**2.1 Surgical principle of midurethral slings**

Petros and Ulmsten proposed the integral or midurethral theory of the female pelvic floor and urethral closure mechanism **(Petros and Ulmsten, 1993)**, which has been the basis upon which many of the newer treatments for SUI have been developed. The idea that a loss of mid-urethral support is a causative factor in female SUI led to the use of synthetic midurethral tapes which became popular because of ease of placement and excellent outcomes. After their introduction by Ulmsten and Delorme, TVT and TOT gained a great popularity and rapid widespread and become now the gold standard treatment minimally invasive treatment of female SUI. Both techniques (TVT and TOT) aimed to recreating urethral support using a polypropylene mesh placed at midurethral without tension to create an artificial collagenous neoligament, using the foreign body reaction induced by the host defense mechanism. TVT acts as a pubourethral neoligament anchored suprapubically, which tightens around the urethra in the setting of increased intra-abdominal pressure. TOT had the following advantage over TVT by avoiding the blind trocar passage in the retropubic space by passing the trocar through the obturator muscles and membrane, thus decreasing the risk of major bladder, bowel perforation and vascular injury also decreasing the need for cystoscopy use after tape placement (figure 1 and 2).

Fig. 1. TVT in position **(Morley and Nethercliffe, 2005)**.

Fig. 2. TOT in position **(De Leval, 2003).** 

Futuristic Concept in Management

**Cindolo et al, 2004** 

**Giberti et al, 2007** 

**Roumeguere et al, 2005** 

**Waltregny et al, 2008** 

**Liapis, Bakas and Creatsas, 2010** 

(table 4).

Table 3. Results of TOT.

**2.2.3 TVT versus TOT outcomes** 

**2.3 Material used for midurethral slings** 

**Author Number of** 

of Female SUI: Permanent Repair Without Permanent Material 295

efficacy to TVT with cure rate > 80% (table 3), however, still long-term studies have yet to be

hypermobility

urethral hypermobility

> SUI and Cystocele

TVT and TOT since their introduction in the treatment of female SUI have gained a great popularity and wide spread use in a large number of studies. Both techniques showed nearly equal efficacy with more than 80% cure rate in the majority of studies as mentioned before (Table 2, table 3). Novara et al, in a large systematic review and meta-analysis showed that patients treated with TVT had slightly higher objective cure rates (OR: 0.8;CI: 0.65–0.99; p = 0.04) than those treated with TOT; however, subjective cure rates were similar in both technique **(Novara et al, 2010)**. In a long term follow-up after 5 years both TVT and TVT-O procedures were safe, with equivalent results (72.9% and 71% of patients objectively

Over the past years there was a great evolution in the use of biological and synthetic materials in the treatment of different reconstructive pelvic surgery e.g. SUI and pelvic organ prolapse (POP) in an effort to improve surgical outcomes. However, the potential benefits of using grafts need to be carefully balanced against the risks of using foreign materials to the patient's body. Amid in 1997 published a classification for synthetic mesh used in abdominal hernia surgery based on the pore size (macroporous, microporous, submicro-porous) and fiber type (monofilaments or multifilament) of the synthetic mesh **(Amid, 1997)**. Synthetic grafts may be non-absorbable, absorbable, or a mixture of the two. The non-absorbable polypropylene mesh is the most common type used in reconstructive pelvic surgery. Synthetic tapes available in the market for urogynecological practice see

80 SUI with urethral

108 SUI due to

**Patient group Duration of** 

120 Urodynamic SUI 1 year 80

91 SUI 3 year 88

**follow-up** 

(16 months)

4 months 92

2 years 80

4 year 82.4 and 80.5 %

**Treatment outcomes (% cured)** 

79.1

respectively

done to evaluate the effectiveness and durability of the TOT procedure.

**Grise et al, 2006** 206 SUI Mean

**patients** 

74 (32 TVT-O and 41 TVT-O + ant. Colporrhaphy

cured after TVT-O and TVT, respectively) **(Angioli et al, 2010)**.
