Transobturator sling with intraoperative cough test is effective for patients with low valsalva leak point pressure

The transobturator sling (TOS) is safe and effective for the treatment of female stress urinary incontinence (SUI). Controversy exists regarding its efficacy in patients with low valsalva leak point pressure (VLPP), a marker of intrinsic sphincter deficiency (ISD). We review our experience of TOS in the treatment of women with SUI and low VLPP.

Patients diagnosed with stress or mixed incontinence treated with TOS were identified by retrospective review. All procedures were performed with local anesthesia and intravenous sedation. Stress incontinence and VLPP were determined preoperatively with urodynamic testing. Chart review identified demographics, perioperative variables, complications, and subjective cure. Low VLPP was defined as VLPP less than 60 cm H2O.

From November 2003 to February 2006, 151 consecutive women underwent TOS. Twenty-seven patients were excluded who exhibited incontinence with cough but not valsalva on preoperative urodynamic testing. Of the remaining 124 patients, 29% had low VLPP and 71% had higher VLPP. There was no difference in subjective cure between patients with low (94%) and higher VLPP (84%) overall (p = 0.12) or in patients with 12 months or more of follow-up (93% versus 79%, p = 0.40). Patients with low VLPP were more likely to be older (p = 0.036), and have pure SUI (p = 0.019).

TOS is effective for patients with low VLPP. Women with SUI and ISD without a fixed urethra should be considered candidates for TOS. The use of intravenous sedation during sling placement allows the surgeon to perform an intraoperative cough test, permitting tensioning of the TOS in relation to the patient's ISD.