Management of Urinary Stress
Incontinence in KSA Tension-free Vaginal
Tape
Prof. Hassan Abduljabbar Dr. Hanan Al-Shamrani ,Dr.Sammeerah
Basri. King Abdulaziz University Hospital ,Jeddah, Kingdom of Saudi
Arabia
Objective To review all cases of urinary stress incontinence treated
with TVT at King Abdulaziz University Hospital Jeddah, Saudi Arabia .
Study Design A prospective study using a standardized protocol for
pre- and post- operative evaluation.
Participants
Thirty one women participated in the study All suffered
from Genuine stress incontinence. The mean age 48 years ( SD 5 ) .All
women were multiparous.
Surgical Methods Tension-free vaginal tape implies the implantation
of a prolene tape around the mid-urethra via a minimal vaginal incision
.The procedure carried out under GA or local . .
Results
28 women could be operated on under general
anaesthesia,the other 3 were under regional (spinal).Only 3 cases took
longer than 45 minutes in the operative time. 27 patients micturated
spontaneously within 24 hrs with insignificant residual urine. 3 patients
within 48 hours.One patient needed in-dwelling catheter for 5 days.
.
Conclusion
TVT is safe , effective and fast surgical procedure for
the treatment of female urinary stress incontinence . Can be done as day
care case under local anesthesia.
INTRODUCTION
In 1990 Ulmsten proposed an integral theory, which challenged the current
theories. He proposed that incontinence can be treated at the level of the mid
urethra instead of the urethrovaginal junction (1, 3, and 5). The TVT procedure
was started by Ulmsten in 1995 (2). The sling is made of a prolene mesh that is
held in place by friction and not sutured to the anterior rectus fascia. The mesh is
meant to only support the urethra and not to elevate it.
With more than 500,000 procedures performed by June 2003, the TVT has
become a widely used procedure in many countries to correct stress urinary
incontinence. It is validated for patients with genuine stress incontinence with or
without sphincteric deficiency providing there is some urethral hypermobility.
This is a prospective study of a standardized tension –free tape technique. Using
a special protocol for the evaluation of the outcome.the study was approved by
the local ethics committee and all women gave an informed consent.
METHODS
Women diagnosed with primary urodynamic stress incontinence were recruited to
the trial from the general gynecology clinic. Thirty one women participated in the
study All suffered from Genuine stress incontinence. The mean age 48 years
( SD 5 ) .All women were multiparous.
Women with detruser overactivity were excluded from the trial`.Patients specific
data were collected prospectively from hospitalization until discharge.Patients
were followed up at 1 month,3 months,6 months and 1 year from discharge.
In the follow up stress provocation test was performed, and the patient was
asked about her quality of life improvement.
Patients were considered completely cured if the stress test was negative and
the women indicated quality of life improvement more than 90%.
Significantly improved patients are those with no incontinence on stress
provocation test and quality of life satisfaction less than 90% but more than75%.
Women who did not meet these criteria were considered failures.
RESULTS
All the surgeries were performed by a single surgical team .28 cases(90.3%)
were performed under general anesthesia while in 3 cases(9.7%) regional
anesthesia was used. Fig . 1.
30
28
25
20
15
10
3
5
0
General
Figure. 1:TYPE OF ANAESTHESIA
Regional
In the majority of the cases the procedure was performed in (30-45) minutes with
only 3 cases(9.7%) lasted more than 45 minutes .In these patients additional.
surgeries in the form of anterior vaginal repair for correction of cystocele were
performed.
25
20
15
10
5
0
0-15
15-30
30-45
45-60
60
Figure 1:Operative time
There were no significant intra-operative complications or post-operative
complications : no severe bleeding ≥250 mL., defective healing ,rejection of the
tape , or bladder injuries except for one case of urinary retention that needed
catheterization for 5 days. 27() women micturated spontaneously within 24 hours
while 3() needed 48 hours.Fig.3.
The patients were seen on the following intervals postoperatively one, three, six,
and twelve months.There were one failure, 26 patients (84%) were cured and, 4
(12.9%) showed significant improvement.
