Publications

Christopher B-Lynch


« | Main | »

Outcome Of Tension-Free Vaginal Tape (TVT) Procedure In Women With Stress Urinary Incontinence—Patients Perspective

Introduction

Stress urinary incontinence affects 10-20% of women.
The incidence is higher in the postmenopausal age group. Treatment of this disorder alleviates symptoms and thereby improves the quality of life. This may be another factor for the relative increase in the number of patients seeking treatment for this disorder (Olsson and Kroon, 1999). Many surgical procedures have been described for its investigations and treatment.
Ulmsten et al. (1996) described the TVT procedure in 1995 as an ambulatory surgical procedure. It is unique because it is potentially simple with low morbidity and a short hospital stay. No previous study has assessed the patient’s perspective using an analogue scale. TVT success rate is comparable to, if not better than, any long-established major urogynaecological procedure for stress incontinence. Our aim was to evaluate the patient satisfaction rate and result using this technique.

Methods

Ninety-six patients who had the procedure between June 1999 to March 2002 were sent a carefully designed questionnaire (see Appendix I). As some of the questions were of a personal and sensitive nature it was approved by the local ethics committee. Patients were identified from our database and cross-checked from records kept by a dedicated minimal access nurse specialist. The questionnaire was sent to women who had a TVT procedure at least 3 months previously. They were assured of anonymity unless they indicated otherwise.
The mean age of the patients was 54 years with a range of 32-84 years. The mean number of children was two, ranging between 0 and 6. The mode of delivery of those with a previous pregnancy was 79% spontaneous vaginal, 3% caesarean section, 4% assisted vaginal delivery, 4% had a vaginal and caesarean section delivery and 6% had no children. All patients in the study were asked about the duration of symptoms of stress incontinence. The mean time was 9 years ranging between 1 and 30 years. Thirty-eight per cent had suffered with urinary tract infections at some point preoperatively which had been treated effectively with appropriate antibiotics. Only 76% had urodynamic studies before surgery. The rest had a clear demonstration of stress incontinence at clinical examination, which confirmed their symptoms. There was no evidence of recent or past urinary tract infection.
Fifty per cent of patients had previous gynaecological procedures; 7% had urogynaecological procedures while 15% had both. Twenty-eight per cent did not have any previous procedure.
All the patients were given written explanatory information and were pre-assessed by a dedicated minimal access nurse specialist. She also saw them postoperatively. All patients were contacted or seen at day 7, 6 weeks and 3 months postoperatively. Patients were sent questionnaires at least 3 months after their procedure. They were asked about the stage at which they felt confident and in control of their micturation in order to assess the success of procedure. There was a wide range of replies. The procedure was conducted either under local analgesia using lignocaine and adrenaline and sedation or regional anaesthesia. Only the first three cases were conducted under local analgesia without sedation. One of these patients did not tolerate it and found the procedure to be extremely uncomfortable. Most patients do prefer spinal anaethesia because of better analgesia and some distrust of local anaesthetic. Continence results were not different between patients who received local anaesthesia with those who received spinal anaesthesia.

Results

A total of 83% of patients considered the procedure to be a total success; 7% graded it a partial success (Figure 1). Although 10% responded that the outcome of TVT was not successful; however, looking at their responses most had an improvement in their symptoms. Seventy per cent of women who reported that their TVT had been a success had preoperative symptoms severe enough to interrupt their normal routine; none had it after the procedure. Forty-eight per cent changed incontinence pads more than twice a day preoperatively; none of these required pads postoperatively. Thirty-eight per cent could not hold urine until they reached the toilet all but one could do so after the procedure.
Twenty-nine per cent experienced pain immediately after the procedure and a very small number had to be catheterised for 1 to 28 days due to urinary retention. Thirty per cent had minimal bleeding postoperatively, 7% had a bladder injury. Discomfort during intercourse continues to be a problem for 2% of patients at 3 months after the procedure. Four per cent felt pain on micturation 3 months after the procedure. Twelve per cent of the 68 patients were readmitted to hospital for indications such as urinary tract infection and severe constipation. One had an examination under anaesthesia and had the vaginal tape removed as it had migrated into the bladder. She remained continent even after this corrective procedure. One patient had worsening detrusor

fig 1:


Figure 1. Outcome of the tension-free vaginal tape procedure in women with stress urinary incontinence (n = 68).
instability Vith recurrent urinary tract infections. This patient remains a problem and was started on oxybu-tinin with regular reviews.

