TVT: Long term results

1. Benha University Hospital, Egypt
Aboubakr Elnashar

2. •By placing a prolene tape around the midurethera without tension Restores the pubourethral ligaments & the suburetheral vaginal wall Dynamic kinking of the midurthera at stress (Rezapour et al, 2001)
•Corrects the central & lateral fascial defects of the anterior compartment of the vagina (Ursula et al,2000)
Aboubakr Elnashar

3. 1.Anticoagulant therapy (stop 14 d or replace with low dose heparin)
2.Urinary tract infection
3.No sexual intercourse, heavy lifting or exercise for 1mo
Aboubakr Elnashar

4. 1.Genuine SI.
2.SI with Intrinsic sphincter deficiency (urethral p <20 cm H2O).
3.Mixed I (urge & stress).
4.Recurrent SI (previous traditional surgical procedure had failed).
Aboubakr Elnashar

5. 1.Pregnancy
2.Women with plan for future pregnancy (prolene mesh will not stretch significantly). Incontinence may recur.
3.Motor urge incontinence & significant detrusor instability (Ulmsten,2001)
Aboubakr Elnashar

6. •Ursula et al,2000: 8.7% in 1762 patients 1. Bladder perforation: 5.4%. The most frequent complication 2. De novo urgency or urge incontinence: 5.1% 3. Retropubic haematoma: 0.8% 4. Rare complications
a.Anterior vaginal wall laceration
b.Retained plastic sheath
c.Obturator nerve irritation
d.Vaginal wound infection
Aboubakr Elnashar

7. • Cochrane library, 2002: 682 women
•1 in 11 had a complication during TVT,
•Most commonly bladder perforation
•None had serious consequences
Aboubakr Elnashar

8. Ursula et al(2000) 1762 patients
Objective improvement: (Cough stress test, pad test, urodynamics)
87.3%
Subjective improvement: 89.3%
Aboubakr Elnashar

9. 4 different groups of patients:
GSI, Recurrent, ISD, Mixed
Cure: Pad test < 10 g of urine/24 h,
Quality of life improved > 90%
Improvement:Pad test <15 g of urine/24 h,
Quality of life improvement >75%
Aboubakr Elnashar

10. 1.Genuine SI Nilsson et al, 2001:85 patients, follow-up 5 yrs
• Retropubic hematoma: 3.3% Bladder perforation: 1.1% Intraoperative bleeding >200ml: 3.3% Postoperative voiding difficulties: 4.4% UTI: 7.8% Infection of operating site: 1.1%
Aboubakr Elnashar

11. •Complete cure (no leak at all & no voiding problems): 84.6% Significant improvement (leak occasionally): 10.6% No significant decline in efficacy over an extended period Failure rate: 4.8%
• De novo urge symptoms: 5.9%
Aboubakr Elnashar

12. 2.Recurrent SI Rezapour & Ulmsten, 2000: 34 patients, Follow up for 5 yrs
• No significant intra-or postoperative complications Bladder perforation: 1 patient Post operative urinary retention: higher than that of uncomplicated SI
• Cure rate: 82% Significant improvement: 9% Failure: 9%
• No long term complications
Aboubakr Elnashar

13. 3.SI with ISD (hypotonic urethera, Type 3 incontinence) Difficult to cure Rezapour et al,2001: 49 women, follow-up 4 yrs
• Bladder perforation: 1 patient Small hematoma: 11% Temporary postoperative voiding problems: 23%
Aboubakr Elnashar

14. • Complete cure: 74% (equal or better than traditional surgery) Significant improvement: 12% Failure: 14% (more than that in genuine SI). The majority in >70 yrs, urethral p <10 cm H2O & immobile urethra.
• No LT complications, No LT urinary retention
Aboubakr Elnashar

15. 4.Mixed ( urge & stress) Rezapour & Ulmsten, 2001: 80 women, follow-up 4 yrs
Urge component may consist of:
1.detrusor instability with low bladder volume <200 ml (excluded & treated with anticholinergics),
2.uretheral relaxation or 3.uninhibited premature micturition reflex
• Postoperative voiding problems: 18% Bladder perforation: 1 patient Small heamatoma: 8% & Significant haematoma: 1patient (on anticoagulant)
Aboubakr Elnashar

16. • Cure rate: 85% Improvement: 4%
Failure: 11% Urgency without incontinence: 25% of the cured & improved women
Aboubakr Elnashar

17. Provided that a urodynamic evaluation is done, TVT can be used in mixed I.
Not only the stress but also the urge I was cured or improved in 85%. ?
TVT:
1. Minimal vaginal dissection, the tape is placed tension-free around the mid urethra. So, the proximal part of the urethra & bladder neck which are densely innervated would be less compromised than in other sling operations
2.Causes only dynamic Kinking of the midurethera at stress & less likely to obstruct urine flow at micturition
Aboubakr Elnashar

18. •Cochrane library, 2002: 682 women
•Cure rates after TVT were similar to those following open abdominal retropubic suspension.
•No difference in: voiding dysfunction, urge incontinence or detrusor instability between suburetheral slings & abdominal or needle suspensions
Aboubakr Elnashar

19. •Ursula et al,2000 Contrary to Burch colposuspension in which a continuous decline of success, no such deterioration has been reported with TVT TVT creates a new hammock under the midurethera. The tape is invaded by fibroblast during the course of time, thereby stabilizing its position with time
Aboubakr Elnashar

20. 1.TVT cannot be expected to treat all types of incontinence
2.TVT is effective, safe & long lasting, also in previous operated patients
3.TVT can be used in ISD SUI, even with low cure rate compared to GSI
Aboubakr Elnashar

21. 4. TVT can be used in MSI to cure or improve also urge symptoms 5. TVT results are comparable to traditional surgery but simple & less invasive 6. TVT cure rate is about 90% lasting for 5 yrs, with few intra & postoperative complications
Aboubakr Elnashar

22. E-mail: elnashar53@hotmail.com
Aboubakr Elnashar