Abstract The transobturator sling procedure is a relatively new technique as compared to the retropubic version. The functional differences between these two procedures are largely unknown. Two cases of failed transobturator slings are reported. In both cases, the procedure was done under local anesthesia and a cough stress test was performed to adjust the tape. The transobturator slings were unable to stop the leakage and we replaced them with the retropubic versions, which were successful. Even when pulled very tightly, some transobturator slings will fail to stop stress incontinence that is amenable to cure from a typically placed &quot;tension-free&quot; retropubic sling. The cough stress test can identify such cases

Moses Mukai

Patrick J Culligan

Ramzi Aboujaoude

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CASE REPORT
Two cases illustrating a potential difference
between transobturator and retropubic slings
Moses Mukai & Ramzi Aboujaoude & Patrick J. Culligan
Received: 28 June 2006 /Accepted: 11 November 2006
# International Urogynecology Journal 2006
Abstract The transobturator sling procedure is a relatively
new technique as compared to the retropubic version. The
functional differences between these two procedures are
largely unknown. Two cases of failed transobturator slings
are reported. In both cases, the procedure was done under
local anesthesia and a cough stress test was performed to
adjust the tape. The transobturator slings were unable to
stop the leakage and we replaced them with the retropubic
versions, which were successful. Even when pulled very
tightly, some transobturator slings will fail to stop stress
incontinence that is amenable to cure from a typically
placed “tension-free” retropubic sling. The cough stress test
can identify such cases.
Keywords Suburethral sling . Cough stress test .
Stress urinary incontinence . Local anesthesia
Introduction
Stress urinary incontinence is defined by the International
Continence Society as involuntary leakage on effort,
exertion, sneezing, and/or coughing [1]. The overall
prevalence of urinary incontinence ranges from 33 to 41%
of women with the highest prevalence among the elderly
[2].
The midurethral sling supports the urethra, prevents its
descent during increases in abdominal pressure, and
provides urethral compression [3]. These slings such as
the tension-free vaginal tape are widely used and appear to
be as effective as the Burch colposuspension for the
treatment of urinary stress incontinence [4].
Recently, many surgeons have been using the trans-
obturator sling as an alternative approach to midurethral
sling placement. The proposed benefits of the transobtu-
rator sling relative to the retropubic sling center around a
theoretical decreased risk of bladder perforation or vascular
injury. However, both of these complications have been
reported with transobturator slings [5, 6].
We report two cases that illustrate the potential differ-
ence between midurethral slings placed via retropubic and
transobturator techniques.
Case report
Case 1
The first case is a 56-year-old patient whose medical
history was remarkable for one vaginal delivery 20 years
before presenting at our facility. Two years after that
vaginal delivery, she underwent a Marshall–Marchetti–
Krantz procedure which cured her stress urinary inconti-
nence for approximately 7 years. Upon presentation to our
clinic, the patient complained of daily stress incontinence.
Her leakage was so bothersome that she was restricting her
fluid intake and increasing her voiding frequency, in hope
of minimizing the incontinence episodes. She was also
experiencing one to two episodes of nocturia each night.
Her physical exam was remarkable for urethral hyper-
mobility which was obvious while visualizing her anterior
Int Urogynecol J
DOI 10.1007/s00192-006-0273-9
R. Aboujaoude
University of Medicine and Dentistry of New Jersey,
Newark, NJ, USA
M. Mukai (*) : P. J. Culligan
Division of Urogynecology and Pelvic Reconstructive Surgery,
Atlantic Health System,
95 Madison Ave., Suite 204,
Morristown, NJ 07962, USA
e-mail: HarleyMukai@yahoo.com
compartment during Valsalva maneuver. In our practice, the
cotton swab test is reserved for patients who do not have
obvious urethral hypermobility on visual exam. This
patient’s urethral mobility was obviously greater than 45°,
so no cotton swab test was performed. Physical exam
revealed no evidence of prolapse or neurologic abnormal-
ities. Multichannel urodynamic studies demonstrated a
maximum cystometric capacity of 385 ml, and urodynamic
stress incontinence was demonstrated with a leak point
pressure of 73 cm H2O.
Due to the theoretical increased risk of bladder perfora-
tion among women with a previous Marshall–Marchetti–
Krantz procedure, we offered her a transobturator sling
(Uretex TO® CR Bard, Murray Hill, NJ, USA).
In the operating room, the patient was given adequate
intravenous conscious sedation. A local anesthetic solution
of lidocaine and marcaine was injected along the entire
path of the device using a 22-gauge spinal needle. The mid
portion of her urethra was identified by palpation against the
Foley catheter. Sharp dissection was used to create tunnels
underneath the vaginal epithelium to the level of the inferior
pubic rami bilaterally without breaking through the perineal
membrane. Under direct finger guidance, both trocars were
placed using the outside to inside technique. Cystoscopy
indicated there were no defects or lesions within the bladder.
The transobturator sling was then placed and the conscious
sedation was discontinued. The bladder was filled to a volume
of 250 ml and the patient was asked to cough vigorously
thereby demonstrating her leakage. Increasing the tension on
the sling failed to stop the patient’s leakage even when the
sling was pulled very tight. Therefore the transobturator sling
was removed and a retropubic sling (Uretex® CR Bard,
Murray Hill, NJ, USA) was placed. To do so, the exact same
vaginal “tunnels” created for the transobturator sling were
used to insert the retropubic trocars. Cystoscopy was again
normal. The tension was adequately set via the cough stress
test. The retropubic sling proved successful with the “usual”
setting. In other words, a very tight setting on the trans-
