 48 to 70) .The mean period of second procedures was 5.2 months (range, 3-11 months) after the first procedure. No serious complications were observed during the tape shortening and repeating sling procedures .One year after TOT shortening, complete dry rate was %44.5,(4 patients) and 2 patients showed improvement, and 3 patient reported failure according to patient self reports . 7 patients have reported complete dryness (%70) and 1 patient showed improvement and 2 patients reported failure in RT group. According to objective evalauation of success rates,we examined no leakage for 5 patients in stress test for group TS and 8 patients for group RT. Eight patients were satisfied in RT group (%80) and five in TS group (%55) according to questionnaire form. One year after tape shortening, de novo urgency and voiding difficulty were observed in 2 patients for each of groups. Mean Q max values were 20.5 for group TS and 22.3 for group RT before procedures and 18.2 for TS and 20.6 for group RT after operations. Changes for mean Q max levels was not statistically significant different for both groups.
Interpretation of results
Repeating of sling material is the most common technique after failure of TOT surgery. Shortening of the previously implanted tape and a repeated TOT procedure both are safe, effective, viable options after initial TOT failure.Tape shortening for patients with recurrent stress urinary incontinence is relatively easy to perform. But success rates for tape shorthening procedure seems lower than repeating of TOT procedure.