Is the Cough-Stress Test Necessary When Placing TVT?
At London Medical Education Academy we are acutely aware of the debate around the mesh procedures in the UK. We run training courses in female anatomy, and train surgeons on using native tissue to repair incontinence, both in vaginal and abdominal procedures. Having previously run courses also in how to utilize implants, we find it curious that such difference in methodology exists between to different countries and indeed, from the original inventor of the TVT procedure and product.
This is a wording in Swedish patient literature (on public healthcare site 1177):”Du kan bli opererad om du inte blivit bättre efter sex månaders bäckenbottenträning. En vanlig operation är TVT, eller Tension Free Vaginal Tape. Vid den här typen av operation får du lokalbedövning. Du behöver oftast inte stanna på mottagningen över natten utan kan åka hem samma dag.”
“you can be operated if you have not improved after 6 months pelvic floor training. A common operation is TVT, or tension free vaginal tape. During this type of surgery you will have local anaestesia. You will most commonly not stay overnight, but can go home the same day.”
Below is an interesting study from back in 2005, highlighting what the UK has learned the hard way: the procedure is designed to be done in local, not in general anaestesia.
Miles Murphy, MD, MSPH, Patrick J. Culligan, MD, Cristina M. Arce, Carol A. Graham, MD, Linda Blackwell, RN, and Michael H. Heit, MD, MSPH
OBJECTIVE: To estimate whether the mode of anesthesia (and the resultant ability or inability to perform the coughstress test) used during the tension-free vaginal tape (TVT) procedure affects postoperative continence.
METHODS:Acohort of 170 women who underwent the TVT procedure without any other concomitant surgery completed the short form of the Urogenital Distress Inventory (UDI-6) to assess their continence status preoperatively and postoperatively. Chi-squared, t, and Mann-Whitney U tests were used to determine the association between these data and anesthesia type during univariate analysis.
RESULTS: Both anesthesia groups showed significant improvement from their preoperative UDI-6 scores to their postoperative scores. However, when comparing the change from pre- to postoperative UDI-Stress Symptoms subscale scores between the 2 groups, we found a significant difference. Mean improvement in the local group was 58.3 ( 33.8) compared with 41.7 ( 39.4) in the general group
CONCLUSION: Women who undergo TVT show significant improvements in incontinence severity regardless of anesthesia type. However, greater improvements in stress incontinence, as measured by the UDI-Stress Symptoms subscale, are seen when the TVT is placed while using the cough-stress test under local analgesia. (Obstet Gynecol 2005;105:319 –24. © 2005 by The American College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: II-2
Like many other new minimally invasive suburethral slings, tension-free vaginal tape (TVT) differs from traditional pubovaginal slings in 3 basic ways: surgeons place the TVT at the midurethra (as opposed to the urethrovesical junction), the ends of the sling are not sutured in place, and it can be performed under local analgesia. Placing the sling under local analgesia enables the surgeon to tailor the placement of the tape to each individual patient by using the “cough-stress test” to adjust the sling intraoperatively. The tape is pulled up in small increments until coughing no longer results in urine loss, theoretically assuring continence while decreasing the risk of postoperative urinary retention.
Although Ulmsten et al described the procedure using local analgesia, TVTs are commonly placed during concomitant prolapse surgery under general anesthesia. As surgeons became comfortable placing the TVT under general anesthesia during larger prolapse cases, many adopted the use of general anesthesia even when placing TVT alone. Although this practice saves time, eliminating the cough-stress test during TVT placement potentially robs this procedure of 2 of its theoretical advantages over traditional slings: improved continence and decreased voiding dysfunction.
Full publication here.
Next training course on urogynaecology here