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Tension Free Trans Vaginal Tape (TFT) Sling

Tension free transvaginal tape (TFT sling) was first introduced in Sweden in the mid 1990's by Ulf Ulmsten and Papa Petros. The TFT sling is a technical advancement of a traditional operation known as a suburethral, pubourethral or pubovaginal sling. The literature supports the pubovaginal sling operation as one of the two most effective operations for the treatment of stress urine incontinence. The other most effective known operation noted in the literature is the Burch urethropexy The TFT sling device is intended to be used as a pubourethral sling for treatment of female stress urinary incontinence (SUI) resulting from urethral hypermobility and/or intrinsic sphincter deficiency. So why is it considered a surgical advancement over traditional pubovaginal slings?

The TFT sling's main advantage is that a sling is placed, providing new support to failed native tissue, with less morbidity than traditional sling procedures. There is no need to harvest graft material. In other words, create another incisions to take a graft from another part of the body. Therefore, fewer incisions and, needless to say, less pain. Additionally, assessment is possible via a cough test, if the procedure is performed under local, spinal or epidural anesthesia. The patient is actually asked to cough with a full bladder at the very end of the operation and when leakage occurs the TFT sling is gently adjusted to correct the leakage. This procedure allows the surgeon to make any fine adjustments at the time of surgery and insure controlling of the urinary incontinence.

The TFT is a designer sling...

A sling procedure that is adjusted for your individual needs. Most slings are indiscriminately pulled "tight" which may indeed correct the leakage but may also cause the patient great difficulty with urination after the operation. This adjustment is individualized for each patient during the TFT operation thus dramatically reducing the chance the patient will need a catheter for any prolonged time period after the operation.

How Does It Work?

The SPARC TFT Tension-free support for incontinence primarily consists of a mesh-like tape that is surgically inserted through the vagina to support the bladder neck and urethra, the tube through which urine exits the bladder. Ordinarily, the urethra maintains a tight seal to prevent involuntary loss of urine. For women with stress urinary incontinence, a weakened pelvic muscle floor or a defect in the urethral fascia cannot support the urethra in its correct position. If you undergo TFT surgery, your surgeon will restore the normal position of the urethra by weaving or placing a "sling" or mesh tape beneath it. Uniquely, TFT provides support at the middle of the urethra, the section that is under the most strain during normal activities. Placing the TFT in this area, therefore, helps restore this part of the urethra---instrumental to the urination process-- to a more natural position. Unlike other procedures, no bone anchors or sutures are necessary.

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How Does the TFT System Alleviate Stress Urinary Incontinence?

Female SUI is caused by an improperly functioning urethra. Unlike other types of incontinence, SUI is not a problem of the bladder. Normally, the urethra - when properly supported by strong pelvic floor muscles and healthy connective tissue - maintains a tight seal to prevent involuntary loss of urine. When a woman suffers from the most common form of stress urinary incontinence, however, weakened muscle and pelvic tissues are unable to adequately support the urethra in its correct position. As a result, during normal movement as pressure is exerted on the bladder from the diaphragm, the urethra cannot retain its seal, permitting urine to escape.

The TFT system combines the use of a safe material, Prolene polypropylene mesh tape, with a traditional surgical procedure known as the sling, to correct SUI. The mesh is positioned underneath the urethra, creating a supportive sling. When pressure is exerted, such as during a cough or sneeze, the tape provides the support needed by the urethra, allowing it to keep its seal.

There are more than 300 different operations described in the medical literature for the treatment of stress urinary incontinence. This statistic is not only confusing for the consumer but to the physicians and surgeons who treat urinary incontinence. Fortunately the American Urological Association (AUA) established a task force to determine the most effective operations in the literature for the treatment of stress urinary incontinence. They concluded the most curative operations as published in the worldwide medically indexed literature were the: Burch urethral suspension procedure and the suburethral sling operation. Cure rates for both procedures were found to fall routinely between 80-90%.

The TFT operation is a "sling" operation and its cure rate falls within the international standards of cure for other types of sling procedures. To date approximately 200,000 procedures have been performed around the world and 75,000 within the United States. The success rate five years after the surgery is 90%.

Complications

All surgical procedures have risks and complications and these entered here should be seen in the context of the published complications of surgery for genuine stress incontinence (Chalia & Stanton 1999). Published papers and personal series on the procedure suggest that complications may occur. However, the total published rate of complications using the TFT device has been minimal.

Surgeons with proper training and proper abilities to understand the complexities of incontinence can successfully perform the procedure with minimal risk or complications. Most patients can be released from the hospital the same day of the procedure. Precise adherence to the procedure described by Ulmsten et al minimizes complications, but deviation from the technique or inexperience with it may lead to severe complications.

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Bladder Perforation

This complication is usually minor and the likelihood decreases with surgeon experience. Bladder perforation occurs more frequently in the retropubic space due to scarring from previous surgery. The needle should be reinserted with the surgeon adhering and paying close attention to technique on the second passage. Care should be taken to ensure that the needle jugs the back of the symphysis as it passes toward the anterior abdominal wall. Cystoscopy must be performed after the reinsertion of the needle. After the bladder perforation a catheter should remain in place for 24 hours. Antibiotic coverage can be initiated.

Post operative Voiding Problems

A patient who is unable to void immediately post-operatively can be discharged with a catheter for 24-72 hours. A Hegar dilator can be placed in to the urethra and a Titling loosening sometimes can be accomplished by performing a "pull down". This is not dilation but instead the physician should use the dilator to torque the urethra and its underlying sling in an attempt at loosening the sling and reduce the obstructive nature of the sling. A 1 % urinary retention rate is reported by several surgeons. Most patients in retention were subjected to a very short second surgical procedure (10 minutes). Nearly all of the patients are no longer experiencing postoperative urination problems.

With the first 5-10 days postoperatively, the outlet obstruction can be relieved by providing local anesthetic, opening the vaginal incision, grasping the tape using a right angle clamp, and pulling the mesh sling approximately 5-10 mm downward.

After 10 days, loosening can be very difficult. In these instances, managing the patient with self-catheterization for four weeks will permit the mesh to heal and to become fixed into position. At this point in time, the outlet obstruction can be relieved by providing local anesthetic, making a vaginal incision, and dividing the tape in the midline. It is helpful to carefully palpate the base of the incision to identify the tape. Normal voiding is restored and the patient's continence is preserved.

Ideally, the prevention of this complication is the goal. This is determined in the operating room by the ensuring that the TFT sling mesh is positioned loosely without tension.

Urgency & Urge Incontinence

Postoperative bladder instability or bladder spasms are associated with anti-incontinence procedures in general. This can potentially be avoided by proper mesh adjustment such as with the cough test and by maintaining a loop beneath the urethra. Incorrect positioning at the bladder neck rather than at the mid-urethra may play a role or contribute to this phenomenon. In the absence of obstruction, anti-cholinergics and/or bladder retraining can be helpful.

Infection of the mesh

Prolene has a well-proven record of not causing infection. It has been used in the vagina without complications in procedures such as the Gittes bladder neck suspension and the Vesica bladder neck suspension. To date, Prolene has yet to be the sole source of an infection using the TFT sling system.

Summary

There have been over 200,000 TFT slings performed world wide and more than 75,000 in the United States. The cure rate is 90% after five years from the date of surgery. Most patients can return to all activities within days after the procedure. Most of the women have little post-procedure pain and seldom do they require any pain medication.

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Reprinted with permission from Dialog Medical, dialogmedical.com

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