Vaginal tape operations for stress urinary incontinence

• Tension-free vaginal tape (TVT)
• Transobturator Tape (TOT)

What is a vaginal tape operation?

The tension-free vaginal tape and transobturator tape operations are carried out for the treatment of stress urinary incontinence.

What is stress incontinence?

Stress incontinence is the sudden, involuntary leakage of urine during activities that cause the pressure in your abdomen to go up, such as coughing, sneezing, straining, lifting and exercising.  It is usually due to weakness in the supports, muscles and nerves supplying the urethra and pelvic floor. This can be caused by:

• Pregnancy and childbirth
• Chronic heavy lifting / straining
• Menopause or oestrogen deficiency
• Obesity

How is the Tension-free Vaginal Tape (TVT) operation done?

This is a minimally invasive procedure (so-called keyhole surgery). The tape is put in through 3 small cuts; one in your vagina and two small cuts in the lower part of your abdomen (the pubic area). A cystoscope (a small telescope) is inserted into your bladder to check for abnormalities and to ensure that your bladder and urethra have not been injured. The operation usually takes about 20 - 30 minutes to carry out and most women are able to go home within 24 hours. Many women can be admitted and discharged home again on the same day as their operation.

What is a Trans Obturator Tape (TOT)?

The TOT procedure is similar to the TVT described above. It is a relatively new operation, so the long-term results are not yet known. In some patients it may be easier or safer to do than the TVT, as the tape is further away from the bladder and the lower abdomen (tummy). In the short and medium term however, it seems to be as safe and as effective as the TVT. The TOT tape is inserted through 3 small cuts, one in the vagina, and one in each side of the upper inner thigh. A cystoscope (a small telescope) is inserted into your bladder to check for abnormalities and to ensure that your bladder and urethra have not been injured during the procedure.

What sort of anaesthetic can I have?

The operation can be carried out under a spinal, local or general anaesthetic, depending on your own wishes and the advice of the surgeon and anaesthetist.  One of the advantages of these operations is that because there are no large cuts and the tape is put in using a needle, recovery is relatively quick.

What are the benefits?

About 85% of women are either greatly improved or cured of their stress incontinence with these operations. If you have had previous incontinence surgery or have other health or complicating conditions, the chances of success may be reduced and the risks of complications increased. If you have urgency (sudden need to rush to the toilet) the overall success rate is lower and urgency and urge incontinence may be a long-term problem.

How long does it take to recover?

Most women are able to return to normal activities within 2 weeks of the procedure. Driving is usually allowed after 1 week and normal non-physical activities may be resumed after 2 - 4 weeks if you feel ready. Sexual intercourse may be resumed after 4 – 6 weeks, and more vigorous activities such as sport and heavy lifting may be resumed after 6 weeks if you feel ready. You will normally be reviewed and seen in clinic for follow up three months after the operation.

What are the risks?

The operation has a failure rate of around 20% (i.e. you may still be incontinent or not much improved).  Sometimes the skin of the vagina does not heal properly over the mesh and a small operation is needed to remove some of the mesh. This happens in about 1 in 20 cases. Because the tape is made of a nylon-like material, there is a chance (probably less than 1%) that it will erode or cut through into the urethra or bladder and need to be removed at a later date. This may involve further surgery and may result in damage to the urethra or bladder.

There is a risk of bleeding which might require more major surgery and a risk of damage to the bladder or the urethra (the tube coming out of the bladder). Usually such damage can be sorted out at the time of the operation by simply taking the tape out and replacing it.  However, sometimes a larger operation is needed.

There is a risk of about 1 in 10 of difficulty in emptying the bladder immediately following the operation. This often lasts for a few days and some women go home with a catheter in their bladder to allow recovery. This complication is unlikely to be a long-term problem.  Some women may need to use a catheter which allows the bladder to empty continuously or sometimes self-catheterisation (in and out), which is performed intermittently (for example 3 times per day). Occasionally the tape needs to be loosened, cut or removed to allow the bladder to empty properly.

There is a 10 -15% risk of developing urinary frequency, urgency or urge incontinence after this surgery, particularly if these symptoms have been present before the operation. The treatment for this is tablets, which may need to be taken long term.

Alternative treatments?

• Pelvic floor exercises
• Burch colposuspension
• Autologous fascial sling