Tension Free

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Tension Free Vaginal Tape (TVT) 

or

Visually Controlled Mini Vaginal Tape (MVT) ?

 

Introduction:

T.V.T. (tension free vaginal tape) is becoming the new "gold standard" in the surgical treatment of stress urinary incontinence. 

The old Burch's colposuspension with its side effects will probably disappear in the near future. 

TVT has been build on very relevant anatomic and physiopathologic data. 

But is it really the less expensive and the less dangerous way to obtain a distal, tension-free, solid, sub-urethral support? 

Read the next chapter before you answer this question.  

!!!!  New  !!!

pelvis3d-bannière

The effect of a suburethral mesh (MVT, TVT, TOT) during coughing is presented in this DVD

To see pudendal nerve stretching during perineal descent on youtube (free sample), click here

 

  

Visually Controlled Mini Vaginal Tape (MVT):   

Logo IPFDS Cairo 2001  Click on the image to see the "power point présentation" (Cairo 2001)

History

It was in July 1985 that the first case of MVT was performed. Since then more than 600 cases have been accomplished by a single operator and more than 2000 cases have been completed both in France and Belgium by several surgeons.

Principles

Based on one anatomic logic similar to those developped later by Ulmsten and De Lancey, the MVT is predicated on similar physiologic principles.

The technique entails placing under the middle urethra a mini-strip of synthetic tissue (Gore-Tex® at the beginning; now Prolene®) or Parietene®) the ends of which are then fastened to the anterior portion of the white line or more recently to the outer areas of the pubic arcuate ligament. 

M.V.T.#1

Endogenic tissue like fascia lata can also be used. Resorbable material (PDS®) and collagen matrix (Pelvicol® Pelvicol ) have been tried but are less effective.

Technique

A U-shaped anterior vaginal wall incision circumscribes an operative field of the size of a stamp. This delimited part of the vaginal wall is then separated from the underlying urethra without injury to the sphincter.

M.V.T.#2

Afterwards, on each side, the para-urethral areas are dissected with wide scissors until feeling the pubic arcuate ligament.

Then, with a constant visual control, stitches of Gore-Tex® or Ethibond® threads set on a small but strong needle are passed, right and left, through the outer parts of the arcuate ligament. 

 

M.V.T.#3


After the resistance of each stitch has been checked, the thread is passed through each end of a 4x1.5 cm strip of polypropylene.

Finally, this strip is fastened on each outer part of the pubic arcuate ligament and thus achieves a sub-urethral hammock.

M.V.T.#4

The vaginal wall is then closed, with a vaginal plasty or not, by six to eight stitches of resorbable material.

M.V.T.#5

All this procedure is usually performed within 20 to 30 minutes.
A bladder probe is left on 24 hours before the patient is discharged but an ambulatory policy could also be used.

 

Results

In the single operator's series of 600 cases performed over a 15 year period, the failure rate is 9.9% after 1 year , 8.4% after 5 years, and 12.5% after 10 years. 

In our opinion, long term outcomes are due to the precision of the anatomo-physiological approach, the rigor of the indications (selection of strict stress incontinence cases) and the use of synthetic tissue capable of effectively replacing over the long term the deficient sub-urethral conjunctive tissue.

Complications

In this series of 600 cases, no serious general or visceral complication was observed. Prosthetic material rejection occurred in 2% of the cases(with Gore Tex®; more rarely with polypropylene). In all cases, extrusion was done towards the vagina. Urinary continence was preserved despite rejection in 70% of cases.

On the whole of 2000 cases, the percentages of rejection are higher function of the learning curve of the operators, an unpublished pubic osteitis and two cases of urethral erosion were pointed out but, as far as we know, without serious repercussions.

In our mind, a solid training is the only method able to reduce the risks of these complications.

Compared to TVT the MVT, in addition to the benefit from using only one sling of synthetic tissue 15 times smaller, has the advantage of being performed under constant visual control at the expense of a minor suburethral dissection, which, at best, is only slightly bigger. Without" a blind dimension to the procedure, it shows respect for the Retzius space and its vessels in addition to be virtually void of any bladder risk.

Conclusion

Now that the anatomo-physiologic principles which justify the use of sub-urethral support procedures (MVT, TVT) are commonly accepted, a better consideration should be expected, especially with regards to the cost, the simplicity and the safety of the MVT of which efficacy was proven through a 15 year practice. 

 

References:

Title: [Fixation of Gore-Tex slings to the pubococcygeal tendons: a simple technic of treating stress urinary incontinence using only the vaginal approach]
Author: Mouchel J
Source: J Gynecol Obstet Biol Reprod (Paris) 1987;16(4):507-12.

To read the abstract: click here 

Title: [Surgical treatment of stress urinary incontinence in women using a suburethral suspension with a polytetrafluoroethylene sling. Apropos of 95 cases]
Author: Mouchel J
Source: Rev Fr Gynecol Obstet 1990 Jun;85(6):399-406.
To read the abstract: click here

Intolérance au Gore-Tex. A propos de 86 soutènements sous-urétraux
Authors : FERRY Ph.*, ANGUILL C.*, OLLEAC A.*, QUENTIN M.*, LECESTRE-LOYER M.J.**Service de Gynécologie-Obstétrique*, Laboratoire d’Anatomo-pathologie **
Centre Hospitalier, 17019 LA ROCHELLE CEDEX.
Available on www.gyneweb.fr: Click to read this paper (in french)

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