TVT(tension-free vaginal tape) TVT(tension-free vaginal tape) vs TOT(transobturator tape)- vs TOT(transobturator tape)- techniques for Female Stress techniques for Female Stress Urinary Incontinence Urinary Incontinence Eija Laurikainen Eija Laurikainen Department of Obstetrics and Department of Obstetrics and Gynecology, Turku University Gynecology, Turku University Central Hospital 23.9.-04 Central Hospital 23.9.-04
31
Embed
TVT(tension-free vaginal tape) vs TOT(transobturator tape ...gks.fi/wp-content/uploads/2012/03/laurikainen.pdf · TVT(tension-free vaginal tape) vs TOT(transobturator tape)-techniques
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
TVT(tension-free vaginal tape) TVT(tension-free vaginal tape) vs TOT(transobturator tape)-vs TOT(transobturator tape)-techniques for Female Stress techniques for Female Stress
Urinary IncontinenceUrinary Incontinence
Eija LaurikainenEija Laurikainen
Department of Obstetrics and Department of Obstetrics and Gynecology, Turku University Gynecology, Turku University
Central Hospital 23.9.-04Central Hospital 23.9.-04
TOTTOToutside-in and inside-out outside-in and inside-out
techniquestechniques
Transobturator approach spares Transobturator approach spares retropubic spaceretropubic space
TVTTVT
• cure rates of approximately 87% ( Ulmsten 98, cure rates of approximately 87% ( Ulmsten 98, Olsson 99, Moran 2000, Nilsson 2001 and Nilsson Olsson 99, Moran 2000, Nilsson 2001 and Nilsson –03 IUGA 7 years follow-up)–03 IUGA 7 years follow-up)
• complications:complications:• perforation of the bladder 3.7-23%perforation of the bladder 3.7-23%• bleeding 0.8-3.3%bleeding 0.8-3.3%• voiding difficulty 1.5-17%voiding difficulty 1.5-17%• DE NOVO urge 2.5-25%DE NOVO urge 2.5-25%• some fatal peritonitis and fatal wounds of the large some fatal peritonitis and fatal wounds of the large
retroperitoneal vesselsretroperitoneal vessels
TVT and PU LigamentsTVT and PU Ligaments
• based on the integral based on the integral theory of stress theory of stress urinary incontinence, urinary incontinence, Ulmsten and Petros Ulmsten and Petros developed an developed an innovative technique innovative technique to compensate for the to compensate for the insufficiency of insufficiency of pubourethral pubourethral ligamentsligaments
The TOT Subfascial HammockThe TOT Subfascial Hammock
• restores anatomical restores anatomical pubourethral ligament pubourethral ligament support like the TVT support like the TVT Pubovaginal SlingPubovaginal Sling
• To reduce TVT complications; avoiding the To reduce TVT complications; avoiding the retropubic space reduces the risk of retropubic space reduces the risk of perforation of the bladder, bowel and major perforation of the bladder, bowel and major pelvic vesselspelvic vessels
Obturator AnatomyObturator Anatomy
Ischiopubic Ramus
IschiumPubic Symphysis
Obturator Obturator ForamenForamen
Obturator Canal
Ilium
Obturator canal
Urethra
SAFE ENTRY ZONE FOR NEEDLE INSERTION
Adductor longusinsertion
Obturator Nerve, Artery and Obturator Nerve, Artery and VeinVein
• Anterior branch of the Anterior branch of the obturator artery lies on obturator artery lies on the external rim of the the external rim of the ischio-pubic ramus and ischio-pubic ramus and is thus protected by this is thus protected by this bony structure from bony structure from being injured by the being injured by the passage of the TOT passage of the TOT inside-out deviceinside-out device
Femoral Nerve, Artery and VeinFemoral Nerve, Artery and Vein
• Large femoral Large femoral neurovascular neurovascular structure are located structure are located within Scarpan within Scarpan triangletriangle
Outside-in Transobturator Approach Outside-in Transobturator Approach -developed by Dr Emmanuel -developed by Dr Emmanuel
Delorme 2001, FranceDelorme 2001, France
• Vaginal epithelium is Vaginal epithelium is dissected off dissected off underlying underlying periurethral fascia, periurethral fascia, dissect bilaterally to dissect bilaterally to the inferior pubic the inferior pubic ramusramus
Needle Path and Needle PlacementNeedle Path and Needle Placement
needle
Mesh Attachment and Needle Mesh Attachment and Needle RemovalRemoval