30
27
25
20
15
10
5
3
1
0
24 hrs
48 hrs
Figure 2:Post-op Voiding
5 days
DISCUSSION
The success rate in our study is high 96.9% total with 12.9% significant
improvement and this is comparable to other studies done by Ulmsten et al
98 %(3)and Wang 86%(4) .In our study previous anterior repair did not affect
the out come Table:1
Case series # of
patients
Ulmsten (7)
131
1998
Wang (6)
83
1998
Abduljabbar
31
2001
Previous
procedure
0
Cure rate
%
91%
Significant
Total
improvement improvement
7%
98%
0
83%
3%
86%
26
84%
12.9%
96.9%
Table.1.Total improvement rate
Our results are in agreement with other reports using the same procedure table
.2.In which they reported over all cure rate.The results in all these studies are in
close agreement which indicate that the procedure is effective with reproducible
cure rates.
The use of general anesthesia instead of local or regional in our study is related
to our population of patients were generally regional anesthesia is not well
accepted. To overcome this gentle suprapubic pressure was used to adjust the
placement of the tape without tension, and still we managed to get an acceptable
success rate.
The procedure lasted mostly between 30 and 40 minutes this includes the time of
anesthesia, which is comparable to other studies.
DATE
AUTHOR
COUNTRY
2001(19)
2000(13)
2000(14)
2000(15)
2000(16)
2000(17)
2000(12)
2000(18)
1999(11)
1999(10)
1999(9)
1999(8)
1998(7)
1998(9)
1998(6)
LO
WANG
BASTA ET AL
KLUTKE ET AL
SOULIE ET AL
JACQUETIN
HALASKA
JIMENEZ
MALTAU
PRIMICERIO
GORDON
OLSSON/KROON
ULMSTEN
NILSSON
WANG
TAIWAN
TAIWAN
POLAND
UAS
FRANCE
FRANCE
CZECH
SPAIN
NORWAY
ITALY
ISRAEAL
SWEDEN
SWEDEN
FINLAND
TAIWAN
NO.OF
PATIENTS
82
52
26
20
120
156
10
20
82
29
20
51
131
31
70
CURE
RATE
93%
90%
92.31%
85%
86.7%
89.1%
100%
95%
96%
82%
95%
90%
90%
n/a
83%
Stanton (2004) conducted a literature review of all midurethral tape procedures
and the studies conducted on each. The clinical studies were small in size and
had short-term follow-up; thus, they cannot provide a statistically significant
clinical comparison. Only one randomized clinical study has compared TVT with
colposuspension. (20)
The update (2005) consensus of the Sub-Committee on Urogynecology of the
Society of Obstetricians and Gynecologists of Canada (SOGC).
RECOMMENDATIONS: 1. The Burch procedure should be offered as the gold
standard. The TVT procedure is promising but currently under evaluation in trials
that will establish its efficacy and safety (II-3A). 2. Proper training is
recommended prior to performing TVT procedures. 3. Long-term trial results are
needed before the TVT procedure can be offered to patients as an equal
alternative to the Burch procedure. (21)
Conclusion
TVT is safe, effective surgical procedure for the treatment of female urinary
stress incontinence.
Can be done as day care case under local anesthesia
.
References
1. Petros PE, Ulmsten U. An integral theory of female urinary incontinence. Acta
Obstet Gynecol Scand 1990;69(suppl 153):1-79
2.U. Ulmsten and P. Petros, Intra vaginal sling plasty (IVS): an ambulatory
surgicalprocedure for treatment of female urinary incontinence. Scand. J. Urol.
Nephrol. 29 (1995), pp. 75–82.
