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Background: There is a lack of information on the long-term outcomes of transobturator tension-free vaginal tape (TO-TVT) in the surgical treatment of female stress urinary incontinence (SUI)., Objectives: To assess the 3-yr outcomes following TO-TVT and to compare the effectiveness of inside-out versus outside-in approaches., Design, Setting, and Participants: A 3-yr follow-up study of the Evaluation of Transobturator Tapes (E-TOT) trial, a randomised controlled trial (RCT) conducted with women undergoing TO-TVT as a sole procedure between April 2005 and April 2007 in a tertiary urogynaecology centre in the United Kingdom., Intervention: Patients (n=341) were randomised to undergo either TVT-O (Ethicon Inc., Somerville, NJ, USA) for the inside-out approach or TOT-Aris (Coloplast Corp., Minneapolis, MN, USA) for the outside-in approach., Outcome Measurements and Statistical Analysis: The primary outcome was patient-reported success rate. Secondary outcomes included further treatment for SUI, improvement in quality of life, late complications, and risk factors for late failures. Categorical variables were compared using the chi-square or Fisher exact test. Within-group comparison was undertaken using Wilcoxon and Mann-Whitney tests. Risk factors for late failures were assessed in a multivariate regression model. All statistical analysis was performed using SPSS v.18.0 (IBM Corp., Armonk, NY, USA)., Results and Limitations: The 3-yr follow-up was completed by 238 of the 341 women (70%). The overall success rate, based on Patient's Global Impression of Improvement response, was 73.1%, with no significant difference between the inside-out and the outside-in TO-TVT (73.18% vs 72.3%; odds ratio: 0.927; 95% confidence interval, 0.552-1.645; p=0.796). Compared with the 1-yr follow-up, there was a significant reduction in the patient-reported success rate (p=0.005); however, no independent risk factors were identified. A clinically significant improvement (≥10 points) was seen in 80% (n=191) of women, with no significant difference between both groups (p=0.113). Twenty-two women (6%) underwent further surgical treatment within 3 yr. The lack of an objective outcome assessment is a potential limitation of this RCT., Conclusions: The E-TOT RCT showed a 73% patient-reported success rate for TO-TVT at 3-yr follow-up, with no significant differences between inside-out and outside-in approaches. There was a significant drop in patient-reported success rates between 1 and 3 yr., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: To assess the efficacy of transobturator tapes in the treatment of women with recurrent urodynamic stress incontinence., Methods: We performed a secondary analysis of a prospective, randomized, single-blinded study. A total of 341 women were recruited (April 2005 and April 2007) and randomly assigned to undergo "inside-out" TVT-O or "outside-in" TOT-ARIS. Of these women, 46 had undergone ≥1 previous continence procedures and were included in the present study. The preoperative assessment included a urodynamic assessment and completion of validated symptom severity and quality-of-life questionnaires. The primary outcome was the patient-reported success rate at 1 year as assessed using the Patient Global Impression of Improvement (very much/much improved). The secondary outcomes included changes in quality of life, sexual function, the objective success rates defined as negative findings on the standard 1-hour pad test, and a comparison between both routes of transobturator tapes. Multivariate analysis was performed to identify the risk factors for failure., Results: All 46 women completed the 1-year follow-up period. The patient-reported success rate and objective cure rate was 69.6% and 76.5%, respectively, with no significant differences between the 2 transobturator routes (P = .104, odds ratio [OR] 2.933, 95% confidence interval [CI] 0.803-10.719; and P = .077, OR 4.524, 95% CI 0.849-24.109, respectively). Of the 46 women, 35 (76.1%) reported >10-point improvement on the total King's Health Questionnaire scores and 71% of sexually active women (n = 22) showed an improvement in the total 12-item Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire scores. On multivariate analysis, a maximal urethral closure pressure of <30 cm H(2)O was the only independent risk factor for failure (P = .016, OR 9.206, 95% CI 1.511-56.104)., Conclusions: Transobturator tapes have good patient-reported and objective success rates at 1 year of follow-up in women with previous failed incontinence surgery. A low maximal urethral closure pressure was the only independent predictor of failure., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To determine significant preoperative risk factors for failure of transobturator tapes., Methods: Secondary analysis of data from the E-TOT (Evaluation of Transobturator Tapes) study. Patient-reported outcomes (n=310) and objective outcomes (n=297) were analyzed using univariate and multivariate analyses., Results: On univariate analysis, body mass index (BMI) >or= 35, maximum urethral closure pressure (MUCP) or=35 (OR 6.37; 95% CI, 1.73-23.44; P=0.005), nocturia (OR 2.18; 95% CI, 1.04-4.58; P=0.039), urgency incontinence (OR 3.35; 95% CI, 1.07-10.51; P=0.039), and previous incontinence surgery (OR 2.33; 95%CI, 1.1-5.48; P=0.048) were independently associated with patient-reported failure. MUCP

