Year : 2003 | Volume
: 20 | Issue : 1 | Page : 33--36
Tension free vaginal tape in the management of genuine stress incontinence in women - the Indian experience
N Rajamaheswari, Karthik Gunasekaran
Department of Urology/Urogynaecology, Govt. Kasturba Gandhi Hospital, Madras Medical College, Chennai, India
Urogynaecology Research Centre No. 18/86. C.P. Ramaswamy Road, Alwarpet, Chennai - 600 018
Objectives: To study retrospectively the results of the Tension Free Vaginal Tape (TVT), a new ambulatory surgical procedure for the treatment of stress urinary incontinence (SUI) among Indian women.
Methods: TVT implies the implantation of a prolene tape around the mid-uretha via a minimal vaginal incision. TVT was done on 54 patients diagnosed to have Genuine Stress Incontinence (GSI). The procedure was done either under regional anaesthesia (RA) or under local anaesthesia (LA) with IV analgesics.
Results: Thirty-eight patients underwent only the TVT procedure and in 16 patients concomitant procedures were done along with the TVT The TVT was done as the primary procedure for GSI in 46 patients. Eight patients had prior surgery for stress incontinence. All patients were followed up from 6 months to 2 years. Forty-eight (88%) patients reported complete cure. There was significant improvement of symptoms in 4(7.4%) patients and in 2(3.7%) the surgery failed.
Conclusions: These results prove that the TVT procedure is a minimally invasive, safe and effective method for the treatment of SUI in women.
|How to cite this article:|
Rajamaheswari N, Gunasekaran K. Tension free vaginal tape in the management of genuine stress incontinence in women - the Indian experience.Indian J Urol 2003;20:33-36
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Rajamaheswari N, Gunasekaran K. Tension free vaginal tape in the management of genuine stress incontinence in women - the Indian experience. Indian J Urol [serial online] 2003 [cited 2020 Sep 30 ];20:33-36
Available from: http://www.indianjurol.com/text.asp?2003/20/1/33/37121
The use of pubovaginal slings for the treatment of GSI was described by Goebell  almost a century ago. The concept of TVT evolved after Petros and Ulmstein published their integral theory  on female SUI. The integral theory proposed that the anterior vaginal wall plays a central role in balancing pelvic floor support and the pubourethral ligaments are pivotal in anchoring the anterior vaginal wall. Ulmstein et al  in Sweden first described the TVT procedure using a knitted prolene mesh to correct the defect in pubovaginal ligament support. The TVT is done as an ambulatory procedure under LA. The tape is reported to produce significant increase in maximum urethral closure pressure and functional urethral length. Urethral hypermobility is however not altered. Stanton and Atherton  suggested that exertion kinked the urethra at the level of the tape (midurethral level).
Patients and Methods
Fifty-four patients underwent TVT procedure. Of these 16 had associated pelvic floor defects. A thorough history was obtained from all patients. Cystoscopy and urodynamic studies were done after gynaecological, urological and neurological examinations in all patients. The various types of incontinence in the study group are given in [Table 1]. The patients underwent surgery either under LA with intravenous analgesics or RA.
Two small, 1 cm incisions were made, 5 cm apart suprapubically. Mid urethra was exposed by a sagittal 1.5 cm long vaginal incision starting 1 cm distal to the external urethral meatus. Minimal dissection was done to separate the vagina from the urethra. The bladder was drained via a foley catheter and a straight catheter introducer facilitated positioning of the urethra and bladder neck and minimized injury. The tape was then introduced with two separate passes of the needles and emerged through the two stab incision suprapubically. Each pass was checked cystoscopically to exclude bladder/urethral perforation. If the bladder had been perforated then the needle was removed and reinserted. The position of the tape was then adjusted by asking the woman to perform a series of coughs or in the case of RA by applying suprapubic pressure. Once the tape was correctly positioned the needles were removed. The incisions were then closed with appropriate suture material. It is essential to keep an instrument between the urethra and the tape while the plastic cover is removed. The tape is selfretaining and needs no fixation. The friction between the prolene tape and tissues retains it in position.
Sixteen patients underwent procedures like anterior colporrhaphy, posterior colporrhaphy and sacrospinous colpopexy along with TVT for their associated complaints. The details of concomitant procedures done with TVT are given in [Table 2]. The TVT was done as a primary procedure in 46 patients and as secondary procedure in the remaining 8 who had previously undergone surgery for SUI unsuccessfully. Refer [Table 3]. One patient had previous urological surgery in the form of bladder neck incision, internal urethrotomy, meatoplasty and subsequently developed GSI. The mean operating time was 29 minutes (20-40). Forty-eight (88%) women reported complete cure and 4(7.4%) were significantly improved. The surgery failed in 2(3.7%) patients. Intraoperative complications were in the form of needle perforation of the urinary bladder in 6 patients. In all these patients the needle was removed and repassed and all of them recovered uneventfully. Five patients had voiding problems postoperatively. In these patients the catheter was kept insitu for a week.
All the women underwent follow-up examinations at 1,2,6,12 and 24 months. There was no change in the postoperative outcome over time.
The results of this retrospective study in India were comparable to those reported internationally. ,,,,,, Our study reports a success rate of 88%, significant improvement in 7.4% and failure in 3.7%. The cure rate for patients who had prior failed incontinence procedures was 100%. In our study many patients underwent surgery under RA because they underwent concomitant procedures or had accompanying ailments. The reason why so few postoperative complications occurred despite the tape being considered a sling procedure was because the tape was placed loosely around the midurethra without tension. Most encouraging is the fact that there was no rejection of tape or defective healing. Treatment outcome did not differ in women who had TVT as the primary procedure from those who had it as a secondary procedure in our study. The incidence of bladder perforation was not higher in patients with prior retropubic procedure in our study.
We had 2 patients in whom the surgery failed. One had GSI with a severe component of intrinsic sphincter deficiency (ISD) and the other had overactive bladder which was more significant compared to her SUI. There are several reports on the use of TVT in treating mixed stress and urge incontinence. De novo urgency can develop in 2-15% of patients.  Sensory urgency disappeared in all our patients. None of our patients developed new onset of urgency.
Our results fully agree with other reports using the same technique. Refer to [Table 4] for details. The mean overall cure rate in international series was 88% with a further 9% showing improvement. The close agreement between these results show TVT to be a highly standardized technique. The postoperative voiding problems are minimal as we found in our study.
The TVT operation is a safe and effective technique for the treatment of female GSI. It is a simple vaginal procedure with a very short learning curve. Perioperative risks are low, the duration of hospitalization is short and the patients return to work rapidly. It is probably the most successful of the slings for GSI so far. Long-term results from prospective randomized clinical trails are awaited.
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