Transobturator Tape (TOT) sling procedure

The transobturator tape (TOT) sling procedure is a surgical treatment for female urinary stress incontinence. The aim of the procedure is to provide support to the bladder by placing a synthetic mesh (which acts as a sling) under the mid-portion of the bladder neck.

Urinary incontinence is the complaint of any involuntary loss of urine. There are 4 types of urinary incontinence: urge incontinence, overflow incontinence, functional incontinence and the most common stress incontinence.

Stress urinary incontinence means the involuntary leakage of urine during exertion (exercise or movements such as coughing, sneezing, and laughing).  It is often seen in women after middle age with repeated pregnancies and vaginal deliveries.

The principal treatment of stress urinary incontinence is proper suspension and support of the vesico-urethral segment in a normal position.

The treatment consists of conservative therapies like pelvic floor muscle training or pharmacologic treatment.

If the conservative treatments didn’t take effect and the leaking is still causing complaints, the TOT surgery is recommended.

TOT sling procedure is prepared in spinal anesthesia. The patient is placed in modified lithotomy position and catheterized to empty the bladder.

Two vertical lines are drawn on each side of the labial fold. At the base of the clitoris, a 2 cm horizontal line is drawn. After retracting the labial fold an incision of 1.5 cm is made 1 cm proximal to the external urethral meatus in the anterior vaginal wall.

Just behind urethra lateral dissection is made on both sides elevating the vaginal wall and taking care not to injure urethra and bladder.

Tip of the TOT needle is brought out from the incision in the vaginal wall and threads of the TOT tape are fed through the eye of the TOT needle.

TOT needle is withdrawn through the same path taking along with it one end of the TOT tape through the incision in the groin. The same procedure is repeated on the other side also.

The urethral segment is correctly placed in relation to the second part of the urethra maintaining the distance of one instrument thickness between the tape and the urethra. Both ends of the TOT tape are cut just beneath the skin incisions in the groin. Vaginal cavity is packed with betadine soaked gauze, which is to be removed on the 1st postoperative day. After the first spontaneous urination, the urinary bladder is checked with ultrasound. If there is no residual urine, the patient can leave the hospital.

The great advantage of the TOT sling procedure is the effective treatment of the initial cause. The success rate of the TOT surgery is 80-85% in terms of total continence, which means the termination of urine leaking.

The frequency of complications is negligible compared to the number of surgeries. After the surgery urge symptom (de novo urge symptom) could occur, which means the sudden urge to urination. This condition is temporary and could terminate spontaneously, but in some cases, medical treatment is needed. After the surgery bleeding, the rejection of the tape, erosion of the urethra, vagina, or the urinary bladder by the tape could occur.

Pre-operatively your urologist evaluates your results after thorough history taking, clinical examination and different diagnostic test.

He explains the nature of the procedure and the principle behind it, and any complication(s) (intra/postoperative) will be noted. The prescribed medications should be taken at the specified time and the necessary preoperative test will be taken before the surgery.

The wounds may remain swollen, sensitive and painful for a few days after the surgery, initially keep it away from water. Bruising may occur on the thigh area and minimal blood leaking is normal from the vagina in the first few days. If no early complications occur, the patient can leave the hospital on the 2nd day of the surgery. The removal of the stitches is not needed as they will absorb after 4-6 weeks.

Patients are advised to start normal daily routine activities after discharge from the hospital, to maintain local hygiene, to avoid straining and lifting heavy weights for 3 – 4 weeks, and to avoid sexual activity for 4 – 6 weeks.

Like every surgical intervention, the TOT sling procedure may have risks and complications. Very rarely the operational area may become inflamed, infected, and the adjacent anatomical structures – tendons, muscles, blood vessels, nerves, neighboring bones – may get injured. In some cases, pharmaceutical treatment may be needed, while in more severe cases, the operation might have to be repeated.

Meatotomy is performed when special conditions are present (like meatal stenosis) and needs to be treated. In these cases, the urethra is narrowed which is why surgery is important to ensure problem-free urination

The price of a TOT sling procedure is composed of several elements. At our hospital, the listed TOT sling surgery cost includes the surgery and the check-up one week after surgery.

We offer a separate consultation package for the first consultation, where the urologist specialist decides if the surgery is recommended. The necessary pre-operative examinations can be taken at our hospital, which has an additional cost.

Our goal is to offer you the most reasonable TOT sling procedure price for the highest quality service and care.