|Year : 2010 | Volume
| Issue : 4 | Page : 600
Can TOT be standard of care for surgical management of stress incontinence?
Ashwin Kumar M Kulkarni, Santosh Kumar
Department of Urology, Christian Medical College, Vellore, India
|Date of Web Publication||31-Dec-2010|
Department of Urology, Christian Medical College, Vellore
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kulkarni AM, Kumar S. Can TOT be standard of care for surgical management of stress incontinence?. Indian J Urol 2010;26:600
Richter H.E., Albo M.E., Zyczynski H.M., Kenton K., Norton P.A., Sirls L.T, et al. Retropubic versus Transobturator midurethral slings for stress urinary incontinence. N Engl J Med 2010;362:2066-76.
| Summary|| |
This large multicenter RCT compared composite treatment success and complications of retropubic and transobturator midurethral sling for stress incontinence.  Five-hundred and ninety-seven eligible females out of 3521 patients were randomized between retropubic and TOT sling groups during 2006-2008. Baseline demographic and clinical characteristics were comparable between the two groups except for valsalva leak point pressure. Randomization was done after induction of anesthesia. Two-hundred and ninety-eight were grouped to retropubic and 299 to TOT group. Gynaecare sling was used for retropubic and in-to-out TOT procedure while Monarc was used for out-to-in TOT sling. Data was collected before surgery, at 2 weeks, 6 weeks, 6 months and 12 months after surgery.
The rates of objectively assessed treatment success meet the prespecified criteria for equivalence for both retropubic and TOT sling groups (80.8 and 77.7%, respectively, 3% point difference with 95% confidence interval). Subjectively assessed treatment success was 62.2 and 58.8% between retropubic and TOT sling groups but that did not meet the criteria for equivalence. The median estimated blood loss is 50 and 25 ml, respectively and operative time was 30 and 25 min, respectively. Bladder perforations and voiding dysfunction (2.7%) occurred only in retropubic group. Patients in TOT group had a higher rate of neurological complications like numbness and weakness (4.0 and 9.4%, respectively: P=0.01). There was no statistical difference between the two groups in postoperative urge incontinence, patient satisfaction and quality of life.
| Comments|| |
Transobturator route placement of sling was shown to be successful in the treatment of stress incontinence by Delorme.  Even though there were studies including Cochrane review  and meta-analysis,  there was no large-scale multicenter well-designed trial powered enough to compare composite (objective and subjective) success and complications which is met by the current study. The study has also shown that treatment of concomitant prolapse did not affect the outcome. Even though not a primary objective, the study has shown that the two types of TOT procedures did not differ significantly. However, the rate of treatment success is lower compared to Delorme series.  The rates of treatment success in the recent Cochrane review  and meta-analysis  are higher compared to present study. There is no mention of learning curve of the procedures. Postoperative complications which differed between two groups did not include pain. Neurological complications were not assessed after 6 weeks. Two different types of slings were used (Gynaecare and Monarc) which might influence the results.
To conclude TOT is comparable to TVT for the treatment of stress incontinence but varies in complications. However, long-term large-scale RCT is required before making TOT as standard of care for surgical management of stress incontinence.
| References|| |
|1.||Richter HE, Albo ME, Zyczynski HM, Kenton K, Norton PA, Sirls LT, et al. Retropubic versus transobturator midurethral slings for stress urinary incontinence. N Engl J Med 2010;362:2066-76. |
|2.||Delorme E. Transobturator urethral suspension: Mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 2001;11:1306-13. |
|3.||Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Sys Rev 2009;4:CD006375. |
|4.||Novara G, Ficarra V, Boscolo-Berto R, Secco S, Cavalleri S, Artibani W. Tension free midurethral sling in the treatment of female stress urinary incontinence: A systemic review and meta-analysis of RCT's of effectiveness. Eur Urol 2007;52;663-78. |