Mid-urethral Slings (TOT & TVT) (Trans Obturator Tape & Tension Free Vaginal Tape)

There are two approaches for the insertion of sling. Retropubic Route In the retropubic approach, the sling is placed through a small cut made in the vagina over the mid-point of the urethra. The two ends of the sling are passed from the vagina through this cut, going on either side of the urethra, to exit through two small cuts made just above the pubic bone on the lower abdomen. The most common retropubic operation to be carried out is the TVT (Tension-free Vaginal Tape). It is suitable for patients with severe stress incontinence.

Transobturator Route: In the transobturator approach, the sling (Transobturator Tape – TOT) is placed through a small cut made in the vagina over the mid-point of the urethra. The two ends of the sling are passed from the vagina through this cut, going on the either side of the urethra via the Obturator foramen (see picture), to exit through two small cuts made in the groin (inner thigh).

The sling (or tape) prevents leakage by supporting the urethra. Once the sling is in position, tissue grows through the holes in the weave and so anchors the sling in position. This may take about 3 to 4 weeks.

It is difficult to predict what will happen to the symptoms in the future. Doing regular pelvic floor exercises improves stress incontinence in up to 50-75% of women which may mean surgery is never required. You should have the operation only if you feel the stress incontinence is affecting the quality of your life now, not to prevent it from deteriorating in the future.

Surgery is avoided until a woman’s family is complete because future pregnancy may compromise the results of the initial surgery.

This surgery like any other surgery is not completely risk-free. These are the complications that can occur in about 1-10 per 100 patients.

• • Urinary tract infections

UTI can be easily treated with a course of antibiotics.

• • Bleeding

Bleeding to the extent of needing blood transfusion is very rare. Sometimes blood can get collected in the area through which tape passes. This usually resolves by itself and rarely may need a evacuation procedure.

• • Urgency and urge incontinence

About half of the women notice an improvement in urgency symptoms also, but these symptoms can even worsen following a mid-urethral sling procedure in about 5 % cases. This can managed with medications.

• • Difficulty in passing urine (voiding difficulty)

Voiding difficulty may occur in 1-5% of patients, often because of edema (swelling) around the urethra or pain or discomfort. It will become normal within 7-10 days. If the problem does not resolve on its own, then you may need loosening or cutting of sling (about 1% cases).

• • Sling exposure

In about 2-4% cases, the sling can erode and appear in the wall of the vagina a few weeks, months, or years after an operation. You may develop vaginal bleeding, discharge, or pain with intercourse. Management would involve either recovering the tape or removing the part of tape that is exposed.

• • Bladder or urethral Injury

Bladder or urethral perforation can occur in 1-5% cases. A check cystoscopy (Looking into the bladder and urethra) is always done after placing the sling to make sure there is no such injury. These injuries are minor and heal spontaneously without the need of any intervention. This would not interfere with the success of the surgery.

About two thirds (66%) of women will be completely dry after the operation and one third will have some minor degree of leakage. To put it another way, about 80 to 90% of women are satisfied with the result after synthetic tape operation. You may very rarely need a second stress incontinence surgery.

You are advised to wait for 3 months after the operation before having sexual intercourse. In the long term, there is no evidence that the operation will impact your sex life.

• Your hospital stay will be about two to three days.
• For the first two weeks, you should avoid any strenuous activity, straining at stools, or heavy lifting (no more than 5 kg).
• After two weeks, you may start to return to everyday activities but, if you have a very physical job, work out in a gym or do a lot of running, you should wait a further two weeks (four in total).
• You should practice sexual abstinence for 3 months after the procedure.

References:
1. Mid-urethral Sling procedures for Stress Incontinence IUGA 2020.
2. Synthetic Mid-urethral tapes for Stress Incontinence BAUS 2018