3.Petros PE, Ulmsten U. Urethral and bladder neck closure mechanisms Am J
Obstet Gynecol. 1994 Jun;170(6):1713-20
4.F. Haab, C. Ciofu and O. Traxer, The tension free vaginal tape technique: Why
an unusual concept is so successful. Curr. Opin. Urol. 11 3 (2001), pp. 293–
297
5. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical
procedure under local anesthesia for treatment of female urinary incontinence
1996;7(2):81-5
6.Wang AC, Lo TS. Tension-free vaginal tape. A minimally invasive solution to
stress urinary incontinence in women. J Reprod Med 1998;43: 429–434
7. Ulmsten U, Falconer C, Johnson P, et al. A multi-centre study of tension-free
vaginal tape (TVT) for surgical treatment of stress urinary incontinence. Int
Urogynecol J 1998;9: 210–213
8. Olsson I, Kroon U-B. A three-year postoperative evaluation of tension-free
vaginal tape. Gynecol Obstet Invest 1999;48: 267–269.
9. Gordon D, Groutz A, Lessing J. PVT--tension-free vaginal tape--a new
minimally invasive surgical technique for female stress incontinence:
preliminary results]Harefuah. 1999 Nov 15;137(10):433-5, 512.
10. Primicerio M, De Matteis G, Montanino Oliva M, Marceca M, Alessandrini A,
Caviezel P, Tocci A [Use of the TUT (Tension-free Vaginal Tape) in the
treatment of female urinary stress incontinence. Preliminary results] Minerva
Ginecol. 1999 Sep;51(9):355-8.
11. Maltau JM, Verelst M, Holtedahl KA, Due J A new minimally invasive surgical
method for stress incontinence in women Tidsskr Nor Laegeforen. 1999 Jun
20;119(16):2342-5
12. Halaska M, Otcenasek M, Havel R, Martan A, Voigt R, Feyreisl J, Masata J.
[Suspension of the lower third of the urethra in ambulatory practice--minimally
invasive treatment of urinary stress incontinence--technique and initial
experience Ceska Gynekol. 2000 Jan;65(1):4-9.
13.Wang AC An assessment of the early surgical outcome and urodynamic
effects of the tension-free vaginal tape (TVT) Int Urogynecol J Pelvic Floor
Dysfunct. 2000;11(5):282-4.
14. Basta A, Pitynski K, Kolawa W Data from our recent trials with tension-free
vaginal tape (TVT) procedure for surgical treatment of genuine urinary stress
incontinence Ginekol Pol. 2000 Sep;71(9):1089-93.
15. Klutke JJ, Carlin BI, Klutke CG The tension-free vaginal tape procedure:
correction of stress incontinence with minimal alteration in proximal urethral
mobility Urology. 2000 Apr;55(4):512-4.
16. Soulie M, Delbert-Julhes F, Cuvillier X, Mouly P, Thanwerdas J, Dufeuil P,
Larroque JM, Bernstein J, Soulie R, Chemasle C, Brucher P, Vazzoler N,
Seguin P, Pontonnier F, Plante P [Repair of female urinary incontinence with
prolene "TVT": preliminary results of a multicenter and prospective survey]
Prog Urol. 2000 Sep;10(4):622-8
17. Jacquetin B. Use of "TVT" in surgery for female urinary incontinence]
J Gynecol Obstet Biol Reprod (Paris). 2000 May;29(3):242-7. Review
18. Jimenez Calvo J, Hualde Alfaro A, Santiago Gonzalez de Garibay A, Lozano
Urunuela F, de Pablo Cardenas A, Pinos Paul M, Jimenez Aristu J, Grasa
Lanau V, Roche Roche M, Montesino Semper M, Ruiz Ramo M, Villanueva
Perez I. [T.V.T. (tension-free vaginal tape). New surgical technique in the
treatment of stress urinary incontinence]
Arch Esp Urol. 2000 Jan-Feb;53(1):9-13
19. Lo TS, Wang AC, Horng SG, Liang CC, Soong YK. Ultrasonographic and
urodynamic evaluation after tension free vagina tape procedure (TVT).
Acta Obstet Gynecol Scand. 2001 Jan;80(1):65-70
20. Stanton SL. Mid-urethral tapes: which? Review of available commercial midurethral tapes for the correction of stress incontinence. BJOG. 2004;111(Supp
1):41-5.
21. Tension-free vaginal tape (TVT) procedure. Int J Gynaecol Obstet. 2005
Dec;91(3):279-82