Tension-free vaginal sling (TVT) for female stress urinary incontinence Lv Jianwei Leng Jing Xue Wei Zhou Lixin Huang Yiran Department of Urology, Shanghai Renji Hospital, School of Medicine, Shanghai Jiao Tong University Abstract: Objective– To investigate the efficacy of tension-free vaginal sling (TVT) for female stress urinary incontinence. METHODS — 130 female patients with stress urinary incontinence, aged 42-71 years, mean 55.4 years, with a mean history of urinary leakage of 3.4 years, were given transvaginal tension-free vaginal sling surgery (TVT). Results – Follow-up ranged from 13-41 months with a mean of 31.8 months. Urinary incontinence symptoms were controlled after removal of catheter in all patients after surgery, 3 patients showed urinary incontinence symptoms again in 6 months after surgery, 5 patients showed difficulty in urination after surgery, and resumed normal urination after 1-2 months respectively, and 9 patients had the symptom of urinary frequency and urgency after surgery. Conclusion – TVT operation is simple, safe and the postoperative results are satisfactory. Keywords — Urinary incontinence, Sling operation, Surgical treatment, The Treatment of Stress Urinary Incontinence by Tension-free Vaginal TapeLv jianwei, Leng jing, Xue wei. Zhou lixin, Huang yiranDepartment of urology, renji hospital, shanghai second medical university Abstract : Objective– To evaluate the treatment of stress urinary incontinence by Tension-free Vaginal Tape. To evaluate the treatment of stress urinary incontinence by tension-free vaginal tape. Methods–TVT was performed in 130 cases (mean age of 55 years). cases (mean age of 55.4 years) with stress urinary incontinence, who were 3.4 years leakage history on average. Result–At mean 31.8 months follow up (from 3-31 months), all cases clinically improved, and only 3 recurred after 6 months. 5 cases occurred dysuria, who got right after 1- 2 months. After operation, 9 cases occurred frequency of micturition. Conclusions –TVT is a simple, safe, reliable procedure for stress urinary incontinence. Conclusions –TVT is a simple, safe, reliable procedure for stress urinary incontinence with good result. Key words–Urinary incontinence; Sling; Operative Stress Urinary Incontinence ( Stress Urinary Incontinence (SUI) is a relatively common disease among middle-aged and elderly women, affecting many women’s life and work. This disease not only damages the physical and mental health of patients, but also has a greater impact on the family and society. Our hospital used tension-free vaginal tape (TVT) to treat 130 cases of female stress urinary incontinence from September 2001 to February 2006, which is reported as follows: Data and Methods I. Clinical Data 130 patients, age 42-71 years old, average 55.4±11.2 years old. The duration of urinary incontinence was 5 months-6 years, with a mean of 3.4 years. Urine leakage could be observed when coughing or laughing in 102 cases, and also when standing and walking in 28 cases; 120 cases were menstruating women, 13 cases had undergone hysterectomy, and 9 cases had a previous history of failed incontinence surgery. All patients had no difficulty in urination and urethral irritation, normal urine routine, negative urine bacterial examination, no residual urine in the bladder, and all of them had completed the 24-hour urinary card record and vaginal lifting test. Second, surgical methods All patients were treated with continuous epidural anesthesia in the lithotomy position. An 18F balloon catheter was inserted beforehand, and 15-20 ml of saline was injected into the balloon to know the position of the bladder neck and the length of the urethra. A longitudinal incision was made on the anterior vaginal wall 1-1.5 cm from the external urethral opening, the vaginal mucosal layer was incised, and both sides of the urethra were sharply separated with dissecting scissors to the inferior border of the pubic bone. A 0.5-cm skin incision was made in each of the suprapubic bone one transverse finger 2 cm from the midline. The bladder was emptied, a guide wire was inserted through the urethra, the bladder was pushed to the left side, and a puncture needle with a sling attached to the right side of the vaginal incision was threaded through a suprapubic abdominal wall incision immediately adjacent to the pubic bone; a sling was threaded through the left side in the same way. Subsequently, cystoscopy was performed to confirm that there was no damage to the bladder, and then the puncture needle was reported to lead the sling from the abdominal wall. At the same time, the sling was lifted upward, the suspension tension was adjusted, and the patient was instructed to cough or press the abdomen until a small amount of urine leaked out. The excess part of the sling is cut off, the skin of the abdominal wall and the anterior wall of the vagina are closed, the vagina is filled with iodoform gauze, and a urinary catheter is left in place, which is withdrawn 3-4 days after the operation. Results Surgical time was 20-45 minutes, with a mean of 33.4 minutes; intraoperative bleeding was 40-200 ml, with a mean of 65.5 ml. 124 patients were followed up for 3-31 months after surgery, with a mean of 21.8 months. All patients were able to control their incontinence symptoms after catheter removal, and there were no symptoms of urinary leakage. 3 patients showed urinary incontinence symptoms again in 6 months after surgery. 5 patients showed difficulty in urination after surgery, and they were given intermittent self-catheterization, and they resumed normal urination in 1-2 months, respectively. 