Home > Transobturator Tape (TOT) Sling

Transobturator Sling for Stress Incontinence (Subfascial Hammock)

Clinical Results and Complications

The transobturator sling (tot sling) procedure was originally described in the Netherlands in 1998 and since then there have been thousands of TOT sling procedures completed in Europe. 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 similar to those of the TVT sling. Professor Georges Mellier (one of the world leaders in the procedure) from France recently reported his data on the procedure at the 2003 International Urogyn Meeting in Buenos Aires. He presented over 100 patients that had TVTs and 100 patients that had TOTs, the cure rates and complication rates were comparable at 1 year (link to IUGA 2003).

The procedure was introduced in the United States in the spring of 2003, since that time there have been over a 1000 procedures done in the US, with no major complications reported and short term results comparable to that of retropubic tension-free sling procedures (ie TVT sling, SPARC, UROTEK, etc).

Risks and complications are rare, however include the same risks associated with any tension-free mesh sling including bleeding, infection, voiding dysfunction, urinary retention, mesh erosion (in the vagina or urethra), pain in the vagina or groins. The risk of bowel or bladder injury as well as the risk of major bleeding are significantly reduced compared to retropubic approaches.

Atlanta Urogynecology Experience

Drs. Moore and Miklos were two of the first surgeons to bring this new tot sling, tvt sling technology to the United States. They are leaders in the Southeast and the US in both performing and teaching the procedure. Both surgeons took several trips to Europe and France to learn the tot sling procedure and operate with the experts who developed the technique. Dr. Moore has traveled throughout the country and has taught surgeons in Dallas, Phoenix, Miami, Raleigh, NC, Sacramento, CA, Las Vegas and Seattle. He was also invited to lecture on the topic tot sling to world leaders at the International Urogyn Meeting in Buenos Aires Argentina. Surgeons from all over the country also travel to Atlanta to learn the new tot sling technique from Drs. Miklos and Moore.

The TOT sling procedure takes as little as 10 minutes to perform and can be completed under local anesthesia with minimal risks

To date Drs. Miklos and Moore have seen the same excellent short term clinical success that the Europeans have experienced. No patients have complained of postoperative pain in the area of the adductor muscles of the thigh, and no sling erosions have occurred. No patients have had any significant bleeding or other major complications. The tot sling procedure takes less than 10 minutes to perform and can be completed under local or regional anesthesia. They also have found this tot sling approach useful in obese patients and women with retropubic scarring, in whom retropubic needle passage can be a challenge. They also believe that by keeping the tot sling sub-fascial and away from the bladder and the retropubic space, that they also may be reducing the risk of creating bladder irritability that may occur with slings that are in contact with the bladder wall.

Surgical Synopsis-TOT Sling

TOT Sling Figures 2 and 3

Step 1. Small incision is made under
Step 2. Vaginal epithelium is dissected free the urethra

TOT Sling Figures 4 and 5

Step 3. Area of groin incision located 1cm
Step 4. Finger placed in vaginal incision inferior to adductor longus tendinous to guide needle. Needle placed in insertion (level of clitoris) groin incision and passed

TOT Sling Figure 6

TOT Sling Figure 7

TOT Sling Figures 8 and 9

Step 5. The needle is brought through the vaginal incision and the tape is attached to the needle with the connector.

TOT Sling Figure 10

TOT Sling Figure 11

Step 6. Connected tape is then brought back through the groin incision.

TOT Sling Figures 12 and 13

Step 7. Needle and tape is passed on the opposite side. Tape is then adjusted with an intra-operative cough test and adjusted until no leakage occurs. Excess mesh is cut off at the groin incisions and these are closed with steri-strips and vaginal incision is closed with absorbable suture.

TOT Sling Figures 14

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TOT Sling