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Transobturator Tape or Tension-Free Vaginal Tape for Stress Incontinence?
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: At 12 months after surgery for stress incontinence, patients who had undergone transobturator tape procedures were doing equally well when compared with patients who had tension-free vaginal tape procedures.
Source: Ross S et al. Transobturator tape compared with tension-free vaginal tape for stress incontinence: A randomized controlled trial. Obstet Gynecol 2009;114:1287-1294.
One hundred ninety-nine women were randomized to undergo surgery using either the transobturator tape procedure (TOT) or the tension-free vaginal tape procedure (TVT). At 12 months, 81% and 77% of the patients in the respective groups were cured (relative risk, 1.05; 95% confidence interval, 0.90-1.23; P = 0.577). The tape was palpable more frequently (80% vs 27%) and more patients experienced groin pain during vaginal palpation (15% vs 6%) in the TOT patients. Quality of life improved in both groups. At 12 months, the two groups were doing equally well. Longer follow-up would be needed to identify the outcome of the palpable tapes (i.e., would they resolve or be extruded?).
I like this kind of study. It's straightforward and clear. The study design allows the author to draw conclusions. It was performed in Canadian academic and community settings with surgeons who were trained in a standardized fashion. No concurrent surgery such as hysterectomy or prolapse surgery was performed, thus allowing outcomes to be tied directly to either TOT or TVT technology. They chose to use products of a single company, in this case Boston Scientific. This eliminated any potential commercial bias.
With the endpoint at 12 months postoperative, the authors used a reasonable amount of time to assess outcome. To their credit, further follow-up is planned, pending funding. The most common TVT complication was bladder perforation, a finding compatible with that in the literature at large. Despite concern in the literature that TOT is associated with more mesh extrusion, only 1 patient in each group required re-operation for removal of an eroded mesh. Whether the increased incidence of palpable mesh after TOT leads to more extrusions remains a question to be answered with longer follow-up.
So what's the "take home" message? First, the two techniques appear to be comparable for up to 12 months. Second, having adequate training reduces the risk of complications, although it doesn't eliminate it. Third, head-to-head long-term follow-up may allow for additional conclusions to be drawn.