الفهرس 
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Abstract
In MUS (mid urethral sling procedures), the sling
provides dynamic kinking of the urethra when abdominal
pressures increase, while maintaining stability at the resting
phase, consequently preventing urinary incontinence (Choi
and Lee, 2004)
Urethral obstruction following anti-incontinence surgery
often presents as urinary retention or obstructive voiding
symptoms (hesitancy, incomplete bladder emptying, weak
urinary stream, urinary straining), but many patients present
primarily with irritative voiding symptoms (urgency, frequency,
nocturia) and urge incontinence. Recurrent urinary tract
infections may also point to occult outlet obstruction. Upon
further evaluation, these patients usually demonstrate elevated
post void residuals (Goldman et al., 1999).
Although the surgical procedures to correct SUI (stress
urinary incontinence) have been reasonably successful, there are
potential complications including persistent stress urinary
incontinence, urethral erosion, de novo detrusor instability, and
urethral obstruction (Goldman et al., 1999).
Tension-free vaginal tape (TVT), which is supposed not to
cause obstruction because it ideally is placed tension free, is not
immune from inducing iatrogenic urethral obstruction requiring
tape division (Romanzi and Blaivas, 2000; Choe, 2001).
The obstruction then leads to obstructive and/or irritative
voiding symptoms or urge incontinence. These symptoms can be
very distressing to the patient, as she has now traded stress
urinary incontinence for what many consider more problematic
and unpredictable-urge incontinence. Thus, the patient should be
informed preoperatively about the possible post-operative
complications and the plan to treat them if the complications
arise (Goldman et al., 1999).
The high, long-term success rate of TVT ranges from 84%
to 95% (Meschia et al., 2001; Doo et al., 2006) but is associated
with concerns about operating safety in terms of risk of injuries
to the bowel and major blood vessels, and of bladder and urethral
perforation. TVT is also associated with postoperative voiding
difficulties such as transient urine retention in 8–17% (Ulmsten,
2001; deTayracet al., 2004) of patients and urgency in 5–15%
(Boustead, 2002; deTayracet al., 2004).
To avoid the complications associated with the retropubic
route, Delorme, (2001) advocated the transobturator route
(TOT). Insertion through the obturator muscles reproduces the
natural suspension fascia of the urethra while preserving the retro
pubic space by avoiding intrapelvic and retro pubic blind
passages. Consequently, the TOT approach seems to limit the
risks of visceral and vesical lesions and, more importantly, of
bowel and vascular injuries. In a preliminary study, TOT was
associated with a high success rate, no bladder injury, and few
perioperative complications in women with SUI. Similar results
were achieved by Krauth et al. (2005) in a large series of
women.
The reported results are very close to those reported in
most of the observational series of tension-free vaginal tape
(Costa and Delmas, 2004), and objective cure rates are as good
as those quoted for the randomized controlled trial of
colposuspension versus tension-free vaginal tape (Ward and
Hiltcn, 2004).
Comparative studies of TOT versus TVT recently reported
no different in efficacy (Mansoor et al., 2003; deTayrac et al.,
2004).
Our study was a retrospective and observational study
on 90 women who underwent TVT and TOT.
Classified into:
The first group included 37 patients who had TVT procedure
done for them.
The second group included 53 patients who had TOT
procedure done for them in both groups data was retrieved
from patients’ files in the department of urogynecology and
included their preoperative urodynamic study.
The primary outcome measurement of our study was to
evaluate voiding dysfunction after the two procedures in
treatment of stress urinary incontinence. We evaluated
comprehensive risk factors that may be predictive of
postoperative voiding dysfunction, and factors having impact
on patient satisfaction after the TVT and TOT procedures.
Thirty seven patients underwent TVT. Mean age 42.62
(±8.87), and 53 patients underwent TOT with mean age 43.66
(±9.59) with no significant difference between both procedures
and as regard age and other parameters. We found that
Voiding dysfunction occurred in 16 patients (43.2%) after TVT
and in 14 patients (26.4%) after TOT with a highly significant
difference between both procedures at a mean years follow up
4.21 years, 3.34 years respectively.
Classified into; denovo urgency occurred in 6 patients
(16.2%) after TVT and 8 patients (15.1%) after TOT with no
significant difference between both procedures, denovo
frequency occurred in 8 patients (21.6%) after TVT and 11
patients (20.8%) after TOT with no significant difference
between both procedures, urge incontinence occurred in 3
patients (8.1%) after TVT and 3 patients (5.7%) after TOT
with no significant difference between both procedures,
immediate urinary retension occurred in 6 patients (16.2%)
after TVT and no one after TOT with high significant
difference between both procedures, sense of incomplete
bladder evacuation occurred in 2 patients (5.4%) after TVT
and 3 patients (5.7%) after TOT with no significant difference
between both procedures, and lastly we found that
interrupted urinary stream occurred in 1 patient (2.7%) after
TVT and 3 patients (5.7%) after TOT with no significant
difference between both procedures. The explanation of this
high incidence of voiding dysfunction in our study was due to
small number of patients enrolled. Boustead, (2002) reported
that 1.5-20% of patients after TVT can develop postoperative
voiding dysfunction.
We found also in our study a subjective post operative
voiding dysfunction as regard urodynamics only without
manifestations as there were 5 patients in TVT and 1 patient in
TOT had high RV (post voidresidual) and low MFR without
voiding troubles manifestations.
The secondary outcome measurement of our study was
evaluation of time of operation, associated procedures, cure
rate and complications after both procedures.
As regard operative time we found that the mean
operative time of TVT procedure was 30.27 minutes and that
of TOT procedure was 18.02 minutes
As regard cure rate after TVT and TOT:
The current study shows that 14 patients (15.56%)
among 90 patients included in this study presented with
residual incontinence 7 of them belonged to TVT (4 patients
had stress urinary incontinence and 3 patients had urge
incontinence) and 7 belonged to TOT (4 patients had stress
urinary incontinence and 3 patients had urge incontinence)
with no significant difference between both groups
Also we found that the objective cure rate after TVT
procedure was 81.1% and in TOT was 86.8% after mean years
follow up 4.21 years and 3.34 years respectivly
It was noted in our study that bladder injury and
perforation occurred in 3(8.1%) cases after TVT one of them
had tape removal and kelly’s suture was done another one had
cystoscopic bladder repaire and the last one managed
conservatively by urinary catheter in contrast to no bladder
injury after TOT this injury happened earlier in our center that
may explained by rising of surgeons skills.