Minimally Invasive Surgery for Stress Urinary Incontinence: Is TVT for Me?

The first in a three part series of minor surgical options for SUI

If you suffer from stress urinary incontinence (SUI) you are not alone. This condition affects more than 16.5 million women in the United States and these numbers are growing each year. More often than not, women who suffer from this condition cope quietly, while their quality of life slowly deteriorates.

While SUI is treatable, not all approaches will work for every woman. Most often a course of behavioral or muscle therapy and medication will be tried as part of the initial treatment plan. If these approaches fail or if the incontinence is more severe (significant leakage with coughing, sneezing, or minimal activity), surgery is often required. Fortunately the surgery is now available through several minimally invasive techniques.

SUI is not truly a problem of the bladder, as many people think. It is actually caused by an improperly functioning urethra, the thin muscular tube like structure that runs from the bladder to the outside of your body where urine is expelled. Normally, the urethra - when properly supported by strong pelvic floor muscles and strong connective tissue - maintains a "water tight" seal to prevent involuntary loss of urine during physical stress (e.g. coughing, sneezing, or lifting). When a woman suffers from SUI, weakened muscles and tissues in the pelvic floor - caused by factors such as childbirth, loss of estrogen and repetitive pelvic muscle straining - are unable to support the urethra in its correct position. As a result, as pressure is exerted on the bladder, the urethra cannot remain closed and urine escapes.

The urethra is primarily supported by the vagina. It lies atop of the vagina which acts like a hammock, much like the one you find in the backyard. The urethra lies on top of this hammock and is supported, like you would be if you were lounging comfortably on the hammock. Two things are important to support you lying on the hammock, the ropes that tie it to the base (connective tissue) and the strength of the actual canvas (vaginal wall). When SUI occurs this hammock effect is weakened and can longer offer the proper support, causing urine leakage with physical activity such as running, jumping, sneezing or coughing.

Currently there are three minimally invasive surgical approaches to treating SUI, trans-vaginal tape (TVT) procedure, a laparoscopic burch procedure, and a radio frequency thermal energy treatment. If you think of the hammock, the TVT uses mesh to reinforce the actual canvas of the hammock; a laparoscopic burch "re-ties" the hammock to its base; and SURx "shrinks" the canvas. This three- part series will discuss each of these minimally invasive surgical options.

The procedure which is the best approach for you will depend on a complete physical examination and evaluation by your physician and frank discussion with him or her on the benefits and risks of each procedure as it relates to your individual situation.

Tension Free- TVT

TVT, trans-vaginal tape, is a minimally invasive surgical procedure for definitive treatment of female stress incontinence that combines the use of a safe material, polypropylene mesh tape, with a traditional incontinence procedure called the sling to support the urethra. The mesh tape loosely supports the middle of the urethra and provides support only when needed, without the tension ("tension -free") associated with traditional sling procedure. It creates a "new" hammock for the urethra.

The surgery takes only 30 to 45 minutes and it can be performed under sedation with local anesthesia, though many surgeons may prefer the use of regional (epidural) or general anesthesia.

The tape is surgically inserted through a small incision in the vagina and then it is woven through pelvic tissue and positioned underneath the urethra. The tape is then pulled up through two tiny incisions in the skin's surface just above the pubic area. As it passes through several pelvic tissue layers, friction is created which initially holds the tape in place (like velcro). Over time your body tissue grows into the mesh which permanently secures it. The surgeon will evaluate whether the tape is providing adequate support by asking you to cough and any necessary adjustments can be made right then and there. At the end of the procedure the tape is trimmed just under the skin's surface and the tiny incisions closed. All you will see are two adhesive bandages.

Am I a candidate for TVT?

The TVT procedure is appropriate for most all patients including overweight patients, elderly patients and even those who have gone through previous operations for stress urinary incontinence. As with any surgery of this kind, this procedure should not be performed on pregnant women. Also, because the mesh-like tape will not stretch significantly, it should not be considered by women who plan a future pregnancy. Only a complete physical examination and consult with your physician can determine if it is right for you.

What does recovery involve?

After the surgery you may be able to go home as early a few hours after the procedure or you will stay in the hospital for one night. Many patients return to normal daily living activities within 2-5 days. Most women recover completely within a two to three week period. During this time there should be very little interference with daily activities, although you will have to avoid heavy lifting, strenuous exercise and sexual intercourse for four to six weeks.

What is the success rate?

The TVT procedure has been proven to effectively treat SUI. In fact, 85% of women treated in clinical trials remained completely dry, while another 11% experienced significant improvement. Furthermore, the surgery appears to "last" as demonstrated by studies that have followed patients for five years.

What are the risks?

All surgical procedures present some risks. Although rare, complications associated with the procedure include injury to blood vessels of the pelvic sidewall and abdominal wall, nerve damage, difficulty urinating and bladder and bowel injury.

A Patient's Perspective

In the past, many women accepted SUI as an inevitable part or the aging process. Today's women have a different outlook on life than their parents and grandparents. They are unwilling to accept limitations on their health and are demanding convenient treatments with high success rates.

When a recent patient came into my office for a visit following her TVT procedure, I asked her how she was feeling. She exuberantly responded, "Wonderful! I am completely dry and I am doing things I have not done in years. I have a new lease on life." I have come to expect this marked enthusiasm and optimism for patients who undergo a TVT repair. Most every woman comments, "I wish I had done it sooner."

Click here for more information on SUI.

Created: 8/24/2003  -  Vincent Lucente, MD, F.A.C.O.G
Reviewed: 8/24/2003  -  Donnica Moore, M.D.