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Tension Free Transvaginal Tape (TVT Sling)
Success & Complications with TVT Sling
What You Can Expect: Success!
There are more than 300 different operations described in the medical literature for the treatment of stress urinary incontinence. This statistic is not only confusing for the consumer but to the physicians and surgeons who treat urinary incontinence. Fortunately the American Urological Association (AUA) established a task force to determine the most effective operations in the literature for the treatment of stress urinary incontinence. They concluded the most curative operations as published in the worldwide medically indexed literature were the: Burch urethral suspension procedure and the suburethral sling operation. Cure rates for both procedures were found to fall routinely between 80-90%.
The TVT sling operation is a "sling" operation and its cure rate falls within the international standards of cure for other types of sling procedures. Dr. Miklos' recent review of the English medically indexed literature show the TVT sling cure rates from around the world.
To date approximately 200,000 procedures have been performed around the world. The following is just a portion of those patients. However this is an attempt at a comprehensive list of documented medically indexed papers.
TVT Sling Literature Review
Click on the author's name to read documents.
DATE |
AUTHOR |
COUNTRY |
NO. OF |
CURE |
|---|---|---|---|---|
| 2001 | MESCHIA ET AL | ITALY | 404 | 90% |
| 2001 | GORDON ET AL | ISRAEL | 30 | 90% |
| 2001 | SOULIE ET AL | FRANCE | 52 | 83% |
| 2001 | JOMAA | SWEDEN | 32 | 93% |
| 2001 | NILSSON ET AL | FINLAND | 72 | 84.7% |
| 2001 | REZAPOUR | SWEDEN | 34 | 82% |
| 2001 | LO | TAIWAN | 82 | 93% |
| 2000 | WANG | TAWAIN | 52 | 90% |
| 2000 | BASTA ET AL | POLAND | 26 | 92.31% |
| 2000 | KLUTKE ET AL | USA | 20 | 85% |
| 2000 | SOULIE ET AL | FRANCE | 120 | 86.70% |
| 2000 | JACQUETIN | FRANCE | 156 | 89.10% |
| 2000 | HALASKA ET AL | CZECH | 10 | 100% |
| 2000 | JIMENEZ ET AL | SPAIN | 20 | 95% |
| 1999 | MALTAU ET AL | NORWAY | 82 | 96% |
| 1999 | PRIMICERIO ET AL | ITALY | 29 | 82% |
| 1999 | GORDON ET AL | ISRAEL | 20 | 95% |
| 1998 | OLSSON/KROON | SWEDEN | 51 | 90% |
| 1998 | ULMSTEN ET AL | SWEDEN | 131 | 90% |
| 1998 | NILSSON | FINLAND | 31 | n/a |
| 1998 | WANG | TAIWAN | 70 | 83% |
Complications
All surgical procedures have risk and complications and these entered here should be seen in the context of the published complications of surgery for genuine stress incontinence (Chalia & Stanton 1999). Published papers and personal series on the procedure suggest that complications may occur. However, the total published rate of complications using the TVT sling device has been minimal.
Surgeons with proper training and proper abilities to understand the complexities of incontinence can successfully perform the procedure with minimal risk or complications. Most patients can be released from the hospital the same day of the procedure. Precise adherence to the procedure described by Ulmsten et al minimizes complications, but deviation from the technique or inexperience with it may lead to severe complications.
Bladder Perforation
This complication is usually minor and the likelihood decreases with surgeon experience. Bladder perforation occurs more frequently in the retropubic space due to scarring from previous surgery. The needle should be reinserted with the surgeon adhering and paying close attention to technique on the second passage. Care should be taken to ensure that the needle jugs the back of the symphysis as it passes toward the anterior abdominal wall. Cystoscopy must be performed after the reinsertion of the needle.
After the bladder perforation a catheter should remain in place for 24 hours. Antibiotic coverage can be initiated.
Dr. Miklos & Dr. Moore have a bladder perforation rate of approximately 2%.
Post-Operative Voiding Problems
A patient who is unable to void immediately post-operatively can be discharged with a catheter for 24-72 hours. A Hegar dilator can be placed in to the urethra and a Titling loosening sometimes can be accomplished by performing a "pull down". This is not dilation but instead the physician should use the dilator to torque the urethra and its underlying TVT sling in an attempt at loosening the tvt sling and reduce the obstructive nature of the tvt sling. Dr. Miklos & Moore have a 1 % urinary retention rate. All 5 patients were subjected to a very short second surgical procedure (10 minutes). All 5 patients are no longer experiencing postoperative urination problems.
With the first 5-10 days postoperatively, the outlet obstruction can be relieved by providing local anesthetic, opening the vaginal incision, grasping the tape using a right angle clamp, and pulling the mesh tvt sling approximately 5-10 mm downward.
After 10 days, loosening can be very difficult. In these instances, managing the patient with self-catheterization for four weeks will permit the mesh to heal and to become fixed into position. At this point in time, the outlet obstruction can be relieved by providing local anesthetic, making a vaginal incision, and dividing the tape in the midline. It is helpful to carefully palpate the base of the incision to identify the tape. Normal voiding is restored and the patient's continence is preserved.
Ideally, the prevention of this complication is the goal. This is determined in the operating room by the ensuring that the TVT sling mesh is positioned loosely without tension.
Urgency & Urge Incontinence
Postoperative bladder instability or bladder spasms are associated with anti-incontinence procedures in general. This can potentially be avoided by proper mesh adjustment such as with the cough test and by maintaining a loop beneath the urethra. Incorrect positioning at the bladder neck rather than at the mid-urethra may play a role or contribute to this phenomenon. In the absence of obstruction, anti-cholinergics and/or bladder retraining can be helpful.
Infection of the mesh
Prolene has a well-proven record of not causing infection. It has been used in the vagina without complications in procedures such as the Gittes bladder neck suspension and the vesica bladder neck suspension. To date, Prolene has yet to be the sole source of an infection using the TVT sling system. Dr. Miklos has had two patients (< 1 %) develop an infection. Both patients' infections resolved after antibiotic therapy. Dr. Miklos has never had to remove a TVT sling due to an infection.