 

Some Comments From The Patients

‘This operation has changed my life and enabled me to lose weight by exercise that previously I was unable to do. I wish it had been advised earlier. I recommend it’.

‘I feel much better after the operation and shopping trips are more enjoyable’.

‘An excellent operation that has completely changed my life for the better. I can now run with the children and do aerobics with total confidence’.

‘Although I have a few symptoms but it is far more preferable to the loss of control I had before I enjoy sneezing now’.

‘I wish more people knew about this procedure’
(Figures 2 and 3).

There were a few comments from patients who thought TVT to be a failure.

‘I do not think it has made any difference to my condition. The pain I experienced during and after operation was one of the worst I had ever experienced’.
Last 12 months have been a disaster. The operation was most uncomfortable and I feel I should have had sedation as well.

Discussion

The majority of patients were extremely pleased by the simplicity and efficacy of the procedure. Shorter stay in the hospital, shorter convalescence time and early return to work were obvious advantages. Regional or local anaesthesia with sedation is vital for the patients to perceive the procedure correctly and to be patient-friendly. There was no difference in the outcome if the patient had spinal or local analgesia with sedation. However, most of the patients preferred spinal anaesthesia (Haab et al., 2001). Early return home and work made it family friendly and economically advantageous. A few of our study patients were already aware of this new procedure or knew friends who had had it performed and asked for it. Full counselling including the indications, procedure, potential hazards and complications were undertaken. It was supported by written information. Some asked to see an educational video of the procedure preoperatively. This procedure has a high patient satisfaction index and with such a high success rate that

fig 2:

Figure 3. Symptom improvement (n = 56).
TVT is more popular than Burch colposuspension. Its long-term outcome showed no signs of deterioration compared to the results shortly after surgery in 3 years follow-up by Olsson et al. (1999). Only a very small per centage of patients developed urge symptoms de novo, which are prevalent with most types of traditional procedures (Nilsson and Kuuva, 2001). The longer-term evaluation of the urethra and of urinary incontinence must be studied before the technique can be validated in the same way as the more conventional procedures, which have proved their worth over time (Soulie et al., 2001). Results from the ongoing randomized control studies comparing tension-free vaginal tape with laparoscopic Burch colposuspension (Finland) are not yet available (Nilsson and Kuuva, 2001). We plan to assess the longer-term patient satisfaction in 3 years time.

fig 3:

 

References

Haab F., Sananes S., Gerard A., Ciofu C, Ujau S., Gattegno B. and Thibault P. (2001) Results of the tension-free vaginal
tape procedure for the treatment of type II stress urinary incontinence at a minimum follow-up of 1 year. Journal of Urology, 165, 159-162.
Nilsson C.G. and Kuuva N. (2001) The tension free vaginal tape procedure is successful in the majority of women with indication for surgical treatment of urinary stress incontinence. British Journal of Obstetrics and Gynaecology, 108, 414—419.
Olsson I. and Kroon U.B. (1999) A three year postoperative evaluation of tension-free vaginal tape. Gynecologic and Obstetric Investigation, 48, 267-269.
Soulie M., Cuvillier X., Benaissa A., Mouly P., Larroque J.M., Bernstein J., Soulie R., Tollon C, Brucher P. and Vazzaler N. (2001) The tension-free transvaginal tape procedure in the treatment of female urinary stress incontinence: a French prospective multicentre study. European Urology, 39, 709-715.
Ulmsten U., Henriksson L., Jhonson P., Johnson P. and Yachos G. (1996) An ambulatory surgical procedure under local anaethesia for treatment of female urinary incontinence. International Urogynecology Journal of Pelvic Floor Dysfunction, 7, 81-86.

Topics: Published Articles |

Published Articles

Topics: Published Articles | Comments Off on Outcome Of Tension-Free Vaginal Tape (TVT) Procedure In Women With Stress Urinary Incontinence—Patients Perspective

Comments are closed.