TENSION FREE VAGINAL TAPE- THE TRANS-OBTURATOR APPROACH
The pubovaginal (PVS) sling is a procedure for the surgical procedure treatment of women who suffer from Stress Urinary Incontinence (SUI). The rationale for the PVS is based on the understanding that SUI in women is caused by diminished pelvic support around the urethra resulting in urinary leakage with an increased abdominal pressure such as with cough, laugh or any physical activity. In this procedure (see illustrations below), a grafted strip of tissue is passed underneath the urethra, like a hammock, thus providing a restoration of the weakened support. Traditionally, the grafted tissue was retrieved from the patient’s own muscle covering (fascia) and then it was passed, via a vaginal approach, around the urethra as a free graft. This allograph (from the patient) technique required additional incision and was a longer procedure with prolonged recovery.
In the late 1990’s the concept of utilizing synthetic grafts as sling material was resurrected. A porous mesh to be placed around the middle of the urethra was developed in Sweden. The new PVS was termed Tension free Vaginal Tape (TVT). This quickness and minimal invasiveness of the TVT allowed it to be performed on an ambulatory basis and the patient is able to be discharged 2-3 hours afterwards. Additional advantage of the TVT is the minimal or absent postoperative pain that is reported by the majority of the patients and the fact that no catheter is needed for any period of time following surgery. The clinical experienced with over 1 million cases that were performed worldwide since then were documented in numerous reports in various medical literature. The international results as well as the experience at Associated in Urology (see below) are all very positive.
The initial procedure was designed so that the tape would pass, through an incision in the vagina, around the urethra and then into the pelvis. This approach, albeit very successful and still widely used, was replaced by many practicing physicians with the transobturator TVT (TVTO) where the tape that supports the urethra is passed into the inner thigh (See illustrations below). The TVTO seems to have similar surgical outcome to the original (retropubic) TVT, but it carries less risk of potential inadvertent injury to pelvic organs such as the bladder, blood vessels or the bowel.
The Associates in Urology's Experience with TVT and TVTO
In late 1998 Dr. Berger and a few urologists, all in a capacity of consultants, traveled to Sweden on behalf of Ethicon of Johnson & Johnson to meet Dr. Ulmsten, the inventor of the TVT. The consultants were commissioned to review the TVT procedure, to perform cases with Dr. Ulmsten and eventually conduct the initial American clinical trial of this innovative surgery. In 2000 Dr. Berger presented the first American experience at the Annual American Urological Association (AUA) meeting in Atlanta Georgia.
Between 1999 and 2005 Dr, Berger performed close to 900 TVT cases and his data were presented at various meetings both in the US and abroad (see Dr. Berger’s CV).
Since mid 2005 we converted to the TVTO and at the present over 220 cases were performed. The data are currently being collected for future presentation.
Our clinical experience with the TVT and TVTO has been very favorable. We retrospectively collected our data and saw complete resolution of the SUI symptoms in over 90% of the patients who underwent TVT and TVTO. Many of these women also had dropped bladders that required reconstructive surgery, needed to have hysterectomy (for gynecological reasons) or rectocele (the rectum protruding into the vagina) repairs. These procedures were done in conjunction with the TVT or TVTO. The hysterectomy and rectocele repairs were done by our gynecological colleagues while the cystocele repairs were performed by Dr. Berger. In reviewing the outcome of the TVT and TVTO when it was done with the above mentioned, the results were as successful as when the TVT(O) were done alone. And finally, it has been well documented that approximately 50% of women who have SUI, also have symptoms of overactive bladder (OAB) and this combined symptoms are termed mixed urinary incontinence (MUI). In reviewing our data, we also identified that among our patients who had MUI and underwent TVT over 70% of them reported that their OAB symptoms were resolved following the surgery. (See power point presentation of our data. It was presented in various meetings and was recently.
by Yitzhak Berger, M.D.
Updated June 23rd, 2007