De novo urgency after tension-free vaginal tape versus transobturator tape procedure for stress urinary incontinence

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Abstract

Objective

To determine the frequency of de novo urgency after tension-free vaginal tape (TVT) compared with the transobturator tape (TOT) procedure in women with stress urinary incontinence (SUI).

Study design

Prospective study of all consecutive women with urodynamically confirmed SUI undergoing anti-incontinence surgery between January 2000 and January 2008. All procedures were performed by experienced urogynaecologists well trained in TVT and TOT surgery. Assessments were carried out at 1, 6, 12 and, 36 months after surgery.

Results

The study population included 366 women (mean age 59.5 years), 243 in the TVT group and 123 in the TOT group. The groups were similar in terms of demographics, preoperative data, and cure rates. De novo urgency occurred in 13.4% of patients at 6 months after surgery, in 19.3% at 12 months, and in 22.1% at 36 months. De novo urgency was significantly more frequent in the TVT group than in the TOT group at 12 (22.2% vs 11.2%, P = 0.025), 24 (24.8% vs 12.3%, P = 0.033), and 36 (0% vs 24.7%, P = 0.034) months. Cure rates were similar in both groups. The final adjusted cure rate was 87.3% (319/366).

Conclusion

Treatment of SUI using the TOT procedure was associated with a lower rate of de novo urgency.

Introduction

In 1979, the International Continence Society defined urinary incontinence as ‘a condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable’ [1]. Urinary incontinence remains a distressing medical disorder that affects approximately 45% of American women [2] and 35% of European women [3] during their lifetimes. In Spain, the prevalence in the general population is approximately 23% and in Catalonia between 5% and 15% [4]. Urinary incontinence is frequently underreported because of the stigma associated with this condition. The most common type of urinary incontinence in women is stress incontinence, defined as the involuntary loss of urine during coughing, sneezing, or physical exertion such as sporting activities or sudden change in position. Urethral hypermobility related to a loss of urethral support – the hammock-like supportive layer described by DeLancey [5] – is putatively associated with most cases of stress urinary incontinence (SUI).

Pelvic floor muscle exercise is the first choice of treatment for SUI and is known to be effective in approximately 50% of cases [6]. Continence surgery is indicated when conservative treatment fails or the patient wants definitive treatment. Tension-free vaginal tape (TVT) is a standard surgical procedure used to treat SUI since 1995 when it was first described by Ulmsten and Petros [7]. This procedure, which involves implantation of a polypropylene tape under the midurethra via a minimal vaginal incision, is one of the most used methods for incontinence surgery. Blind passing of the needle into the retropubic space, however, could cause bladder perforation and injury to the urethra, retropubic organs and blood vessels. To avoid such complications, a new surgical approach using the transobturator tape (TOT), either from outside to inside or inside to outside, has been developed [8]. The transobturator route enables the paravesical space to be preserved, limiting the risks of vesical, visceral, and vascular injuries. Moreover, the TOT procedure has a lower overall complication rate and no absolute need of postoperative cystoscopy [9], [10].

Other long-term complications after continence surgery have not been frequently reported because data in most clinical series are limited to short-term outcomes. De novo urgency is a symptom that occurs after placement of a tension-free tape in patients with preoperative genuine stress incontinence and persists 6 months after surgery. Urge incontinence is in general more bothersome for women than stress incontinence. The origin of de novo urgency and its mechanisms are poorly understood. Bladder outlet obstruction has commonly been used as one explanation. Long-term data regarding the frequency of this complication are scarce. In one study of 463 women who had undergone a TVT procedure for genuine SUI, de novo urgency occurred in 14.5% of the women after an average follow-up of 5.2 years [11]. The long-term frequency of this complication, however, according to the type of procedure performed (TVT vs TOT) has not been previously studied as a principal variable. The objective of this prospective study was to compare the frequency of de novo urgency after TVT and TOT procedures in women with SUI.

Section snippets

Materials and methods

Between January 2000 and January 2008, consecutive women with SUI underwent continence surgery, including the TVT procedure and, since 2005, the TOT procedure. Only patients with SUI due to urethral hypermobility of longer than one year's duration were eligible. Patients with intrinsic sphincter deficiency, intrinsic urethral sphincter deficiency with urethral hypermobility, mixed incontinence, and occult SUI were excluded from the study. All patients were free of neurological diseases,

Results

The study population included 366 women with a mean age of 59.5 years (range 31−85 years). The mean parity was 3 and only 0.9% (n = 3) were nulliparous. A total of 243 patients had the TVT procedure and 123 had the TOT procedure. The groups were similar in terms of demographics, parity and history of previous anti-incontinence surgical operations. The number of hysterectomies, however, was greater among patients treated with the TVT procedure. The majority of patients in both study groups were

Comments

In this clinical series of 366 women with SUI undergoing anti-incontinence operations, the TVT procedure was associated with a higher incidence of de novo urgency at 12 and 24 months after surgery than the TOT procedure. The differences between both techniques were 11% and 12.5% at 12 and 24 months, respectively. The difference of 24.7% in favour of the TOT procedure at 36 months should, however, be interpreted taking into account that only 14 patients with a full follow-up time of 36 months

Conflicts of interest

None to be declared.

Funding

None.

Acknowledgements

The authors thank Marta Pulido, MD, for editing the manuscript and editorial assistance.

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