Objective: To compare the 'inside-out' versus 'outside-in' routes for transobturator tape insertion for urodynamic stress incontinence, and to identify independent risk factors for failure at 1 year., Design: Prospective single-blinded randomised trial., Setting: Tertiary urogynaecology centre., Population: A cohort of 341 women undergoing transobturator tape procedures between April 2005 and April 2007., Methods: Women were randomised to tension-free vaginal tape-obturator (TVT)-O for the 'inside-out' route (n = 170) and transobturator tape (TOT)-ARIS for the 'outside-in' route (n = 171). Participants completed validated symptom-severity, quality-of-life and sexual-function questionnaires before and after surgery. In addition, they completed the patient global impression of improvement questionnaire (PGI-I) and standard 1-hour pad test postoperatively., Main Outcome Measures: The primary outcome was the patient-reported success rate reported on the PGI-I scale. Secondary outcomes included objective cure rate and improvement in King's Health Questionnaire scores., Results: A total of 341 women were recruited: 171 women to the 'outside-in' (TOT-ARIS) group and 170 to the 'inside-out' (TVT-O) group; 299 completed the 1-year follow up. The patient-reported success rate was 80% with no statistically significant differences between the groups ('outside-in' 77.6% versus 'inside-out' 81.2%; OR 1.25; 95% CI 0.71, 2.20; P = 0.54). The objective cure rate was 91% with no statistically significant difference between the groups ('outside-in' 88% versus 'inside-out' 94%; OR 2.21; 95% CI 0.85, 5.75; P = 0.157). Previous incontinence surgery (OR 1.41; 95% CI 1.18, 1.91; P = 0.029) and preoperative urgency incontinence (OR 1.78; 95% CI 1.21, 3.91, P = 0.048) were significant risk factors for failure of transobturator tape at the 1-year follow up., Conclusions: There are no significant differences in patient reported and objective cure rates between 'inside-out' and 'outside-in' transobturator tapes. Quality of life and sexual function significantly improved following surgery. Both previous incontinence surgery and preoperative urgency incontinence are associated with significantly lower patient-reported cure rates.

Objectives: To compare the "inside-out (TVT-O)" vs. "outside-in (ARIS)" transobturator tapes in the management of female urodynamic stress incontinence (USI) and to identify independent risk factors of failure of transobturator tapes., Study Design: A prospective, single blinded, randomised trial. Women undergoing transobturator tapes as sole procedure in the period April 2005 and April 2007 were randomised to TVT-O for the inside-out approach and TOT-ARIS for the outside-in approach. The primary outcome measure at 6 months was the absence of USI on urodynamics. Secondary outcomes included; patient-reported success rates, overall patient satisfaction and peri-operative complications., Results: 341 women were recruited: 171 in the outside-in group and 170 in the inside-out. Severe post-operative thigh pain was twice as common in the inside-out group but this was not statistically significant (6.7% vs. 3.5%, p=0.19). 317 women completed the 6 months follow-up; objective cure rates and patient-reported success rates were 85.4 and 80.5%, respectively, with no significant difference between the groups (p=0.28 and p=0.138, respectively). On multivariate analysis: low maximum urethral closure pressure (MUCP) (<30 cm H2O) and previous incontinence surgery were confirmed as independent risk factors for objective failure of transobturator tape with increased odds of failure of 7.06 (2.85-17.48) and 6.22 (2.34-16.52), respectively., Conclusion: This study shows no significant differences in the objective cure rates and patient-reported success rates between the "inside-out (TVT-O)" and "outside-in (ARIS)" transobturator tape procedures in the management of female USI at 6 months follow-up. Previous incontinence surgery and low MUCP were significant risk factors for failure of transobturator tapes., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Urodynamic stress incontinence is a common complaint. There have been over two hundred procedures described for treatment. In 2003, the Royal College of Obstetricians and Gynaecologists in London published a guideline highlighting the evidence for different surgical approaches. These guidelines are intended to guide practice in the United Kingdom, including the two countries that were surveyed. It was our impression however that more sub-urethral tape type procedures were taking place than was recommended. We therefore undertook a postal survey of the consultant gynaecologists in Scotland and Wales, to compare current practice with the evidence base, and also to assess practice from a clinical and manpower perspective. Two hundred and forty consultants were identified in Scotland (161) and Wales (79). About two-thirds of those who saw patients with stress incontinence would always arrange pre-operative physiotherapy, and the majority of consultants would always organise urodynamics preoperatively. There were several different choices of primary procedure, with Tension Free Vaginal Tape (TVT Gynecare- Johnson & Johnson) the most common option. More than half of the respondents in both countries would refer a patient with recurrent stress incontinence to a specialist. TVT was also the most common choice of procedure for recurrent stress incontinence. The procedures that have a grade A recommendation in the RCOG guideline are Burch colposuspension and TVT, and 72% in Scotland and 63% in Wales would perform one of these procedures as first choice. Clinical practice moves on and there are several new sub-urethral tape procedures available on the market. It is important to balance the available evidence base with new developments in order to optimise the management of this common condition.

