Transobturator surgery for female stress incontinence: a comparative anatomical study of outside-in vs inside-out techniques

Significance of 4D US parameters for the clinical treatment of female patients with stress urinary incontinence

Background

Stress urinary incontinence (SUI) that has been associated with abnormal pelvic floor muscle function or morphology is a common condition. This research aimed to study the impact of the four-dimensional (4D) pelvic floor ultrasound on the treatment of female patients with clinical diagnosis of SUI and to evaluate its clinical significance on SUI.

Methods

We enrolled 51 women with SUI. Before transobturator suburethral tape procedures, the patients underwent 4D pelvic floor ultrasonography. The measurements include residual urine volume, bladder detrusor thickness in resting state, the vertical distance from the bladder neck to the posterior inferior edge of pubic symphysis at rest and Valsalva movement, posterior angle of bladder urethra, and urethral rotation angle. The degree of movement of the bladder neck (the difference between the vertical distance from the bladder neck to the posterior inferior edge of the pubic symphysis under the resting state and the maximum Valsalva movement) and the formation of a funnel at the internal orifice of the urethra were calculated.

Results

The mean bladder detrusor thickness was 2.6 ± 0.9 mm, the vertical distance from the bladder neck to the posterior inferior edge of pubic symphysis was 27.7 ± 4.5 mm, the posterior angle of the bladder was 122.7 ± 18.9°, the vertical distance from the rectal ampulla to the posterior inferior edge of pubic symphysis was 18.5 ± 4.6 mm, and the mean area of hiatus of the levator ani muscle was 22.1 ± 6.0 cm2. The mean posterior angle of the bladder on Valsalva was 159.3 ± 23.1°, and the mean urethral rotation angle was 67.2 ± 21.4°.

Conclusions

The 4D pelvic floor ultrasound is a reliable method in evaluating preoperational morphological characteristics of patients with SUI. With the help of the 4D pelvic floor ultrasound, the individualized treatment regimen can be developed and, more importantly, the inappropriate surgical decision can be avoided.

[Suburethral tension-free vaginal tape or transobturator tape. When should which procedure be recommended?]

The introduction of tension-free vaginal tapes has led to a complete change of surgical therapy in female urinary stress incontinence. Different materials are used. In many departments, the classic TVT procedure with retropubic placement of the tape has been replaced by transobturator procedures. The current discussion involving transobturator tapes focuses on the question of whether the inside-out technique or the outside-in technique leads to significantly different results. Current state of the art is that all techniques are almost comparable concerning treatment success and complications. Depending on possible pretreatments or concomitant diseases that result in a higher risk for complications, the decision for one technique can be taken individually for each patient. In patients suffering from recurrent stress urinary incontinence after implantation of a tension-free tape, the retropubic implantation of a TVT seems to be superior to a transobturator tape.

Persistent groin pain following a trans-obturator sling procedure for stress urinary incontinence: a diagnostic and therapeutic challenge

Groin pain after a tension-free vaginal tape-obturator (TVT-O) procedure can occur but mostly disappears within 4 weeks. Persistent groin pain is extremely rare and there is a paucity of literature on how to diagnose and manage this adverse event. We present two cases with severe persistent groin pain after uncomplicated TVT-O, in which magnetic resonance imaging and electromyography did not reveal the cause. We concluded that the tape entrapped or cut through peripheral branches of the obturator nerve. We removed as much of the tape as possible in both cases. Removal partially relieved the pain although sensory loss of the obturator nerve persisted 1 year after surgery. In case of abnormal post-operative groin pain, soon removal of the tape enhances the chance that damage to the obturator nerve is reversible, although it is important to counsel patients with similar pathology that recovery can take long and may be only partial.