Transobturator slings

Transobturator Slings

Dr. DeLorme from France originated the idea of passing the same mesh as was used in the TVT procedure through the obturator fossa.  His initial inspiration came from literature in veterinary medicine for treatment of incontinence in female dogs.  This procedure, known as the transobturator sling, involved passage of the polypropylene mesh through incisions in the groin area and vagina to create a hammock under the midurethra.  This procedure was performed entirely in the pelvic area and avoided the abdomen.  As a consequence, the procedure appeared to be much safer than the TVT.  Cadaver dissections proved the procedure to be safe with passage of inserters several centimeters from the only vessels and nerves in the obturator fossa.  This technique was first performed in humans in the late 1990s.  Since that time, over 12,000 transobturator slings have been performed in Europe and the U.S..  Results have proven to be as good as with the TVT but there have been only rare reports of complications.  Currently there are three procedures available to surgeons.  The Monarc from AMS and Obtape from Mentor employ an “outside-in” approach for placement of the sling.  The Gynecare TVT-O is placed with an “inside-out” approach.

Procedure

Anesthesia for the transobturator sling can be general, spinal, or local with intravenous sedation (conscious sedation or “twilight” anesthesia).  A single vertical incision is made in the top part of the vaginal wall, approximately one centimeter from the urethral opening, extending two centimeters into the vagina.  After some dissection under the vaginal wall toward the groin area, the surgeon can palpate the under surface of the pubis and the inner portion of the obturator fossa.  Small incisions, approximately one-half centimeter in size, are made over groin on both sides, at the level of the clitoris.  The incision, which is in the fold of the leg where it meets the perineum, overlies the obturator fossa.  With the index finger of one hand in the vagina, a curved inserter is passed using the opposite hand, through the incision in the groin, through the obturator fossa and guided into the vaginal opening.  The polypropylene mesh is then passed back through the same path.  A similar maneuver is performed on the opposite side.  The tape is now under the mid-urethra and passing through the skin of the groin on both sides creating a hammock.  Tensioning of the sling is performed taking care to be sure there is no tension on the urethra.  The vaginal wall is closed with dissolvable sutures and the groin incisions are closed with a type of skin glue.

Post-operative Course

After approximately one hour in the recovery room, the patient will be sent to the day surgery unit.  A few patients may have undergone additional surgery that may require a hospital stay.  If only a transobturator sling is performed, no catheter will be placed in the  urethra therefore the patient will need to void prior to discharge.  Approximately 85% of the patients will be able to void spontaneously.  If the patient is unable to void, a catheter will be placed and removed the following day in our office.  Those patients that undergo  “combination” surgery will have the catheter removed after 1-2 days in the hospital.  Patients will usually note pain in the groin area but not in the vagina.  This usually will require the use of pain medications for several days.  This should not prevent normal movement around the house.  Usually, the patient can return to desk-type duties at work within one week (or sooner if the patient feels able).  If the patient is not having pain and is not on pain medication, driving is not restricted.  Vigorous physical activity is restricted for 4 weeks.  Walking up to 3.5 mph on the treadmill or walking briskly in the neighborhood is the maximum aerobic activity reasonable in the post-operative period.  Lifting is restricted to 10 pounds or less.  Intercourse is restricted for 4 weeks.  After the 4 week period, there are no further restrictions on activity.

Post-operative Visits

Patients will be seen in the office two weeks after surgery.  This visit includes a urinalysis and a symptom check.  Residual urine will be checked with a non-invasive bladder scanner. Assuming that the patient is doing well, she will be seen in the office approximately 3 months later.  The patient will be examined during this visit to be sure there are no problems with healing in the vaginal wall or groin.  If all is well, the patient will be discharged at that time.  If there are any further difficulties post-operatively, additional visits may be necessary.

Potential Complications

There are only a few potential problems following a transobtruator sling.  Failure to adequately treat stress incontinence occurs in approximately 8% of patients.  If a patient had preexisting urge incontinence in addition to the stress incontinence, there is only a 30-40% chance the urge incontinence will be treated by the sling procedure.  Mesh extrusion, or exposure, into the vaginal wall occurs in 1-2% of cases.  Obstruction of the urethra occurs in 2-3% of cases.  If either of these complications occur, a simple vaginal procedure can cure these problems.  Of interest, most patients still preserve continence after the repairative procedures.  Of greater concern is the risk for urethral injury or erosion.  The risk for urethral erosion is less than 1% and usually occurs if injury is missed at the time of surgery or undue tension is created by the sling on the urethra.

Conclusion

The transobturator sling is a safe and effective surgical procedure to treat stress incontinence.  If you have any questions, please feel free to call our office.