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TVT and TOT - Indications and Complications

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This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.

Indications

Trans Vaginal Tape (TVT) and Trans Obturator Tape (TOT) Procedure

  1. Stress urinary incontinence
    1. Cough or valsalva and observed leak of urine from urethra
    2. Urethrovesical neck descensus–greater than 45 deg at rest or change of >= 30 degrees change with strain

Criteria for successful procedure

  1. Switch or discontinue medicines that affect internal urethral sphincter (alpha one blockers) if possible
  2. Switch medicines that affect external urethral sphincter (benzodiazepines, skeletal muscle relaxants) if possible
  3. Diagnose and treat any associated urge incontinence prior to surgery
  4. Diagnose and treat any associated excessive bladder capacity (>800 ccs) or excessive residual urine (>300ccs) prior to surgery
  5. Rule out or treat any urinary tract infection prior to surgery
  6. Set reasonable post op expectations (decreased leakage, not absolutely dry)
  7. Teach diaphragmatic cough, lift and strain

Complications (5-27%)

  1. Continued bothersome incontinence (10%)
  2. New onset urinary urgency (4-40%)
  3. Obstructed voiding (7-12%)
  4. Bladder perforation or injury (2-14%)
  5. Urethral injury/fistula
  6. Bowel injury
  7. Bleeding/hematoma
  8. Infection
    1. Urinary tract infection
    2. Mesh erosion (5-10%)
    3. Retropubic abscess (TVT)
    4. Necrotizing fasciitis (TOT)
    5. Adductor brevis myositis (TOT) (rare)
  9. Nerve injury
  10. Dyspareunia
  11. Suprapubic pain

Complication Prevention

  1. Continued bothersome incontinence
  2. New onset urinary urgency
    1. treat menopausal patients with topical estrogen cream for 6 months
  3. Obstructed voiding
    1. For TVT, place some type of spacer between urethra and mesh or tighten just to point of preventing leakage by crede or cough
  4. Bladder perforation or injury
  5. Urethral injury/fistula
  6. Bowel injury
    1. rule out inguinal hernia
    2. use steep trendelenburg patient positioning
  7. Bleeding/hematoma
  8. Infection
    1. Urinary tract infection
      1. Consider prophylactic antibiotic administration
    2. Mesh erosion
    3. Adductor brevis myositis (TOT)
    4. Retropubic abscess (TVT)
    5. Necrotizing fasciitis (TVT)
  9. Nerve injury (TOT)
  10. Dyspareunia
  11. Suprapubic pain

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