“We still don’t know if the transobturator is as effective as TVT, but we are slowly adopting it because it is easier and probably safer”
KARRAM: The current rage is the transobturator approach, although we have very little data about it. Theoretically, it is safer than TVT, since there is no need to pass the needles through the retropubic space, and thus it is unlikely to lead to vascular and bowel, or bladder and urethral injury.
Should go ahead and adopt it as a primary procedure, or do you recommend waiting for more data on its efficacy?
BLAIVAS: I do not recommend that it be adopted until it is proven safe and effective, but I feel the same way about most of the other slings as well. When performed by experts, almost all these procedures are very safe, but we don’t know very much about long-term efficacy. If someone selects the transobturator approach out of fear of complications from a different procedure, he or she is probably not skilled enough to perform these operations in the first place.
KARRAM: I agree that we need to wait until efficacy data are established. As slings become less and less invasive, industry is aggressively pushing them into the hands of novices. Most of the time these are gynecologists who have not performed antiincontinence surgery and may even lack cystoscopy privileges. Do you think this will be a problem down the road?
BLAIVAS: Yes, unless the procedures are dumbed down enough and they are truly safe and effective.
Transobturator and TVT learning curves and outcomes
WALTERS: As for the transobturator approach, I am convinced, based on my surgical experience over the past 2 years, that it is easier than TVT and results in less voiding difficulty and urgency.
However, I am not convinced that it is equivalent to retropubic TVT in cure rates for SUI. This issue especially needs to be rigorously tested.
In my experience, TVT has a very high cure rate for SUI, but can cause urgency, including intractable urge and voiding dysfunction requiring transection of the polypropylene tape. This rarely occurs with the transobturator sling, making it attractive for simple SUI.
The transobturator sling also is easier than TVT to learn and teach, and completely avoids any risk of retropubic hematoma and bowel perforation. Also, unless there is extensive prolapse, the risk of entering the bladder and urethra is practically nil, assuming you are able to pass the needle and touch your finger from the lateral side.
The next big, important study will likely be a randomized comparison of transobturator and TVT slings, similar to the way TVT was compared with the open Burch procedure.
“I perform cystoscopy on virtually every patient, and find abnormalities in 2% to 4% of cases a year”
WALTERS: For their own protection, I don’t think gynecologists should be doing surgery for prolapse and incontinence if they do not have privileges for cystoscopy.
KARRAM: I agree. It is very important that the gynecologists performing these procedures evaluate the patient thoroughly enough to decide wisely between surgical and nonsurgical management. Certainly they should have the ability to evaluate the lower urinary tract with cystoscopy before doing these procedures.
WALTERS: I perform cystoscopy on virtually every pelvic reconstructive surgery and find abnormalities in the bladder, urethra, or ureters in 2% to 4% of cases a year. Although I encourage gynecologists to learn these operations, cystoscopy is crucial, so an effort should be made to obtain training and privileges for it.
“I’m glad my partners and I have the ability to perform the Burch procedure when necessary”
KARRAM: You mentioned the Burch procedure, Dr. Walters. Do you think there is still a role for retropubic urethropexy—done laparoscopically or via an open technique?
WALTERS: I perform an open Burch procedure if I have already made a laparotomy incision for another reason, such as abdominal sacrocolpopexy or hysterectomy. I occasionally perform laparoscopic Burch procedures in younger women undergoing laparoscopy for other reasons, such as tubal sterilization or ovarian disease.
KARRAM: I perform retropubic urethropexy if operating in the abdomen for another reason, provided the patient has SUI, urethral hypermobility, and vaginal pliability.
BLAIVAS: Retropubic urethropexy has a proven track record, but requires skill and experience.
With uncomplicated incontinence, long-term success appears as good as any operation. If a surgeon is skilled, this procedure should be part of his or her armamentarium.
KARRAM: You are correct. Data suggest the retropubic operation and TVT procedure are equally effective.2,3