9 patients showed urinary frequency and urgency after surgery, and they were given oral anticholinergic drugs to treat the symptom. All patients were free from postoperative pain, infection and bladder residual urine. DISCUSSION Stress urinary incontinence is prevalent in middle-aged and old-aged women, according to foreign data [1] the incidence of urinary incontinence in women aged 30-59 years is 25%, and the incidence of those aged 60 years or older is 38%. Stress urinary incontinence can be broadly divided into two types: anatomical type (bladder neck and posterior urethra around the supportive tissue relaxation of the bladder and urethra anatomical position changes) and intrinsic sphincter dysfunction (some intrinsic factors affect the normal closure of the anterior and posterior walls of the urethra can not provide the appropriate closure of the pressure). 1994 DeLancey put forward “hammock hypothesis” (hammock hypothesis). In 1994, DeLancey proposed the “hammock hypothesis”, which suggests that the increase in urethral closure pressure is due to the urethra being compressed against a hammock-like support structure, emphasizing the importance of reestablishing urethral support in stress incontinence [2]. The tension-free vaginal tape (TVT) is a 1-cm wide Prolene mesh sling that provides a hammock-like support plane to create the appropriate closure pressure of the urethra and prevent leakage.The TVT system consists of a pusher, a guide wire, and a mesh sling with a puncture needle. The mesh sling has a number of tiny barbs on it, and when the plastic jacket of the sling is withdrawn intraoperatively, the barbs allow the sling to be firmly fixed in the tissue. Normally, the sling has no tension on the urethra. If the patient coughs or laughs, which causes an increase in abdominal pressure, the sling can lift the urethra and provide a suitable closing pressure, thus preventing urinary incontinence. In the operation of TVT surgery, care must be taken to prevent complications.Kuuva et al[3] found that the common complications include: bladder perforation, dysuria, and urinary tract infection, etc., while other complications such as retropubic hematoma, occlusive nerve injury, and macrovascular injury are less common. During the puncture operation, the puncture needle must be tightly attached to the pubic bone to penetrate the skin incision of the abdominal wall, not too close to the outer side nor too close to the inner side, so as to avoid damage to the bladder, the obturator nerve and the large blood vessels [4, 5]. There was no case of bladder perforation in our group, and if perforation occurs, the puncture needle should be withdrawn immediately, and can be re-punctured again from outside the bladder with an indwelling urinary catheter for 5-7 days. Suspension tension control is the key to the success of the operation, the operation can be placed on the anatomical scissors between the sling and the urethra to maintain a certain gap between the suspension tension to the patient coughing or pressing the abdomen with a small amount of urine leakage for the best, rather loose than tight, otherwise easy to produce postoperative urinary difficulties. In this group, there are 5 cases of postoperative urinary difficulties, given with intermittent self-catheterization, respectively, in 1-2 months after the return to normal urination. If the patients still can not resume normal urination, urethral release surgery is needed.The occurrence of overactive bladder such as urinary frequency and urgency after TVT may be related to the sling position too close to the bladder neck and the sling is too tight.9 patients in this group had the symptom of urinary frequency and urgency after surgery, which can be treated with oral anticholinergic drugs. The TVT method can be applied to people with anatomical and intrinsic sphincter dysfunction type of stress incontinence, those who have failed previous incontinence surgeries, and those with combined incontinence aggravating factors [6]. Nine patients in our group had a history of incontinence surgery, and the previous surgical approach was bladder neck urethral suspension, and these patients may have varying degrees of intrinsic sphincter dysfunction. Suspension can only address the change in the anatomical position of the bladder neck and posterior urethra, and it does not provide a suitable hammock-like support plane for the urethra. control. 1. Kim, S. G., Song, B.: The significance of urodynamic examination in the diagnosis and treatment of urinary incontinence. Chinese Journal of Urology. 1998.19 vol (3): 190-192 2. DeLancey JOL. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. Obstet Gynecol. 1994; 170: 1713-1723.3. Kuuva N, Nilsson CG. A nation wide analysis of complications associated with tension-free vaginal tape (TVT) A nation wide analysis of complications associated with tension-free vaginal tape (TVT) procedure [J]. Neurourol Urodyn, 2000, 19: 394-400. 4. Sander P, Moller L M, Rudnicki P M, et al. Dose the tension-free vaginal tape procedure affect the voiding phase? Pressure-flow studies before and 1 year after surgery. BJU Int, 2002, 89: 694-698. 5. Peyrat L, Boutin J M, Bruyere F, et al. Intestinal perforation as a complication of tension-free vaginal tape procedure for urinary incontinence. Eur Urol, 2001, 39: 603-605. 6. Leach G E, Dmochowski R R, Appell R A, et al. Female stress urinary incontinence clinical guidelines panel summary report on surgical management of female stress urinary incontinence. Am Urol Associ. J Urol, 1997,158: 875-878.