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Transobturator Sling for Stress Incontinence (Subfascial Hammock)

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 these procedures have been performed in Europe and the United States.  In 2002 Dr. Moore traveled to Lyon France to learn the new technique.  He came back and adopted the technique and trained Dr. Miklos.  Dr. Moore is considered the first user of TOT sling in the USA today and he and Dr. Miklos have been performing the procedure routinely since that time.  Drs. Moore and Miklos served as preceptors for years teaching the technique to surgeons throughout the world.

TOT Slings Offer:

  • 80-90% cure rates (5-7 years after surgery)
  • Less pain than TVT slings
  • Less blood loss than TVT slings
  • Less chance of morbidity
  • Less chance of bladder injury

TOT Sling Figure 1

For whom is the TVT sling procedure not recommended?

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.


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