Side effects were not serious: urinary tract infection in 3 patients and transient urinary retention in 4. Six patients with detrusor overactivity and impaired contractility were treated with intermittent self-catheterization for 1 month, after treatment resulted in increased postvoid residual urine volumes.
Patients with impaired bladder emptying before treatment may be at higher risk of posttreatment retention, although even when retention occurs, it seems to be transient and responds well to time-limited management with intermittent self-catheterization.
Stress incontinence surgery: What’s in, what’s out
Is TVT out?
Costa P, Grise P, Droupy S, et al. Surgical treatment of female stress urinary incontinence with a transobturator-tape (TOT) Uratape: Short-term results of a prospective multicentric study. Eur Urol. 2004;46:102–107.
Faster than you can say “tension-free vaginal tape,” an even newer procedure is coming to the fore: TOT, the transobturator tape.
The TVT operation revolutionized stress incontinence surgery, with placement at the midurethra instead of traditional placement at the bladder neck. Although case series and the first randomized trials showed good results with TVT, concern about retropubic complications fueled development of alternate placement through the obturator foramen. This alternative is intended to avoid complications attributable to penetration of the peritoneal cavity or retropubic space with TVT.
In a study conducted by Costa et al, 183 women with stress or mixed incontinence associated with urethral hypermobility underwent the TOT procedure, which involved midurethral placement of a polypropylene tape with a silicone-coated central part, using a transobturator percutaneous approach. With follow-up at more than 6 months on 130 of the 183 study subjects, 83% were reported as “cured” (absence of subjective complaint of urine leakage and absence of leakage on cough stress testing) and 5.4% as “improved” (decrease of stress incontinence, not further specified).
Obviously, we need more information and, ideally, comparative information to determine how this new technique fits in with other surgical options for stress incontinence. So far, 2 trials comparing TVT and TOT were reported in abstract at the 2004 meeting of the International Continence Society.
Of 17 failures, tape removal was necessary in 5, due to vaginal extrusion in 3 and urethral erosion in 2. Because of this high rate of extrusion, the silicone portion of the tape has been removed.
TOT (but not silicone) is in
Comiter CV, Colegrove PM. High rate of vaginal extrusion of silicone-coated polyester sling. Urology. 2004;63:1066–1070.
This case series reported 10 patients treated with the silicone-coated polyester sling for stress or mixed urinary incontinence. Two patients (20%) developed vaginal extrusion requiring tape removal, at 6 and at 10 months after initial placement. Although the sling was otherwise effective in treating stress incontinence, this high rate of extrusion obviously precludes further use. No silicone on slings!
Laparoscopic Burch is out
Ankardal M, Ekerydh A, Crafoord K, et al. A randomized trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence. Br J Obstet Gynaecol. 2004;111:974–981.
What about laparoscopy, the grandfather of minimally invasive surgery? In this large, adequately powered, randomized trial of open Burch and laparoscopic colposuspension, the open technique was performed with permanent suture, 2 stitches on each side; the laparoscopic technique used polypropylene mesh and titanium staples. Of 120 subjects randomly assigned to each group, 98 underwent open and 109 underwent laparoscopic colposuspension.
Unfortunately, twice as many subjects (22) assigned to open Burch were excluded after randomization, compared with the laparoscopic group (11). Nonetheless, the results 1 year after surgery unequivocally favored open versus laparoscopic colposuspension: objective cure by pad test in 92% versus 74%, and subjectively dry in 89% versus 62%, respectively.
One wonders why any more trials of laparoscopic colposuspension should be performed at all, although the authors call for future randomized studies comparing different laparoscopic techniques such as suture versus staples and mesh. If the goal is to provide effective, “minimally invasive” surgery for incontinence, with traditional slings updated to include TVT and now TOT, it seems we already have reasonably good alternatives—with the caveat, “pending further studies,” especially for long-term results of the new techniques.
Clinicians who prefer slings have always wondered why laparoscopy—with 3 or 4 abdominal ports, pneumoperitoneum, and general anesthesia—was seen as minimally invasive. Not that laparoscopic continence procedures should never be performed, but it seems likely that they will occupy a narrow niche in the range of surgeries for stress incontinence in women.
Watch for these 2 reports
In other incontinence news, look for results from 2 important trials in 2006: