الفهرس | Only 14 pages are availabe for public view |
Abstract Pioneered by Delorme (2001), the transobturator tape approach (TOT) was developed with the aim to reduce side effects of this retropubic sling procedure by not entering the space beyond the endopelvic fascia. The mechanism of action of these sling procedures differs from that of conventional pubovaginal slings that usually were placed beneath the bladder neck to elevate this area according to pressure transmission theory. Using tension-free or low tension slings the bladder neck is not displaced backwards into the abdomino-pelvic pressure zone but the defective pubo-urethral ligament is replaced. In addition the defective connection between the urethra and vagina is restored and thereby the sub-urethral hammock reinforced or restored . In this study we prospectively compared between the ordinary retropubic pubovaginal sling ,TVT and TOT procedures in treatment of female SUI as regards safety and efficacy. A total of 60 patients were randomly assigned to PVS (20) or TVT (20) or TOT (20) during the period from April 2005 to December 2009. All patients were assessed before surgery by history, clinical examination, urine analysis, abdomino-pelvic ultrasonography, ascending cystourethrography and urodynamic examination. Our exclusion criteria were detrusor under-activity, detrusor overactivity, obstructed flow, significant post-void residual urine, central or peripheral neurological pathologies and presence of other gynecological pathologies needing a simultaneous hysterectomy. The preoperative criteria (age, menopausal state, previous deliveries, type, cause and grade of SUI, presence of cystocele and presence of previous pelvic surgery) were similar in the 3 groups. Patients were assessed at 2 weeks, 3, 6 and 12 months postoperatively. The surgical outcome results were classified into cured, improved and failed. All patients were operated upon under spinal anesthesia with the mean ± SD operative time significantly shorter in TOT and TVT vs pubovaginal sling PVS (22.7 ± 9.6 min for TOT vs 29.5± 8.7 min for TVT, p= 0.025). No intra-operative bleeding requiring blood transfusion was observed in the 3 groups. Bladder injury occurred in 3 patients (15%) of the TVT group (2 of them had past history of previous pelvic surgery) and non of the PVS and TOT groups. There were 3 patients with urethral injury, one in each group (ALL had past history of anterior colporhaphy). There were no long term effects for these bladder and urethral injuries. There were 2 minor lateral wall vaginal tears in the TOT group without any sequelae. The mean hospital stay was 1.5 days for all groups. There was no significant difference between PVS, TVT and TOT in the rates of cure ( 85%,85% and 90%), improvement (5% , 10% and 5%) and failure (5% , 10% & 5%) respectively. Preoperative urge incontinence resolved in 71.4% of the TVT group and 75% of the TOT in patients suffering from mixed SUI (7 patients in the TVT group and 9 patients in the TOT group). There was no significant difference in the cure rate between patients with past history of previous pelvic surgery and fresh cases in the three groups . Concomitant classical repair was done in 2 patients of the TVT group and one patient of the TOT group and the preliminary results suggest that concomitant prolapse repair and vaginal tapes may yield acceptable results. |