Introduction

Because retropubic midurethral slings require blind passage of a trocar through the retropubic space, inadvertent bladder perforation occurs in 3% to 5% of cases. Also, vascular and bowel injuries, albeit very rare, were reported that resulted in significant morbidity and mortality (see Chapter 6). In the hope of avoiding these complications, Delorme described the transobturator technique for midurethral sling placement in 2001.

As with retropubic synthetic slings, this is a minimally invasive midurethral sling using a synthetic tape; however, it is placed using a transobturator approach rather than a retropubic one, almost eliminating any potential for bladder or bowel perforation and major vascular injury. Specially designed needles are passed either from the inner groin into the vaginal incision (outside-in technique) or from the vaginal incision into the inner groin (inside-out technique). When the procedure is performed in an appropriate fashion, the needle and subsequently the sling pass through (from outside in) the subcutaneous fat, gracilis tendon, adductor brevis, obturator externus, obturator membrane, and obturator internus. (See Chapter 3 for a detailed discussion of obturator anatomy.) Transobturator tape (TOT) slings use the basic concept of midurethral support with the sling placed underneath the urethra; resistance against the urethra is generated when intra-abdominal pressure increases, which increases outlet resistance and prevents stress urinary incontinence (SUI).

TOT slings have become the most popular surgical treatment for SUI. The technique has been shown to be a low-risk procedure that is comparable to most other surgical options in effectiveness.

TOT slings are associated with a lower risk of urethral obstruction, urinary retention, and subsequent need for sling release compared with retropubic slings. For primary cases, a TOT sling demonstrates similar rates of cure compared with retropubic synthetic slings, with fewer bladder perforations and postoperative irritative voiding symptoms. Also, as mentioned, rare but catastrophic risks of bowel and major vessel injury are almost eliminated. The trade-off is that patients experience more complications referable to the groin, such as pain and leg weakness or numbness, with the TOT approach. Retropubic slings may be more effective for recurrent incontinence and in women with intrinsic sphincter deficiency (ISD), although the data supporting this statement are difficult to interpret owing to controversy regarding how best to define and diagnose ISD.

This chapter reviews the technique for transobturator sling placement and discusses potential complications and outcomes. Numerous transobturator sling kits are available at the present time (Table 7-1). Indications for TOT sling placement include patients with symptomatic SUI or mixed incontinence in which the stress component is more severe than the urge component. TOT slings are also commonly placed in women undergoing repair of pelvic organ prolapse in the hope of preventing the de novo development of SUI (occult incontinence).

Table 7–1 Commercially available transobturator midurethral sling kits

Surgical Technique

As previously mentioned, TOT slings can be placed inside-to-outside or outside-to-inside. The indications, effectiveness, and frequency of complications seem to be similar between the two groups (Novara et al., 2010). One study found a higher frequency of de novo sexual dysfunction secondary to the sling being palpable and tender, creating penile pain in the male partner after the outside-in approach (Scheiner et al., 2012). However, this complication has not been observed in all studies (Sentilhes et al., 2009). At the present time, the decision regarding which approach to use is based mostly on how a surgeon was initially trained to perform these procedures.

Inside-Out Technique

1. Preoperative considerations include antibiotic administration for skin and vaginal flora coverage. The antibiotic classes commonly used include intravenous cephalosporins and fluoroquinolones.

2. Sterile urine should be confirmed before the procedure; some physicians postpone the surgery if an active urinary tract infection is documented.

3. Patient positioning and preparation. The patient is positioned in the dorsal lithotomy position with legs supported in Allen or candy cane stirrups with all pressure points padded appropriately. The perineum and vagina are sterilely prepared, and surgical draping is placed so as to allow access to the vagina and inner groin.

4. Anesthesia. Although the authors prefer to perform these procedures under general anesthesia, they can be performed using intravenous sedation with local infiltration of the vaginal tissue, which allows the use of a cough test to assist in appropriate tensioning of the sling.

5. The exit site of the needle is marked. It should be 2 cm above the level of the urethra and 2 cm lateral to the labial fold (Figures 7-1 and 7-2).

6. Vaginal incision. Anterior retraction of the vaginal mucosa with an Allis clamp facilitates visualization. We prefer to hydrodistend the anterior vaginal wall with either a combination of epinephrine and lidocaine or injectable grade saline. A scalpel blade is used to make a distal anterior vaginal wall incision.

7. Vaginal dissection. Sharp dissection is used to mobilize the anterior vaginal wall off the underlying urethra. The authors prefer to make the incision slightly longer for TOT and single incision slings than the incision required for retropubic midurethral sling. We prefer to mobilize the distal anterior vaginal wall completely off the posterior urethra allowing placement of the surgeon’s finger into the paraurethral space for palpation of the inferior pubic ramus (Figure 7-3). Some physicians prefer to hydrodissect the trocar trajectory bilaterally before placing the sling and its trocar.

8. Trocar passage. The trocar tip is inserted into the previously dissected vaginal incision lateral to the urethra and advanced gently while rotating the trocar handle. This insertion is done while hugging the pubic rami knowing that the obturator canal, which houses both obturator nerve and vessels, is at the opposite anterolateral margin of the foramen. The tip should emerge at the level of the exit site generated previously at the level of the clitoris. The vaginal sulcus is inspected to ensure no perforation or mucosal damage has occurred. Certain TOT sling kits (TVT-O [Gynecare, Somerville, NJ] and TVT-Abbrevo [Gynecare]) have a winged guide introducer that helps facilitate appropriate passage of the needle through the obturator membrane easily guiding the trocar into position. Some surgeons prefer perforating the membrane with Metzerbaum scissors before passing the trocar (Figure 7-4). Once the membrane is penetrated with the tip of the trocar, the surgeon’s hand is lowered or dropped toward the patient to allow the helical trocar to rotate around the ischiopubic ramus and exit in the inner thigh (Figure 7-5).

9. Cystourethroscopy

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