Inside-out Transobturator ApproachInside-out Transobturator Approach-developed by prof. Jean de Leval 2003, Belgium-developed by prof. Jean de Leval 2003, Belgium
Delorme et al.One year results of Delorme et al.One year results of TOT outside-in procedureTOT outside-in procedure
Costa et al.TOT( outside in)for Costa et al.TOT( outside in)for SUI:multicenter study, FranceSUI:multicenter study, France
• ICS 10/2003 FlorenceICS 10/2003 Florence• 7 centres, 165 patients7 centres, 165 patients• mean age 57 yearsmean age 57 years• 61% mixed incont.61% mixed incont.• urodynamics,5% ISDurodynamics,5% ISD• 15% recurrent inc.15% recurrent inc.• with or without associated with or without associated
prolapseprolapse• spinal (50), general (115)spinal (50), general (115)• follow-up 5 monthsfollow-up 5 months
• 15.9% ( 17) pain in the 15.9% ( 17) pain in the thigh foldsthigh folds
• mean hospital stay 1.8 mean hospital stay 1.8 days(0.5-8)days(0.5-8)
• 3 ret.(2.8%), no 3 ret.(2.8%), no transectionstransections
• one vaginal erosionone vaginal erosion
• an abscess drainage at an abscess drainage at day 8day 8
• follow-up one monthfollow-up one month
Waltregny et al.Inside-out transobturator Waltregny et al.Inside-out transobturator vag. tape(TVT-O): short- term results of vag. tape(TVT-O): short- term results of
a prospect.study.ICS/IUGA 8/2004a prospect.study.ICS/IUGA 8/2004
• 53 patients53 patients• mean age 61 yearsmean age 61 years• urodynamics, 48 SUIurodynamics, 48 SUI• 6 ISD,12 concomitant 6 ISD,12 concomitant
prolapse operationsprolapse operations• 33 spinal, 20 general33 spinal, 20 general• follow-up over 6 follow-up over 6
months in all patientsmonths in all patients• 3 de NOVO URGE3 de NOVO URGE
• no vaginal, urethral or no vaginal, urethral or bladder perforationsbladder perforations
• no hematoma, vaginal no hematoma, vaginal or urethral erosion, or urethral erosion, fistula or tape reject.fistula or tape reject.
• when the tunneler is entered more when the tunneler is entered more anteriorly, there is a danger for a superior anteriorly, there is a danger for a superior passage and perforation of the anterior passage and perforation of the anterior aspect of the bladder ; when the tunneler is aspect of the bladder ; when the tunneler is entered more posteriorly, perforation of the entered more posteriorly, perforation of the vagina is possible as urethral perforationvagina is possible as urethral perforation
Transobturator techniqueTransobturator technique
• may eliminate vascular, bladder and bowel may eliminate vascular, bladder and bowel injuriesinjuries
• avoids retropubic scarringavoids retropubic scarring• may prove useful in patients with earlier may prove useful in patients with earlier
passagepassage• may prove useful in obese patientsmay prove useful in obese patients
Transobturator techniqueTransobturator technique
• offers short-term efficacy similar to TVToffers short-term efficacy similar to TVT
• offers shortened procedure timeoffers shortened procedure time
• may prove useful in treatment failures?may prove useful in treatment failures?
• may eliminate the need for cystoscopy?may eliminate the need for cystoscopy?
• easy to learneasy to learn
With the transobturator technique the tape is With the transobturator technique the tape is inserted at a 45 angle to the vertical and inserted at a 45 angle to the vertical and horizontal planes. A narrower angle, such horizontal planes. A narrower angle, such as that which occurs with the TVT, can as that which occurs with the TVT, can contribute to difficult micturition? TOT: contribute to difficult micturition? TOT: fewer voiding difficulties, urinary retention fewer voiding difficulties, urinary retention and urge symptoms?and urge symptoms?
ConclusionConclusion
• The U-shaped placement of the TVT-tape The U-shaped placement of the TVT-tape can contribute to long-term efficacy?can contribute to long-term efficacy?
• Prospective, randomized study between Prospective, randomized study between tension-free vaginal tape and a new tension-free vaginal tape and a new transobturator procedure is needed with transobturator procedure is needed with longer follow-up times.longer follow-up times.