This study aims to assess the suitability of the transobturator tape (TOT) as a day surgery procedure. A retrospective study of all the patients who underwent TOT as a day surgery procedure, at a tertiary referral centre in the south-west of Scotland, over a 3-year period (August 2002-July 2005). The outcome measures were as follows: complication rates (both intra- and immediate postoperative), voiding dysfunction rates, analgesic requirements and unscheduled in-patient ward admission following the procedure. One hundred and sixty-seven case notes were examined; the mean operating time was 14.7 min (range: 12-28 min, median: 14 min). 97.8% of patients had blood loss <100 ml and the mean blood loss was 54 ml (range: 10-500 ml). None of the patients had major complications such as urethral or bladder injury or anaesthetic complications. 79.6% of patients had satisfactory postoperative voiding pattern achieved within the time frame of the DSU (08:30-17:00 hours). No patient had complete urinary retention. However, 34 patients (20.4%) failed to achieve satisfactory voiding within that time frame and warranted in-patient admission. Three other patients required in-patient admission; the reasons being vaginal bleeding (n=1), postoperative nausea and vomiting (n=1) and postoperative pain (n=1). Therefore, a total of 37 patients required in-patient ward admission, with an admission rate of 22.2%. In conclusion, the transobturator tape procedure is suitable as a day surgery procedure in selected patients. There is minimal peri-operative morbidity, and nearly 80% of patients are discharged home within the scheduled time frame.

Objectives: The transobturator approach for sub-urethral tension free vaginal tapes had gained wide popularity in surgical treatment of urodynamic stress incontinence over the last few years. This study aims to survey the practice and preferences of urogynaecologists and urologists worldwide as regards the transobturator tapes., Material and Methods: Seven hundred and twenty surgeons worldwide were surveyed via postal/email questionnaire about their views and practice regarding the transobturator tape procedures (TOTs). They were asked about their technique and tape material preference and their reasons for choosing them. They were also asked about every detail of the procedure., Results: Adjusted response rate was 68%. Of the responding surgeons, 97% were well aware of the TOTs and only 44.3% undertake them. While 34.16% of the surgeons thought that TOTs are the way forward in the treatment of USI, 14.84% surgeons disagreed and the majority (51%) are yet to decide. With regards to technique of TOTs, most surgeons (38%) would prefer to use both techniques, while 34% use "In-Out" technique only and 28% use "Out-In" technique only. The vast majority (72%) use polypropylene mesh tapes due to better tissue incorporation and proven safety records. A few surgeons deviate from the originally described TOTs; 13.6% use a catheter guide to deviate the bladder and urethra during the trochar insertion and 31.41% use routine cystoscopy as part of the procedure., Conclusion: Whilst one-third of the responding surgeons think that the transobturator approach for tension free vaginal tapes is the way forward for the management of USI, the majority are awaiting studies with longer-term results. The variation from the originally described TOT procedures seems to be inherited from the TVT procedure.

Objectives: To identify the rate of, and risk factors for, lower urinary tract (LUT) injuries associated with the transobturator tension-free vaginal tape (TOT) procedure., Design: Retrospective cohort study., Setting: Tertiary referral urogynaecology centre., Population: 390 women who underwent transobturator suburethral tapes for management of urodynamic stress incontinence between July 2002 and January 2006., Methods: Early cases were identified from theatre records and a case note review performed. From May 2005 (n = 94), data from an ongoing prospective audit were reviewed. Data for LUT injuries with TOT procedures were examined and routes of insertion were compared using Fischer's exact test., Main Outcome Measures: Rate of LUT injuries associated with the TOT procedures. Assessment of factors increasing risk of LUT injury, and comparison of the 'outside-in' and 'inside-out' techniques., Results: 241 women underwent TOT outside-in technique and 148 of them underwent inside-out technique. Four LUT injuries occurred (1%): two urethral injuries (0.5%) and two bladder injuries (0.5%). All LUT injuries occurred in the outside-in group, although this difference did not reach significance (P = 0.146). Bladder injuries occurred in women who underwent concomitant vaginal surgery, while urethral injuries occurred in women undergoing secondary procedures., Conclusion: LUT injury is an uncommon complication of the TOT procedures, and in our hands only occurred with the outside-in technique. Intraoperative cystoscopy should be considered only in selected cases.

