This Journal Club presentation provides a summary and discussion of the following free access article published in UOG: Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures J.M. Yang, S.H. Yang, W.C. Huang, C.R. Tzeng Volume 39, Issue 4, Date: April 2012, pages 458-465 This can be accessed here: http://onlinelibrary.wiley.com/doi/10.1002/uog.10086/abstract

1. UOG Journal Club: April 2012
Correlation of tape location and tension with
surgical outcome after transobturator suburethral
tape procedures
J.-M. Yang, S.-H. Yang, W.-C. Huang and C.-R. Tzeng
Volume 39, Issue 4, Date: April 2012, pages 458–465
Journal Club slides prepared by Tommaso Bignardi
(UOG Editor for Trainees)

2. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Background
Tape location and tension are among the factors that might affect
surgical outcome of transobturator suburethral tape procedures
(TOTs).
The location and course of the suburethral tape can be
studied with translabial and/or transperineal sonography.

3. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Objective
To explore, using 4D ultrasound, the importance of
location and tension of transobturator suburethral tape
(TOT) with respect to clinical outcome measures.

4. Methodology
Prospective observational study of 56 women who had TOT
(Monarc®) for urodynamic stress incontinence
Exclusion criteria:
Diabetes, neurological disease or stroke, previous or concomitant
pelvic reconstructive surgery, concurrent symptoms of urgency or
urgency incontinence, ≥ Stage II pelvic floor prolapse, detrusor
overactivity
4D ultrasound assessments using an introital approach
a) at rest, b) during maximum strain and c) with coughing

5. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Tape location measurements
sTSD: sagittal tape–symphysis pubis
distance (dashed double-headed
arrow)
sTSA: sagittal tape–symphysis pubis
angle
Tape percentile: percentage of
proximal urethral length (PUL) by
total urethral length (TUL)
(double-headed arrows)
B, bladder; SP, symphysis pubis;
T, tape; U, urethra

6. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Tape tension measurements
sTUDu, sTUDc and sTUDl:
shortest distance between upper,
center and lower ends, respectively,
of the tape and the midline
of the urethral echolucent area in the
sagittal plane
Urethral encroachment: indentation
in the urethral outer wall by the tape
with an elevation of the inner wall
B, bladder; SP, symphysis pubis;
and narrowing of the echolucent
T, tape; U, urethra
urethral core

7. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Tape tension measurements
aUCEAc, circle: urethral central
echolucent area at the tape center in
the axial plane
SP, symphysis pubis; U, urethra;
T, tape

8. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Surgical outcomes
Postoperative assessments: 3 months,12 months and 24
months
Incontinence severity: Sandvik Incontinence Severity Index
and Ingelman- Sundberg Scale
Quality of life: short forms of Urogenital Distress Inventory
(UDI-6) and Incontinence Impact Questionnaire (IIQ-7)

9. Results
The intra- and interobserver reliability of ultrasound measurements of
sagittal tape–symphysis pubis distance (sTSD) and sagittal tape–
symphysis pubis angle (sTSA) were good to very good.
ICC (95% CI)
Measurement Intraobserver Interobserver
Resting
sTSD 0.840 (0.639–0.933) 0.794 (0.551–0.913)
sTSA 0.799 (0.559–0.915) 0.831 (0.622–0.930)
Straining
sTSD 0.795 (0.552–0.913) 0.851 (0.661–0.938)
sTSA 0.747 (0.465–0.892) 0.857 (0.674–0.941)
Coughing
sTSD 0.769 (0.504–0.902) 0.807 (0.576–0.919)
sTSA 0.852 (0.664–0.939) 0.805 (0.571–0.918)

10. Results
• TOT placement is associated with increased sTSA and urethral
encroachment and decreased sTUDu, sTUDc, sTUDl and
aUCEAc during increased intra-abdominal pressure.
• Tapes in women with recurrent SUI were placed more proximally.
• Women with SUI postoperatively demonstrated no urethral
encroachment at rest or with increased intra-abdominal pressure.
• Women with postoperative OAB symptoms had decreased resting
sTSD and larger resting sTSA.
• Women reporting de novo or worsening voiding difficulty had
increased resting sTSA and urethral encroachment.
SUI, stress urinary incontinence; OAB, overactive bladder

11. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Conclusions
•Both tape location and tape tension are associated with
surgical outcome of TOT procedures.
•Assessment of tape location and tension can be achieved
using 4D ultrasound.

12. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
Discussion points
• How do suburethral slings work?
• Do you think we have to compress the urethra to achieve stress continence?
• Why would you want to know whether a suburethral sling is too tight, just right or
too loose?
• What kind of symptoms would you expect if a tape was too tight/too loose? What
parameters does this paper suggest we measure to define tape 'tightness'?
• Do you know of any other, simpler sonographic measures? (see ref. 1 below)
• Would the findings in this paper regarding de novo overactive bladder symptoms
and worsening voiding difficulty be altered by statistical correction for multiple
comparisons?
• Apart from ultrasound, what other investigations would you suggest? What would
you do if symptoms and investigations suggest a tape that's too tight? And what
would you do if it's clearly too loose?
• What can we do to get sling tension right every time?
• Do you think ultrasound can help?

13. Correlation of tape location and tension with surgical outcome after
transobturator suburethral tape procedures
Yang et al, UOG, 2012
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