Tension Free Trans Vaginal Tape (TFT sling) :
Urology And Urosurgery
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Tension free transvaginal tape (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 exists 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.
Surgery using the GYNECARE TVT usually takes approximately 20-30 minutes. While it can be performed under general anesthesia most of the studies performed recommend local or regional anesthesia (ie epidural or spinal). Under local anesthesia the patient will be semi-awake, but will not feel the surgery. This allows the surgeon to evaluate whether the tape is providing adequate support by asking you to cough. Any necessary adjustments can be made right then and there. So, even before you leave the operating the room, the surgeon can usually determine if the procedure is successful. Performing this evaluation before the procedure is complete also reduces the need for using a urinary catheter, unlike other sling operations. Patients report minimal discomfort following surgery with the TVT for incontinence.
The surgeon should:
Two hands are required to pass the needle. The surgeon should concentrate on the role of each hand. Position the needle tip through the vaginal incision directed lateral to the urethra. When passing the needle, the vaginal mucosa is between the surgeon's finger and the tip of the needle.
- Be aware of the pace and direction of each movement
- Review the angle of the introducer handle for orientation
- Focus on the role of each hand throughout the procedure
- Try to maintain a visual mental image of the needle tip as it guides through the female pelvis
Palpate the inferior ramus laterally and the urethra medially with the straight catheter guide inside. Once the endopelvic fascia has been penetrated beneath the inferior ramus, the handle of the needle is directed downward and pressure is applied upward by the hand in the vagina. The force advancing the needle actually comes form the palm or the thumb of the vaginal hand and the vaginal finger guiding it. The second hand is used to direct the back end of the handle. It determines the angle and steers the needle. The second hand does not torque or advance the needle.
Once the needle tip has been passed through the abdominal incision the handle can be disconnected. The needle should not be pulled completely though to the abdomen until cystoscopy has verified its position.
All surgical procedures have risk 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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