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Transobturator Sling for Stress Incontinence (Subfascial Hammock)

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TOT Sling Table of Contents

• Introduction/Background
• What Does 'Tension-Free' Mean?
• Transobturator Sling (TOT Sling) - New, Safer Approach
• The Transobturator Sling (TOT Sling)
• Transobturator Anatomy
• TOT Sling Mimics Normal Anatomy
• Clinical Results and Complications
• Atlanta Urogynecology Experience
• Surgical Synopsis-TOT Sling

As stated by the American Urologic Association consensus statement in 2001, there are only 2 procedures that are proven to have effective long-term cure rates for the treatment of stress urinary incontinence (SUI). These procedures are the abdominal Burch Colposuspension (or MMK) and the transobturator sling procedure that is completed vaginally. However, in the past, the tot sling procedure was far from standardized. There have been multiple different descriptions using different materials for the tot sling (fascia from the patient, cadaveric fascia or dermis from humans or animals, synthetics, etc), different anchoring points, and different methods to adjust the tension of the sling. In many cases patients had to undergo general anesthesia, were in the hospital for several days, required a catheter coming out of the abdomen to drain the bladder (because it took so long to void on their own) and many patients suffered high rates of voiding dysfunction following the! se slings. However the introduction of the tension-free vaginal tape (tvt sling) procedures to the United States in the late 90s revolutionized the treatment of SUI. It introduced a standardized transobturator sling procedure that could be completed safely in 20 minutes under local anesthesia, utilizing 3 very small incisions with minimal dissection, a cough test for individual tension patient adjustment and excellent cure rates. Over 500,000 of these tot sling procedures have been completed worldwide.

What does 'tension-free' mean?

Tension-free slings (tvt sling) are used to treat stress urinary incontinence caused by urethral hypermobility and intrinsic sphincter deficiency. In this approach, a synthetic transvaginal suburethral sling is placed through the retropubic space without using suspension sutures. The vaginal sling is held in place by the friction between the mesh and the tissue canals created by the metallic needle passers. Scar tissue later fixes the mesh, preventing migration. Because the sling is not anchored to the pubic bone, ligaments, or rectus fascia, it is considered "free of tension." The result is a mid-complex urethral support that limits urethral descent, improves the stabilization mechanism generated by pubourethral ligaments and levator ani muscles, and reinforces support of the backboard vaginal hammock.

Transobturator Sling (TOT Sling) - New, Safer Approach

Despite its relative safety, the tension free vaginal tape procedures (tvt sling) require the blind passage of needles through 2 small incisions in the abdomen just above the pubic bone. The retropubic space that the needle has to pass through to get to these abdominal incisions is also a very vascular space with venous plexuses and the potential for injury to large blood vessels in the pelvis. Secondary to this and the areas that the needle has to pass to place the mesh tape, there is potential for complications such as injury to the bladder, intestines, or nerves in the pelvis and/or abdomen. All of these injuries have been reported in the literature. Secondary to this, physicians in Europe began investigating to find a safer approach to place the mesh tape sling. This new method has become known as the tot sling procedure.

Risks of Retropubic Needle Passage

• Bladder injury
• Bowel injury
• Major vascular injury
• Nerve injury

Figure 3. Passage of Retropubic Needles for TVT, SPARC, etc.

The needle on the left shows a safe passage, the needle on the right shows potential injury to abdominal wall vessels or pelvic vessels or nerve.

The Transobturator Sling

In the Netherlands in 1998, Nickel et al reported a successful sling procedure using a polyester ribbon passed through the obturator foramen and around the urethra for treatment of refractory urethral sphincter incompetence in female dogs. In France in 2001, Delorme introduced the transobturator sling procedure (tot sling) in humans. Dargent et al then performed the operation in 71 patients using a technique inspired by Delorme, and found the short-term results of the transobturator sling procedure were similar to those of the TVT. Thousands of procedures have been performed in Europe and more recently in the United States . Dr. Moore and Miklos were two of the first surgeons in the United States to utilize this newer, safer approach to the tension free tape sling procedure. They both have traveled to France to operate and train with the experts and world leaders to bring this technology to the US.

Advantages of Transobturator Approach

• Safer, faster, more efficient
• Decreased risk of:
• Bowel Injury
• Bladder Injury
• Major Bleeding
• No Retropubic Needle Passage
• No Abdominal Incisions
• More Anatomic Position of Tape

During the tot sling procedure, very small incisions are placed in the groins (one on each side) and the same small incision is made in the vagina under the urethra, allowing the mesh tape to be placed under the urethra in the correct position without having to pass needles blindly through the retropubic space and the abdominal wall. The space that the needle passes through has been extensively studied (Drs. Moore and Miklos have done numerous cadaveric dissections to study the anatomy of the space) and has been found to be a very safe space to work in for the tot vaginal sling. There is essentially NO risk of major bleeding (no major blood vessels), bowel, bladder or nerve injury. Many physicians are concerned of the route of the obturator nerve; however, we have completed dissections showing that if done correctly, the obturator nerve is nowhere near the surgical tract of the needle (see anatomy below). The needle is also guided by a finger placed vaginally throughout i! ts tract, therefore there is minimal blind passage of the needle.

The transobturator sling (tot sling) is subfascial, ie the needle or the sling NEVER enters the retropubic space.

Figure 4. The dotted arrows show the final position of the transobturator sling (tot sling) placement. The blue circles in the groin are where the small stab incisions are made to place the polypropylene mesh tape sling.

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