Surgeons' ineptitude should have been the focus.
"UPDATE ON URINARY INCONTINENCE" JHANSI REDDY, MD, AND MARIE FIDELA R. PARAISO, MD (DECEMBER 2009)
I am an avid reader of OBG MANAGEMENT, but this is my first letter to the editor. I am writing today because I am surprised and puzzled by the inclusion and discussion of a study of 67 cases--involving placement of a midurethral sling--in which surgeons sustained six bladder perforations and had a failure rate of 21% after 6 months. (1)
These results do not reflect the quality and benefit of the procedure, but the ineptitude of the ones performing it.
Guy E. Blaudeau, MD
(1.) Schierlitz L, Dwyer PL, Rosamilia A, et al. Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial. Obstet Gynecol. 2008;112(6):1253-1261.
Drs. Reddy and Paraiso respond: TVT complication rates vary widely
We appreciate Dr. Blaudeau's interest in our Update on Urinary Incontinence. We chose to include the article by Schierlitz and colleagues to highlight the growing trend of identifying urodynamic parameters that may raise the risk of failure with certain midurethral slings. Because it was a recent, randomized, controlled comparison of transvaginal tape (TVT) and transobturator tape in the treatment of intrinsic sphincter deficiency, we thought it might be of interest.
In the literature, the incidence of bladder perforation during TVT is highly variable. At our own institution (the Cleveland Clinic), we reported an incidence of 7% in 2008, but others have observed much higher rates. (1) For example, Andonian and colleagues reported a rate of 23% in 2005. (2)
In a comprehensive review of midurethral sling complications, Stanford and Paraiso reported a 5% bladder perforation rate with TVT. (3) Many surgeons have postulated that the risk of bladder perforation is commensurate with experience and pointed to the learning curve involved. This is an important variable for academic centers invested in the training residents and fellows.
The definition of success after a midurethral sling procedure also remains a topic of considerable debate. Many surgeons base success on the patient's lack of symptoms; others utilize objective measures such as a negative cough stress test, a 1-hour pad test, or urodynamic parameters. In the study mentioned by Dr. Blaudeau, only 84% of subjects underwent urodynamic testing 6 months postoperatively, potentially biasing the results.
(1.) Barber MD, Kleeman S, Karram MM, et al. Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2008; 111 (3):611-621.
(2.) Andonian S, Chen T, St. Denis B, Corcos I. Randomized clinical trial comparing suprapubic arch sling (SPARC) and tension-free vaginal tape (TVT) : one-year results. Eur Urol. 2005;47(4):537-541.
(3.) Stanford El, Parasio ME A comprehensive review of suburethral sling procedure complications, J Minim Invasive Gynecol. 2008; 15(2):132-145.
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|Title Annotation:||Comment & Controversy|
|Author:||Blaudeau, Guy E.|
|Date:||Mar 1, 2010|
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