TVTO (Tension Free Vaginal Tape {Obturator})  & TOT (Trans Obturator Tape)


Over the past 12 years the TVT procedure has revolutionised the treatment of stress incontinence, and given very good results. Complications are very rare and in most cases this has remained the proven treatment of choice. Before reading this page I would suggest reading the TVT page to get the background on this, the established, successful and main technique, by clicking on this link.


What then are the TVTO and TOT ? Why change a very successful technique?


During a conventional TVT we make 2 tiny cuts at the bottom of the tummy just above the bone and then pass the tape behind the bone and in front of the bladder as shown below.






Later French and Belgian surgeons were responsible for developing the technique further. These approaches use a similar tape and principal, but instead of passing the tape behind the bone and upto the abdomen, the tape is passed from the vagina to 2 incisions just to the side of the vagina, almost at the top of the thigh. An alternative is to pass the tape from the incisions into the vagina. The end result of both is shown schematically in the two diagrams below.








There are several current designs, 2 of which use an almost identical tape to the TVT (TVTO & Monarch (TOT)); these are the designs which I use and find the most effective. There is no reason to suppose that the identical tape will produce any surprises in practice and indeed in nearly 1000 cases it has been safe and effective.


The advantages appear be a slightly quicker recovery rate, less chance of disturbing the bladder, ease of adding to other prolapse surgery and even fewer possible complications such as difficulty emptying the bladder and bleeding. It must be stressed however that complications are minimal with the conventional TVT. The down side however is that the follow-up to date is shorter with fewer operations performed. To date (Jan 2011) I have performed 1000 of these operations. Collecting the data and auditing the results shows a comparable success rate to the conventional TVT in most women at this stage, and when combined with certain other repair operations it has definite technical advantages. It is also less tension dependent which means that women have even fewer difficulties emptying the bladder and go home quicker. Because of this we can do it under a general anaesthetic and as a day case more reliably. At Robert Peel Hospital (Tamworth) this has been my preferred approach, all women having been able to go home the same day.


In women with gross leakage, mixed bladder symptoms (urgency, frequency etc as well as stress incontinence) or previous failed surgery however the TVT remains the better approach.


As things now stand the TOT procedure complements the conventional TVT, and has been reviewed for NICE approval, although in certain circumstances as above the TVT remains more appropriate. NICE recommend that the procedure (and also the TVT) is only performed by those with appropriate experience and that results are audited as we have and continue to do. Certainly the TOT offers an alternative which is of value in many women with mild to moderate stress incontinence and particularly in certain groups such as larger women, those undergoing prolapse surgery at the same time and those who already have difficulty emptying their bladder. We can discuss this option with you further once you have decided surgery is for you. Whichever is decided upon appears to offer a very good chance of cure from the embarrassing and distressing condition of stress incontinence.