Is the Use of Synthetic Mesh Safe for Anti-Incontinence Surgery in Patients At High Risk for Erosion?


Introduction and Objectives: Since the initial description by Ulmsten, the wide use of TVT was associated with per and post operative complications. Alternative routes were later described and more recently mini slings procedures without skin exit. We recently developed the Sub Pubic TVT route (TSP) using a small sub urethral sling. Anatomical considerations and short term results are presented.

Methods: Formalin embalmed pelves (8 females, 2 males) were dissected to study involved structures with this route and TSP was inserted in 2 fresh, frozen female cadavers to identify neurovascular elements in vicinity with the tape. The surgical procedure after urethral location by a 30 French Hegar sound, the para urethral dissection is carried to reach the lower pubic ligament and pass a tension free mini invasive polypropylene sling (5 to 6 cm) under urethra. Since mid-2006 a prospective study including 190 female patients with stress or mixed urinary incontinence were operated by the TSP procedure, after clinical exam, questionnaire, urodynamic tests, and clear information and adherence of patients.

Results: Anatomical study confirmed the solidity of lower pubic ligament and innocuousness of the sub pubic route far from the deep noble organs (bladder, bowel, or major vessels and nerves). Urethra is under direct visual control and the dorsal nerve of clitoris was located in a different plane and at 15 mm distance from the tape while in the literature in the other classic sling procedures the mid distance was 11 mm The mid follow-up of 12 months (3 to 22) was available for 172 patients and a longer follow-up of 15 months (12 to 22) for the first 112 patients. No serious complications. Post-void residual urine was 85 mL (0 to 250). No significative pain was seen at hospital. Nine patients suffered of sling exposition. One hundred and forty-two patients (82.55%) were cured of incontinence. 30 patients (17.45%) still have either some stress incontinence 17 (10.22%) or by urgency 13 (7.23%). One hundred and forty-one patients (82%) are satisfied while 31patients (18%) were few or not satisfied.

Conclusions: Sub-pubic TVT is a solid and safe route for adjacent structures and the dorsal nerve of the clitoris. It is a simple, totally visual, and tension-free procedure to treat patients with SUI. Short-term results are very encouraging and close to those of classic slings, with low morbidity.

KEYWORDS: TVT, stress urinary incontinence, suburethral slings, anatomical risks, mini slings

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