Complications of TVT and TOT
11/1/2015 - Aaron E. Goldberg, MD
Mentor: Ellen Brock, MD
Editor: Eduardo Lara-Torre, MD
Tension-free transvaginal tape (TVT) and transobturator tape (TOT) are polypropylene mesh “slings” placed in a midurethral position to treat stress incontinence. TVT incorporates a retropubic approach with the tape exiting the anterior abdominal wall along the superior border of the pubic symphysis. TOT is placed via the obturator foramina, exiting in the groin. Both are generally safe with success rates approaching 80%. There are several complications:
- Bladder perforation is more common with TVT due to passage of needles through the retropubic space. Intra-operative cystoscopy is required for timely diagnosis. If perforation is identified, the needle should be removed and careful re-insertion may be attempted. Foley catheter drainage is often recommended for at least 24 hours and antibiotics may be indicated.
- Transient urinary retention/incomplete emptying is common, typically caused by urethral obstruction from the mesh. An intra-operative stress test may help reduce this problem in awake patients, allowing loosening of the mesh as needed. This is not possible with general anesthesia. Management with post-operative catheter drainage with voiding trials every 2-3 days is recommended. Most cases resolve within 10-14 days. Persistent urinary problems occur in 1-2% of patients, often requiring surgical release of the mesh. Most of these patients have preservation of continence.
- Urge Incontinence/urgency occurs in approximately 25% of patients with TVT, but is less common with the TOT. Initially, patients can be managed expectantly or with behavioral or pharmacologic therapy. Most patients will have partial or complete resolution within 4-6 weeks
- Post-operative infection may occur as either a urinary tract infection or wound infection. Patients with pain, erythema, fever, or other evidence of infection must be carefully evaluated for either wound infection or urinary tract infection. Antibiotics are typically effective, but removal of the mesh may be necessary for refractory cases.
- Hemorrhage due to venous or arterial injury during needle passage may result in post-operative hematomas that can usually be managed conservatively. Rapid intra- or post-operative hemodynamic instability may be evidence of major vascular injury and rapid intervention is mandatory.
- Mesh erosion may occur despite appropriate mesh placement. Evidence of bladder or urethral erosion includes hematuria, recurrent urinary tract infections, and pain. Vaginal erosion symptoms include pelvic pain, discharge, and dyspareunia. Mesh excision is often required, although conservative approaches may be appropriate.
- Vaginal injury is more common with TOT due to the course of the needle near the vaginal fornices. Primary repair intra-operatively resolves most problems.
- Pain/nerve injury is more common with TOT due to puncture of the muscular pelvic sidewall. Initial management is conservative. Mesh excision may be required for refractory cases.
- Bowel injury is a rare but potentially catastrophic complication that remains hard to recognize intra-operatively.
TVT and TOT are generally safe and effective minimally invasive interventions for stress incontinence. Long term, 4-8% of patients may experience reoperation for stress incontinence, tape erosion or extrusion, or groin pain. Careful adherence to correct surgical technique and respect for pelvic anatomy will help prevent most complications. Appropriate and timely intervention will minimize the long-term sequelae when complications do occur.
Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society. ACOG Practice Bulletin No. 155: Urinary Incontinence in Women. Obstet Gynecol. 2015 Nov;126(5):e66-81. doi: 10.1097/AOG.0000000000001148.
Ford AA, Rogerson L, Cody JD, et al, Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev. 2017 Jul 31;7:CD006375. doi: 10.1002/14651858.CD006375.pub4.
Initial Approval: April 2011; Revised September 2018.
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