????? ?? ???? ???? ?? : TVT, TOT

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INTRODUCTION

• ?? 30??? ??
• ?? 20.4-63.4
• 41.2 ??? ??. ?? ?? ??? ??
• ??????? ?????? ??
• ???? ?? ??
• ????? ?? ???? ???? ?? TVT, TOT

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• Pressure transmission ??
• ??? ??? ?? ?? ???? ???? ???? ???
• ????? ??? ??? ?? ??? ???? ??? ???
• ???? ??? ?? (Burch, Raz)

• Integral theory (Ulmsten, 1993)

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Anatomy based on appearance
Pubo-urethral Ligament (PUL)
Bladder
Vagina
Symphysis
Rectum
Levator plate
Pubococcygeous
Longitudinal Muscle of the Anus
External anal sphincter
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The Mid-Urethra Concept
Integral Theory (Petros Ulmsten,1993 )
With abdominal pressure
Incontinent
Continent
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The Hammock hypothesis
PUL

• Normal pubourethral ligaments form suburethral
  hammock of support
• Downward force against this hammock causes
  urethral compression
• and prevents bladder neck descent
• TOS restores anatomical pubourethral ligament
  support

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Physiology
PS Pubic Symphysis PCM Pubo-coccygeus
muscle LP Levator Plate LMA Longitudinal muscle
of the anus H Hammock A Closed S Open
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Changing trend

• IN THE PAST...
• AI Bladder Neck Suspension -
  Burch, Stamy, MMK, Raz.
• ISD Sling

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Changing trend

• IN THE PAST...
• AI Bladder Neck Suspension -
  Burch, Stamy, MMK, Raz.
• ISD Sling

• NOW...
• All SLING esp. Mid-urethral Sling

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Goal of SUI Surgery Current Concepts

• Restore and/or reinforce the pubo-urethral
  ligaments sub-urethral vaginal hammock at the
  mid-urethra
• Reinforce the paraurethral connective tissue

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Mid-urethral Sling Procedure

• Vaginal approach
• TVT (Gynecare)
• IRIS (Made in Korea)
• IVS (Tyco)
• Suprapubic approach
• SPARC (AMS)
• Lateral approach
• Trans-obturator sling

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Trans-obturator Sling

• MonarcTM subfascial hammock AMS
• ObtapeR Mentor

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Rationale for a Transobturator Approach

• Avoiding the retropubic space reduces the
• risk of perforation to the bladder, bowel
• and major pelvic vessels
• Hammock-shape mesh with lateral fixation
• mimics normal pubourethral support

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TOS Normal PU Ligament
LA Levator Ani U Urethra V Vagina
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Obturator Anatomy
Obturator Canal
Ilium
Obturator Foramen
Ischiopubic Ramus
Pubic Symphysis
Ischium
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Obturator Anatomy
Adductor longus insertion
Urethra
Obturator canal
SAFE ENTRY ZONE FOR NEEDLE INSERTION
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Support Vector of TOT vs. TVT/SPARC
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Needle Passage
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Position of Mesh
clitoris
urethral meatus
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Position of Mesh
Pubic Symphysis
Mesh
Obturator Canal
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Summary

• Mimics normal pubourethral support
• Course of needle path is 3 cm to 4 cm from
• obturator canal and neurovascular bundle
• Short blind needle passage
• Avoidance of retropubic needle passage reduces
• reliance on cystoscopy in most cases

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TOT ?? ?? ?? ( No learning curve)
???? ??? 80
???? ??? 20
???? ?? !!!
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TVT SECUR PRODUCT
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?? ????? ??
? 53?
??? 9? (17)
???? ?? 44? (83)
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?? ????? ??
??? ??? 3?/mon, ????, ???(x) ??? ???
3?/mon, ????, ???(x), retention ??, TOT ??? ???
5?/mon (60?/yr), ????, ???(x), TOT ??? ???
5-10?/mon (?120), ????, ???(10), TOT ??? ???
3-4?/mon (? 40), ??, ???(x), TOT ??? ???
12?/mon, ????, ???(1?), TOT ??? ??? 50-60/yr,
??, ???(??), TOT ??? ??? ????? ??, IV ??,
???(?????), TOT ??? ??? 10-12/mon (67?/6mon),
??,???(x), TOT ?????? ??? ?? (50??), ??? GY?
??. ??? ??? 10?, ??? ? ?, ??, ??, ???(????)

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• Complication

Urethral injury 5
Vaginal wound problem 3
Vagina laceration 2
Urge incontinence 2
Retention 1
Bladder injury 1
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Thank you for your attention !!!