Moore_edit.qxp 16/10/08 02:04 Page 80
Incontinence and Overactive Bladder
Conclusion sling into the pelvic sidewall with minimal trauma and bleeding. Fixation is
Treatment for female SUI has undergone revolutionary changes during excellent and immediate, and does not alter with release of the placement
the last 10 years, with new minimally invasive techniques that have been needle. To test the fixation strength of the sling after it has been placed, we
proved safe and effective. The TVT sling was developed first, and the completed pull-out strength testing on four unembalmed female cadavers
TOT sling followed, providing a safer means by which to place a TVT after placing the MiniArc sling using the standard technique described
above. The average force required to pull out the sling was found to be
5.87lb (a calibrated force gauge that was attached to a mosquito clamp was
used to calculate pull-out strength). This is approximately five times the force
Urinary urgency and frequency
that an average pelvic floor event, such as a cough, places on a sling.
19
symptoms were significantly present in
Therefore, this should help hold the sling in place during the healing and
tissue in-growth phase, which ultimately may help in overall cure rates.
66% of patients pre-operatively and in
only 9.1% of patients post-operatively.
The MiniArc sling can be implanted under local anaesthesia with the
cough test, or general anaesthesia at the discretion of the surgeon. Early
clinical results in the current multicentre trial show it to be a safe and
effective minimally invasive procedure for female SUI, with objective and
sling, with seemingly equivalent cure rates and lower rates of voiding subjective cure rates at 12 weeks in the range of 93%. Further
dysfunction. However, the TOT sling is not risk-free, as groin pain has investigation with longer-term follow-up and prospective studies are
been reported in some series, especially with the inside-out approach. In ongoing and will add to the above data; however, it does appear in initial
attempts to make the procedure even less invasive, with no needle
passage required through the abdomen or groin, the single-incision
mini-sling has been developed. This is the next logical step in the
Early clinical results in the current
progression of minimally invasive sling techniques.
multicentre trial show the MiniArc sling
Released in late 2006, the TVT-Secur was the first mini-sling; however,
to be a safe and effective minimally
initial results have not been as promising as hoped. This may be secondary
invasive procedure for female stress
to the design of the kit, not the procedure itself. The trocars are somewhat
wide and cumbersome to place, and we have found it difficult to release
urinary incontinence, with objective
the trocar away from the mesh once placed in the sidewall. This can cause
and subjective cure rates at 12 weeks
the sling to loosen and alter the initial tensioning placed. Studies have
in the range of 93%.
reported a high learning curve, and surgeons are advised to place the sling
tighter than one would with a TOT to try to prevent the possibility of
loosening while attempting to release the blade from the mesh. studies that the mini-sling may offer equivalent efficacy with a less
invasive approach than the procedures being used today, and may be the
The newer MiniArc single-incision sling showed promising early clinical next step in the minimally invasive treatment of female SUI. ■
results, and is the least invasive sling to be released to date. The procedure
has several advantages over currently available mini-slings, including being Acknowledgements
less cumbersome with a smaller, less traumatic delivery system that is simple We would like to thank Scott Serels, Ajay Rane and Steve Wolfe for
to use, and easy-to-control placement and adjustment/advancement of the assistance in the MiniArc pull-out strength testing data.
1. Luber KM, The definition, prevalence and risk factors for 17(5):460–65. Opin Urol, 2004;14:313–15.
stress urinary incontinence, Rev Urol, 2004;6(Suppl. 3): 8. Moore RD, Miklos JR, Cervigni M, et al., Monarc 14. Achtari C, McKenzie BJ, Hiscock R, et al., Anatomical study
S3–9. Transtobturator sling: Combined analysis of one-year follow- of the obturator foramen and dorsal nerve of the clitoris and
2. Ulmsten U, Henriksson L, Johnson P, Varhos G, An up in nine countries with 266 patients, Int Urogynecol J Pelvic their relationship to minimally invasive slings, Int Urogynecol J
ambulatory surgical procedure under local anesthesia for Floor Dysfunct, 2006;17:S203. Pelvic Floor Dysfunct, 2006;17:330–34.
treatment of female urinary incontinence, Int Urogynecol J 9. Daraï E, Frobert JL, Grisard-Anaf M, et al., Functional results 15. Delmas V, Anatomical risks of transobturator suburethral
Pelvic Floor Dysfunct, 1996;7:81–5. after the suburethral sling procedure for urinary stress tape in the treatment of female stress urinary incontinence,
3. Ward K, Hilton P, Minimally invasive synthetic suburethral incontinence: a prospective randomized multicentre study Eur Urol, 2005;48:793–8.
slings: emerging complications, Obstet Gynaecol, 2005;7: comparing the retropubic and transobturator routes, Eur Urol, 16. Salz SM, Haff RE, Lucente VR, Short-term assessment of
223–32. 2007;51(3):795–801. patients undergoing the new tension free vaginal tape: Secur
4. Delorme E, Transobturator urethral suspension: mini-invasive 10. Lee KS, Han DH, Choi YS, et al., A prospective trial procedure for SUI, Int Urogynecol J Pelvic Floor Dysfunc, 2007;
procedure in the treatment of stress urinary incontinence in comparing TVT and TOT vaginal tape inside-out for the 18:S27.
women, Prog Urol, 2001;11:1306–13. surgical treatment of female SUI, J Urol, 2007;177(1): 17. Albrich S, Nauman G, Skala C, Koelbl H, TVT-Secur: A novel
5. Mellier G, Benayed B, Bretones S, Pasquier JC, Suburethral 214–18. approach for the treatment of female stress urinary
tape via the obturator route: is the TOT a simplification of 11. Collinet PC, Ciofu CC, Cosson MC, Jacquetin BJ, Safety of incontinence, Int Urogynecol J Pelvic Floor Dysfunc, 2007;18:
the TVT?, Int Urogynecol J Pelvic Floor Dysfunct, 2004;15: inside-out transobturator approach for SUI: Multicentre S25.
227–32. prospective study of 994 patients, French TVT-O registry, Int 18. Marsh FA, Assassa P, An audit of the introduction of TVT
6. Morey AF, Medendorp AR, Noller MW, et al., Transobturator Urogynecol J Pelvic Floor Dysfunct, 2006;17:S103. Secur in clinical practice, Int Urogynecol J Pelvic Floor Dysfunc,
versus transabdominal mid urethral slings, J Urol, 2006;175: 12. Lim J, Cornish A, Carey MP, Clinical and quality-of-life 2007;18:S26.
1014–17. outcomes in women treated by the TVT-O procedure, BJOG, 19. Howard D, Miller JM, Delancey JO, et al., Differential effects
7. Davila GW, Johnson JD, Serels S, Multicenter experience with 2006;113(11):1315–20. of cough, valsalva and continence status on vesical neck
the Monarc transobturator sling system to treat stress urinary 13. Costa P, Delmas V, Transobturator tape procedure – inside- movement, Obstet and Gynecol, 2000;95(4):535–40.
incontinence, Int Urogynecol J Pelvic Floor Dysfunct, 2006; out or outside-in: current concepts and evidence base, Curr
80 EUROPEAN UROLOGICAL REVIEW