Perioperative Complications And Early Follow-up With 100 TVT-SECUR Procedures

Main Category: Urology / Nephrology
Article Date: 31 Jul 2008 - 2:00 PDT

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UroToday.com - The TVT procedure has become very popular ever since it was first described by Ulmsten in 1996. Common complications in previously performed surgeries for the treatment of stress urinary incontinence, such as intra-operative blood loss, pelvic and abdominal organ injury, post-operative de novo detrusor instability, dyspareunia and urethral erosion, are rare in the TVT era.

Prospective randomized multi-center studies, comparing TVT to the former gold standard,Burch colposuspension, demonstrated similar therapeutic impact for both. However, TVT was associated with a higher intra-operative complication rate while colposuspension was associated with a higher post-operative complication rate and a longer recovery period. The previously reported TVT-related complications included bladder penetration, intra-operative bleeding, post-operative infection and vessel and bowel injuries.

Since surgical procedures are more likely to cure stress urinary incontinence rather than non-surgical procedures, Delorme first and then de Leval adapted the TVT-Obturator procedure to avoid the aforementioned complications with the bladder, the femoral blood vessels and the bowel. This is achieved by exploiting the Obturator fossa as a route for the Prolene tape, replacing the retropubic space.

The reported data regarding efficacy of the TVT-Obturator in terms of cure as well as intra-operative and early post-operative complication rates is encouraging. Therapeutic failure, intra-operative bleeding, post-operative infection and voiding difficulties also seem to occur less with the TVT-Obturator than previously reported for TVT. However, the TVT-Obturator is not free of operative complications: thigh-pain is reported to interfere with patient satisfaction, operative infections and post-operative bladder outlet obstruction still occur as well as occasional operative hemorrhage. The TVT-SECUR was designed to minimize the operative procedure as much as possible in order to reduce those undesired complications. This new device is composed of an 8 cm long laser cut polypropylene mesh and is introduced to the internal Obturator muscle (Hammock position) by a metallic inserter, while no exit skin cuts are needed. This approach imitates the sub-mid-urethral support provided with the TVT-Obturator, yet imitating the TVT is possible as well, by introducing the TVT-SECUR arms retropubically rather than to the Obturator area. This "U" position approach necessitates urethral catheterization as well as diagnostic cystoscopy for recognition of possible bladder penetration. As the main possible advantage of the TVT-SECUR is minimalisation of the procedure and its side-effects, the simpler "hammock" approach was elected for this patient's series.

The 100 TVT-SECUR operations reported herein illuminants the primordial learning curve: given that the new laser cut tape and novel inserters are different than the former equipment, one could understand the early difficulties. The extra tension applied to the TVT and TVT-Obturator tapes during removal of the covering plastic sleeves, does not occur with the TVT-SECUR. Hence, some extra tension needs to be applied to the TVT-SECUR compared to the TVT in order to achieve the desired therapeutic result. Even doing so, no clinical signs for post-operative bladder outlet obstruction were observed. To accommodate the flatter, wider tape under the urethra that laser cutting produced, further mucosal undermining was done in order to permit the tape to sink deeper, away from the vaginal mucosa. The inserters, being more than twice as wide as TVT and TVT-Obturator needles, necessitates wider tunnels; 12 mm' at least, in order to permit smooth passage of the tape and inserter and avoid gathering of vaginal skin which might lead to vaginal wall penetration. The tunnel depth should not go beyond the bone edge to avoid damaging the tissue meant to hold the coated tape edge; otherwise the initial pull out force might be impaired. The locking mechanism, attaching the tape to the inserter, should be unlocked properly and detached gently, to avoid unwanted tape removal with withdrawal of the inserter. Doing these simple surgical steps the author was able to lead toward successful completion of the operation.

In summary, the TVT-SECUR procedure appears to be potentially easy to perform and relatively trouble-free for both surgeons and patients and might not require urethral catheterization or diagnostic cystoscopy during surgery. Paying respect to the above mentioned procedural specific surgical steps might shorten the TVT-SECUR learning curve. The novel TVT-SECUR's actual place among TVT and TVT-related procedures can only be determined with randomized prospective longitudinal comparisons.

Written by Menahem Neuman, MD, as part of Beyond the Abstract on UroToday.com.

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