Resumos Comentados

TVT-O vs TVT: a randomized trial in patients with different degrees of urinary stress incontinence

Araco F, Gravante G, Sorge R, Overton J,
De Vita D, Sesti F, Piccione E.
Int Urogynecol J Pelvic Floor Dysfunct. 2008 Jan 24


TVT-O and TVT were compared in patients stratified according the severity of Stress Urinary Incontinence (SUI). Those patients with intrinsic sphincter deficiencies, overactive bladders, associated prolapses, neurovegetative disorders and recurrent SUI or under rehabilitative/medical therapies were all excluded. There were 208 women included. Operating times were longer, and postoperative pain greater for TVT (p < 0.001). TVT produced longer hospitalizations in severe SUI patients (p < 0.001). After 1 year of follow-up, incontinence was cured in all mild SUI patients with both techniques, in all severe SUI patients when treated with TVT and in 66% of them when treated with TVT-O (p < 0.001). Vaginal perforations occurred during the TVT-O (p = 0.01), bladder perforations during TVT (p = NS), bladder obstructions in mild SUI patients after TVT (p < 0.001). The severity of SUI is an important parameter that influences results after TVT-O and TVT, and could be used to guide surgeons in selecting the most effective intervention.


Editor’s comment


Synthetic suburethral slings, which are highly effective and associated with low morbidity rates, have been widely accepted by urologists and gynecologists as a method for the treatment of SUI. Minimally invasive, they have advantageously taken the place of autologous slings. More recently, the development of the transobturator route method has reduced some of the complications associated with the rectopubic technique (urethral obstruction, pelvic hematomas and bleeding, pain and vesical perforations). Infravesical obstruction, more frequently observed with the rectopubic route, is associated with the higher pressure produced by the tape “involving” the urethra. In the transobturator approach, the prolene tape is more anatomically placed just supporting the mid-urethra. However, in cases of severe UI, which require higher urethral compression to prevent urine loss, the transobturator route would, theoretically, increase the probability of surgical failure, rather than represent an advantage.  In spite of theoretical premises, there are no reliable studies to support the choice of one of the techniques. In a recently published metanalysis1, no difference in outcomes was observed when both methods were compared. The work of Araco and collaborators tries to shed some light on this matter. However, the difficulty in selecting the patients and assigning them to “severe” or “mild” UI groups based on a questionnaire and the classification system of McGuire shoud be taken into account. The subgroup including the actual patients with severe UI (Type III) did not participate in the study. Nonetheless, the authors found a significant difference in outcome after one year among patients with severe incontinence (TVT = 100% cure; and TOT = 66% cure). Despite this finding and theoretical bases, the superiority of TVT in the treatment of severe UI cases remains questionable.

1. Sung VW, Schleinitz MD, Rardin CR, Ward RM, Myers DL. Comparison of retropubic vs transobturator approach to midurethral slings: a systematic review and meta-analysis.Am J Obstet Gynecol. 2007 Jul;197(1):3-11.


Aparecido Donizeti Agostinho