obturator sling could not stop leakage that was readily
controlled with a typical “tension-free” setting on the
retropubic sling.
The patient was discharged home 4 h later after a
satisfactory voiding trial in the recovery area. That voiding
trial consisted of a spontaneous void greater than 300 ml
and a postvoid residual amount of 30 ml. At the 3-month
postoperative interval, the patient was voiding well and
having no stress incontinence symptoms.
Case 2
The second case was a 37-year-old patient who had two
previous vaginal deliveries. Six years before her presenta-
tion to our clinic, the patient had undergone a pubovaginal
sling with bone anchor fixation. This sling alleviated her
stress incontinence for only 6 months. One year later—also
before her presentation at our clinic—she underwent a
periurethral collagen injection which gave her no benefit.
On presentation to our clinic, she was experiencing
incontinence on a daily basis with coughing, sneezing, and
routine physical activity. She was unable to exercise, had
decreased her fluid intake and increased her voluntary
voiding frequency—both in a conscious effort to diminish
the size of her leakage episodes.
On physical exam, her anterior compartment suggested
very little urethral mobility during cough and Valsalva
maneuver. Minimal urethral mobility was verified with a
cotton swab angle of negative 15° with straining. Her
multichannel urodynamic studies demonstrated stress in-
continence with a leak point pressure of 85-cm H2O and a
maximum cystometric capacity of 515 ml.
She declined repeat periurethral injections and was
therefore offered a transobturator sling. In the operating
room, the patient was given adequate conscious sedation
and local anesthesia using the same techniques described in
case 1.
Under direct finger guidance, the transobturator sling
(Uretex TO® CR Bard, Murray Hill, NJ, USA) was placed
after the usual outside to inside technique. Cystoscopy
indicated that there was no damage or other abnormal
findings within the bladder. The bladder was filled to a
volume of 250 ml and the conscious sedation was
discontinued. The cough test was used to set sling tension.
Increasing the tension on the sling failed to stop the
patient’s leakage even when the sling was pulled very tight.
The transobturator sling was removed and replaced by a
retropubic sling (Uretex® CR Bard, Murray Hill, NJ, USA)
in the usual fashion using the exact same “tunnels”
previously dissected for the transobturator sling. Cystosco-
py was again normal. The tension was adequately set via
the cough test to stop the leakage. At this time, the sling
was successful with a “tension-free” setting.
Four hours later, the patient was discharged after she
passed her voiding trial. She spontaneously voided greater
than 350 ml and her postvoid residual amount was 60 ml.
Her recovery was uneventful except for bilateral self-
limited superficial cellulitis in the groin area at the level of
the transobturator sling incisions. At the 5-month postop-
erative interval, the patient was voiding well and having no
stress incontinence symptoms.
Discussion
We report two cases of recurrent stress urinary inconti-
nence. Both patients underwent a transobturator sling
placed under local anesthesia. These tapes were elevated
Int Urogynecol J
incrementally but failed to restore continence. Therefore,
these transobturator procedures were converted to retro-
pubic procedures in which successful continence was easily
obtained. For both patients, no amount of tension on the
transobturator sling could produce dryness. In other words,
each transobturator sling was placed under quite a bit of
tension and still could not stop the leakage produced during
the cough stress test. However, for each patient, a
retropubic sling placed via the same vaginal incision was
able to stop the leakage while in a “tension-free” position.
In 2001, Delorme described the technique of transobturator
placement for midurethral slings. The sling is inserted around
the inferior ischiopubic ramus in a relatively horizontal plane
through the obturator foramen [7]. In contrast, the retropubic
sling is placed in a more vertical plane. While many
surgeons believe the transobturator slings to be less
obstructive than the retropubic slings, little objective
evidence supports these beliefs. Nevertheless, some surgeons
tend to use transobturator slings for “routine” stress
incontinence patients or for those patients with a perceived
increased risk of postoperative voiding dysfunction. Like-
wise, some surgeons reserve retropubic slings for patients
with more severe incontinence.
These two cases support the idea that transobturator
slings are less obstructive than retropubic slings. We would
not have known that such a difference existed in these
patients if we had not used local anesthesia and the cough
stress test.
Some evidence suggests other advantages of the cough
stress test for sling placement. In a retrospective cohort
study, Murphy et al. [8], found better long-term success
among patients who underwent retropubic sling via local
anesthesia as compared to those who had general anesthesia
and no cough stress test.
In that study, 132 patients were followed for an average
of 32 months (range 18–48). Seventy-four (46.5%) women
had their sling placed under general anesthesia, and the 85
(53.5%) remaining subjects received local analgesia.
Greater improvements in stress incontinence were seen
when the suburethral sling was placed under local anesthe-
sia and adjusted using the cough stress test. Based on this
study, we believe that the cough stress test under local
anesthesia is a helpful step in predicting the procedure
outcome. In the two cases presented above, the patients
were likely to have experienced poor surgical results if their
procedures had been performed under general anesthesia
without benefit of the cough test.
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Int Urogynecol J


Two cases illustrating a potential difference between transobturator and retropubic slings

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Two cases illustrating a potential difference between transobturator and retropubic slings

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