Trans-obturator-tape procedure--"inside out or outside in": current concepts and evidence base

Surgical treatment of female stress urinary incontinence has become very popular as a consequence of the good results given by the minimally invasive tension-free vaginal tape. This has attracted great attention from industry, resulting in a proliferation of new slings and different implantation techniques. This review focuses on published literature on the two trans-obturator procedures, outside in or inside out, recently described.

Tension-free vaginal tape was originally reported as a very safe procedure. However, analyses performed in Scandinavia and Austria and several clinical case reports have emphasized the risk of serious complications, related to the penetration of the retropubic space. Two new surgical approaches have been introduced maintaining the position under the mid-urethra of the tension-free vaginal tape but reducing or even eliminating complications related to the penetration of the retropubic space by placing the tape between the two obturator foramens, from outside to inside or from inside to outside.

Efficacy reported results are very close to those reported in most of the observational series of tension-free vaginal tape. Both trans-obturator procedures have been reported with very few complications. Anatomical dissections have shown that these two procedures can be very safe, but that the tip of the tunneller could injure the bladder, the urethra or the obturator pedicle. Surgeons have to respect the key points of the procedures. No evidence-based conclusion can yet be drawn on these two procedures. Long-term follow-up trials and tracker studies including very large cohorts of patients are needed.