الفهرس | Only 14 pages are availabe for public view |
Abstract In MUS (mid urethral sling procedures), the sling provides dynamic kinking of the urethra when abdominal pressures increase, while maintaining stability at the resting phase, consequently preventing urinary incontinence (Choi and Lee, 2004) Urethral obstruction following anti-incontinence surgery often presents as urinary retention or obstructive voiding symptoms (hesitancy, incomplete bladder emptying, weak urinary stream, urinary straining), but many patients present primarily with irritative voiding symptoms (urgency, frequency, nocturia) and urge incontinence. Recurrent urinary tract infections may also point to occult outlet obstruction. Upon further evaluation, these patients usually demonstrate elevated post void residuals (Goldman et al., 1999). Although the surgical procedures to correct SUI (stress urinary incontinence) have been reasonably successful, there are potential complications including persistent stress urinary incontinence, urethral erosion, de novo detrusor instability, and urethral obstruction (Goldman et al., 1999). Tension-free vaginal tape (TVT), which is supposed not to cause obstruction because it ideally is placed tension free, is not immune from inducing iatrogenic urethral obstruction requiring tape division (Romanzi and Blaivas, 2000; Choe, 2001). The obstruction then leads to obstructive and/or irritative voiding symptoms or urge incontinence. These symptoms can be very distressing to the patient, as she has now traded stress urinary incontinence for what many consider more problematic and unpredictable-urge incontinence. Thus, the patient should be informed preoperatively about the possible post-operative complications and the plan to treat them if the complications arise (Goldman et al., 1999). The high, long-term success rate of TVT ranges from 84% to 95% (Meschia et al., 2001; Doo et al., 2006) but is associated with concerns about operating safety in terms of risk of injuries to the bowel and major blood vessels, and of bladder and urethral perforation. TVT is also associated with postoperative voiding difficulties such as transient urine retention in 8–17% (Ulmsten, 2001; deTayracet al., 2004) of patients and urgency in 5–15% (Boustead, 2002; deTayracet al., 2004). To avoid the complications associated with the retropubic route, Delorme, (2001) advocated the transobturator route (TOT). Insertion through the obturator muscles reproduces the natural suspension fascia of the urethra while preserving the retro pubic space by avoiding intrapelvic and retro pubic blind passages. Consequently, the TOT approach seems to limit the risks of visceral and vesical lesions and, more importantly, of bowel and vascular injuries. In a preliminary study, TOT was associated with a high success rate, no bladder injury, and few perioperative complications in women with SUI. Similar results were achieved by Krauth et al. (2005) in a large series of women. The reported results are very close to those reported in most of the observational series of tension-free vaginal tape (Costa and Delmas, 2004), and objective cure rates are as good as those quoted for the randomized controlled trial of colposuspension versus tension-free vaginal tape (Ward and Hiltcn, 2004). Comparative studies of TOT versus TVT recently reported no different in efficacy (Mansoor et al., 2003; deTayrac et al., 2004). Our study was a retrospective and observational study on 90 women who underwent TVT and TOT. Classified into: The first group included 37 patients who had TVT procedure done for them. The second group included 53 patients who had TOT procedure done for them in both groups data was retrieved from patients’ files in the department of urogynecology and included their preoperative urodynamic study. The primary outcome measurement of our study was to evaluate voiding dysfunction after the two procedures in treatment of stress urinary incontinence. We evaluated comprehensive risk factors that may be predictive of postoperative voiding dysfunction, and factors having impact on patient satisfaction after the TVT and TOT procedures. Thirty seven patients underwent TVT. Mean age 42.62 (±8.87), and 53 patients underwent TOT with mean age 43.66 (±9.59) with no significant difference between both procedures and as regard age and other parameters. We found that Voiding dysfunction occurred in 16 patients (43.2%) after TVT and in 14 patients (26.4%) after TOT with a highly significant difference between both procedures at a mean years follow up 4.21 years, 3.34 years respectively. Classified into; denovo urgency occurred in 6 patients (16.2%) after TVT and 8 patients (15.1%) after TOT with no significant difference between both procedures, denovo frequency occurred in 8 patients (21.6%) after TVT and 11 patients (20.8%) after TOT with no significant difference between both procedures, urge incontinence occurred in 3 patients (8.1%) after TVT and 3 patients (5.7%) after TOT with no significant difference between both procedures, immediate urinary retension occurred in 6 patients (16.2%) after TVT and no one after TOT with high significant difference between both procedures, sense of incomplete bladder evacuation occurred in 2 patients (5.4%) after TVT and 3 patients (5.7%) after TOT with no significant difference between both procedures, and lastly we found that interrupted urinary stream occurred in 1 patient (2.7%) after TVT and 3 patients (5.7%) after TOT with no significant difference between both procedures. The explanation of this high incidence of voiding dysfunction in our study was due to small number of patients enrolled. Boustead, (2002) reported that 1.5-20% of patients after TVT can develop postoperative voiding dysfunction. We found also in our study a subjective post operative voiding dysfunction as regard urodynamics only without manifestations as there were 5 patients in TVT and 1 patient in TOT had high RV (post voidresidual) and low MFR without voiding troubles manifestations. The secondary outcome measurement of our study was evaluation of time of operation, associated procedures, cure rate and complications after both procedures. As regard operative time we found that the mean operative time of TVT procedure was 30.27 minutes and that of TOT procedure was 18.02 minutes As regard cure rate after TVT and TOT: The current study shows that 14 patients (15.56%) among 90 patients included in this study presented with residual incontinence 7 of them belonged to TVT (4 patients had stress urinary incontinence and 3 patients had urge incontinence) and 7 belonged to TOT (4 patients had stress urinary incontinence and 3 patients had urge incontinence) with no significant difference between both groups Also we found that the objective cure rate after TVT procedure was 81.1% and in TOT was 86.8% after mean years follow up 4.21 years and 3.34 years respectivly It was noted in our study that bladder injury and perforation occurred in 3(8.1%) cases after TVT one of them had tape removal and kelly’s suture was done another one had cystoscopic bladder repaire and the last one managed conservatively by urinary catheter in contrast to no bladder injury after TOT this injury happened earlier in our center that may explained by rising of surgeons skills. |