Objective: To compare two transobturator suburethral tapes (Obtape, Mentor-Porges and TVT-O, Gynaecare, Johnson and Johnson) used in the management of urodynamic stress incontinence (USI), for tape erosion (vaginal/urethral) rates, clinical presentation, management and outcome., Patients and Methods: We retrospectively studied women who underwent a transobturator suburethral tension-free vaginal tape (TVT) procedure for managing USI in a tertiary referral centre in the West of Scotland over a 36-month period. In our department, the transobturator approach has been the first-choice approach for TVTs since July 2003. Two types of tapes were mainly used, Obtape and TVT-O, and the choice of tape was primarily decided by the surgeons' preference., Results: In all, 316 women had a transobturator tape procedure, of which 96 were associated with another procedure; 112 women had TVT-O using the 'inside-out' technique and 204 had the 'outside-in' technique. Of the latter, 192 had Obtape, four had Obtryx (Boston Scientific) and eight had Monarc (American Medical Systems Inc.) tapes. Sixteen women developed vaginal tape erosion, and significantly more were in the Obtape group than in the TVT-O group (7.29% vs 1.78%, P = 0.038). The patients' age, body mass index, previous vaginal surgery and concomitant vaginal surgery were not significant risk factors for erosions. The time between surgery and diagnosis of erosion was 1-45 weeks, with only one patient being asymptomatic; all others presented with clinical symptoms such as vaginal bleeding, discharge and dyspareunia. Thirteen patients were continent at presentation and 10 of these remained continent after surgical management. In the TVT-O group the erosions were in the lateral vaginal wall, while in the Obtape group the erosions were in the form of central tape extrusion secondary to defective vaginal wall healing., Conclusion: There were significantly more vaginal tape erosions in the Obtape group than in the TVT-O group. No cases of urethral erosions were identified.

Seventy-four patients presenting with a mixed pattern of urinary symptoms were randomly allocated to undergo either inpatient or outpatient continence programs as initial treatment, without prior urodynamic investigation. Both programs consisted of physiotherapy, bladder retraining, fluid normalization, dietary advice and general support and advice. Nine out of 39 in the outpatient group and 8 out of the 35 of the inpatient group failed to complete the study. There was a significant decrease in frequency, nocturia, number of incontinent episodes and visual analog scores for both groups. In addition the outpatients had a significant reduction in loss on pad testing, and a significantly greater improvement in their visual analog score. In each group 63% were cured or improved to the extent that they did not require further treatment. Staff costs per outpatient were half those for an inpatient. We conclude that outpatient conservative treatment as detailed above is a successful first-line treatment of urinary incontinence in women. It is as successful and possibly better than inpatient treatment, and is significantly cheaper.

It is well established that urethral pressure variations occur in patients with or without urinary incontinence, but to what extent they contribute to a patient's symptoms remains unclear. Previous work has suggested that in stress incontinent patients, a rise in bladder neck electrical conductance (BNEC) occurs simultaneously with a fall in urethral pressure, and that this represents bladder neck opening. Six patients with genuine stress incontinence (gsi), and six normal controls underwent simultaneous urethral pressure and BNEC measurements, the results being subjected to time-series analysis, to determine whether the previous finding could be confirmed statistically, and to establish whether a similar association was present in normal women. All six patients with gsi and five of the normal patients had unstable urethral pressure. Estimated cross-correlation of differenced data for the two parameters showed a significant negative correlation at zero time lag in three patients with gsi and two of the control group. There was no significant correlation between the two parameters in the other seven patients. We conclude that the previous finding of a correlation between urethral pressure variation and BNEC, suggesting bladder neck opening occurs as urethral pressure falls in patients with gsi is confirmed, but appeared to be present in only 50% of patients; the finding is just as likely in normal patients, and therefore whilst it may be of relevance to the severity of symptoms, could not be held to have any aetiological significance.