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THE JOURNAL OF FEMALE
URINARY INCONTINENCE


Surgical Techinique
 

Modification of the Tension-Free Vaginal Tape ( TVT )


Alexander Tsivian,  Avraham Shtricker, Shalva Benjamin, A. Ami Sidi
Department of Urologic Surgery, The Edith Wolfson Medical Center,
Holon, and Sackler Faculty of Medicine, Tel Aviv University, Israel

 
Abstract
Long-term follow-up of  TVT,   has revealed  that the procedure could be associated with intraoperative and postoperative urethral complications, such as injury, erosion and obstruction. We describe a technical modification of the procedure, which prevents direct contact of the synthetic tape  with the urethra, and may  reduce the risk of urethral complications.

Key Words: Urinary incontinence, tension-free vaginal tape procedure.
Brief Summary
: We describe a TVT modification , which prevents direct contact of the tape with the urethra, and may  reduce the risk of urethral complications.

 
 
 
 
 
 
 
 







 
 
 
 
 
 
 


Introduction


The tension-free transvaginal tape (TVT) procedure has apparently become the most popular technique for the treatment of genuine urinary stress incontinence. Long-term follow-up, however, has revealed that the procedure could be associated with intraoperative and postoperative urethral complications, such as, injury, erosion and obstruction.1-3  Our analysis of these complications has shown that, in most cases of urethral obstruction and vaginal erosion, the tape has rolled over and assumed a string-like shape while, in other cases, it was displaced towards the bladder neck.3 To prevent these problems and reduce urethral complications rate, we have modified the TVT procedure as originally described by Ulmsten et al4.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Technique
After insertion of a urethral catheter, at a distance of 15 mm from the urethral meatus in the midline anterior vaginal wall, a 10-mm diameter circular incision is performed, raising a coin-shaped vaginal wall flap (Fig. 1 a). The flap is de-epithelized with electrocoagulation, after which both sides of the tape are passed into the retropubic space in the usual manner. The mesh tape in the midline is applied and fixed to the raised flap with two Vicryl 3/0 stitches (Fig. 1 b).The vaginal wall defect is closed, covering the tape and the flap (Fig. 1 c).

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Results

Since 2001, 21 women (aged 32 - 78 years) with genuine urinary stress incontinence underwent this modified TVT procedure, and no complications have been observed to date during mean follow-up of  51.4 months (ranged 43–56 ). Eighteen out of 21 patients(85.7% ) achieved full continence.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discussion
 

It is now recognized that the TVT procedure could be associated with intraoperative and postoperative urethral complications, such as, injury, erosion and obstruction1-3.The rate of tape-related complications after a TVT procedure is at least 6%3. At first, we had applied the modification we now describe in cases of stress urinary incontinence in women who had undergone surgery for urethral diverticula, to avoid any contact with the urethra. The maneuver of vaginal wall flap formation minimizes periurethral dissection. Later, during surgery for complications of TVT, the tape was found to have rolled over to a string-like shape in most of our cases of urethral obstruction and vaginal erosion, while it had been displaced proximally under the bladder neck in some cases3.Similar findings were reported by other authors with autologous sling5.We reasoned that fixation of the flattened tape could avoid subsequent twisting and displacement. Shah et al used absorbable sutures to secure the broad-based synthetic sling on the periurethral tissue to prevent rolling of the sling6.Dietz et al and Wang et al reported that the TVT tape appears to slowly migrate caudally7-8.Sousa-Escandon developed and reported a “sandwich technique” using a combination of a vaginal wall sling and a Mersilene mesh pubovaginal sling, with an 87% rate of continence9.  We de-epithelized the vaginal wall flap tissue with electrical coagulation to prevent inclusion cyst formation following buried vaginal tissue9-11.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Conclusion
 
The technical change that we propose prevents direct contact of the synthetic tape with the urethra, and may reduce the possibility of urethral complications. The fact that the tape is flattened and fixed beneath the urethra contributes to a better urethral coaptation, may reduce the risk of erosion or obstruction caused by rolled‑over tape, and prevents cephalad migration of the tape, which probably occurs during posture change from supine to erect . We proposed this technique in cases of recurrent SUI, especially after previous urethral surgery.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figures
 
 

Fig 1 a – At a distance of 15 mm from the urethral meatus in the midline anterior vaginal wall, a 10‑mm diameter circular incision is performed, raising a coin‑shaped vaginal wall flap..

1 – Anterior wall of the vagina
2 – Coin-shaped vaginal wall flap
3 – Urethra






 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig. 2 b – The mesh tape in the midline is applied and fixed to the raised flap with two Vicryl 3/0 stitches.

1 – Anterior wall of the vagina
2 – Coin-shaped vaginal wall flap
3 – Urethra
4 – TVT-Tape

 
 
 
 
 
 
 
 
 
 
 
 
 
 




 



Fig. 3 c – The vaginal wall defect is closed, covering the tape and the flap.

1 – Anterior wall of the vagina
2 – Coin-shaped vaginal wall flap
3 – Urethra
4 – TVT-Tap
e

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
References
  1. KLUTKE., C. SIEGEL S., CARLIN B.,et al .Urinary retention after tension-free vaginal tape procedure: incidence and treatment. Urology, v.58,p.697 – 701,2001.

  2. PIT M-J . Rare complications of tension-free vaginal tape procedure: late
    intraurethral displacement and early misplacement of tape. J Urol, v.167,p.647,2002.

  3. TSIVIAN A., KESSLER O., MOGUTIN B., et al. Tape related complications of the tension-free vaginal tape procedure. J Urol, v.171,p.762 – 4,2004.

  4. ULMSTEN U., HENRIKSSON L., JOHNSON P., et al. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J., v.7,p. 81 – 6,1996.

  5. SWEAT SD., ITANO NB., CLEMENS JQ., et al. Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction. J Urol., v.168,p.144 – 6,2002.

  6. SHAH DK., PAUL EM., AMUKELE S.,et al. Broad based tension-free synthetic sling for stress urinary incontinence: 5-year outcome. J Urol., v.170,p. 849 – 51,2003.

  7. DIETZ HP., MOURITSEN L., ELLIS G.,et al. Does the tension-free vaginal tape stay where you put it? Am J Obstet Gynecol., v.188,p. 950 – 3,2003.

  8. WANG KH., NEIMARK M., DAVILA GW,et al. Voiding dysfunction following TVT procedure. Int Urogynecol J., v.13,p.353 – 7,2002.

  9. SOUSA-ESCANON A. “Sandwich technique” for suburethral placement of Mersilene mesh sling during pubovaginal suspension surgery:preliminaryresults. Urology,v.51,p. 49 – 54,2001.

  10. PHILLIPS T., ZEIDMAN E., THOMPSON I..  The fate of buried epithelium. J Urol., v.148,p.1941 – 3,1992.

  11. BALDWIN D., HADLEY H. Epithelial inclusion cyst formation after free vaginal wall swing sling procedure for stress urinary incontinence. J Urol.,v.157,p.952.1997

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