Transobturator Tape Urethral Sling Procedure Under Local Anesthesia

CASEREPORTTransobturator TapeUrethral Sling ProcedureUnder Local Anesthesia:A StudyAl Muzzammel, MDWhen performed in the office settingwith local anesthesia, thisprocedure for stress urinary incontinenceallows for more accurateplacement and, if necessary,immediate adjustment of the tapeto optimize the outcome for eachindividual patient.Recently, there has been a tendencyamong health care providers of allspecialties to perform more proceduresin an outpatient or officesetting, both to reduce the cost and toincrease patient convenience. In gynecology,such procedures include hysteroscopy,endometrial ablation, and sterilization viamicroinsert tubal occlusion. The study presentedhere examines the possibility ofperforming a midurethral sling procedurefor female urinary stress incontinenceusing transobturator tape (TOT) underlocal anesthesia without sedation in anoffice setting.MATERIALS AND METHODSThis initial series involved 15 women aged31 to 65 years with clinical features of urinarystress incontinence. All subjectsAl Muzzammel, MD, is Attending Physician, Departmentof Obstetrics and Gynecology, Fairfax Hospital, FallsChurch, VA.underwent the midurethral TOT slingprocedure under local anesthesia in anoffice setting between December 2006and October 2007.Patients were advised to consumeonly liquids on the morningof surgery. After arrival at theoffice and 30 to 60 minutes priorto the procedure, they receivednaproxen, 550 mg orally, andeither cephalexin, 500 mg orally,or ceftriaxone, 1 g intramuscularly.Lidocaine solution, a total of300 to 350 mL, was then injectedin the operating field. 7 This dilute0.15% anesthetic solution wasprepared by mixing 150 mL of 1%lidocaine with epinephrine and40 mL of sodium bicarbonate into1000 mL of lactated Ringer’s solution;this is a modified Kleintumescent local anesthetic solution that isnow widely used for liposuction. It wasultimately injected in 5 different locationsduring the TOT sling procedure.The patients were placed on an electricallypowered table in the dorsolithotomyposition using regular gynecologic stirrups.An intravenous (IV) line of 1000 mLof lactated Ringer’s solution was initiated.The patient’s external genitalia andvagina were prepared with povidoneiodinesolution, and she was draped in thestandard sterile fashion. A Foley catheterwas placed, and the bladder drained.FOCUSPOINTAbout 30 to50 mL of the 0.15%lidocaine solutionwas injected intothe anterior vaginalwall, extendingfrom the urethra tothe lateral vaginalwall.The Female Patient | VOL 33 APRIL 2008 69

CASEREPORTTransobturator Tape Urethral Sling ProcedureFIGURE 1. Local anesthesia infiltration of anterior vaginal wall.Courtesy of Al Muzzammel, MD.FIGURE 2. Local anesthesia infiltration behind anterior-inferiorpubic ramus.Courtesy of Al Muzzammel, MD.FOCUSPOINTThis series utilizedtwo different brandsof TOT; both brandsappeared to performequally well duringthe procedures.About 30 to 50 mL of the 0.15% lidocainesolution was injected into the anterior vaginalwall, extending from the urethra to thelateral vaginal wall (Figure 1).A longitudinal incision of 2 to 3 cmwas made below the midurethra,between two Ellis clamps. 1,6 Theanterior vaginal mucosa wasseparated from the underlyingurethra with sharp and blunt dissection,and the dissection wasextended laterally up to theanterior-inferior pubic ramus 1 onboth sides. Another 25 to 30 mLof 0.15% lidocaine solution wasinjected into the space behindthe anterior-inferior pubic ramuson both sides using a 7-in spinalneedle through a pudendal needleguide (Figure 2).Next, 2 injection locations weremarked in the groin at the levelof the clitoris, just below theinsertion of the adductor longus. Theskin was infiltrated with 1 mL of the0.15% lidocaine solution using a 30-Gneedle. One finger was placed behind theanterior-inferior pubic ramus throughthe dissected space behind the anteriorvaginal wall. About 100 to 125 mL of0.15% lidocaine solution was injected,extending from the skin to the lateralaspect of the anterior-inferior pubicramus (Figure 3). This injection was performedbilaterally.This series utilized 2 different brands ofTOT; 3 both brands appeared to performequally well during the procedures. Alsoused were both rounded and helical 1 trocarneedles. Stab incisions were made oneither side of the groin in the previouslymarked sites at the level of the clitoris. 6The needle trocars were introduced andpassed through the obturator membraneat the inferior-medial aspect of the obturatorforamen and into the space behindthe anterior vaginal wall, exiting through asuburethral incision bilaterally (Figure 4). 6The TOT sling was then attached to thetrocar needles on both sides, and the tapewas pulled through on each side of thegroin until it lay loosely below the urethrafor adjustment. 1,6The bladder was filled with 200 to 400 mLof lactated Ringer’s solution, until thepatient felt the urge to void. The Foley catheterwas then removed. A stress test wasperformed with the patient in the supineposition. The tape was gradually pulledon either side until the stress test becamenegative⎯ie, no further leakage of urine.The excess length of the tape was excised70 The Female Patient | VOL 33 APRIL 2008

MuzzammelFIGURE 3. Deeper local anesthesia infiltration of transobturatortape needle tract.Courtesy of Al Muzzammel, MD.FIGURE 4. Completed transobturator tape needle placement.Courtesy of Al Muzzammel, MD.from each side of the groin. The anteriorvaginal mucosa below the urethra wasapproximated with several interruptedsutures using 3-0 polyglactin.At the completion of the procedure, thepatient was asked to stand, and the stresstest was performed again. All of the casesdemonstrated a resolution of incontinence.The patient was then asked to gointo the bathroom and completely emptythe bladder. Fourteen of the patientsvoided completely. Ultrasonographicexamination confirmed no (or minimal)residual urine. One patient was unable tovoid postprocedure. She was taken backto the operating table and, using totalaseptic precautions, the incision wasopened and further adjustment of thetape was performed with minimal relaxationof the tape below the urethra. Subsequentto this correction, the patientsuccessfully completed the voiding andstress tests.All of the patients left the office painfree in 60 to 90 minutes, without a catheter.Postoperatively, none of the patientsreported any difficulty with voiding orincontinence in follow-up of 1 to 11months. 3,5 All patients were advised totake cephalexin, 500 mg, 3 times a day forone week and naproxen, 550 mg, twicedaily for pain as needed. All patientsreported no operative pain or postoperativediscomfort. All 15 patients were comfortableenough to return to work on thefollowing day. There were no postoperativehematomas, infections, or urinarycomplications. 3,5 Four patientscomplained of numbness of theinner thigh and temporary weaknessof the adductor muscles ofthe thigh, which resolved spontaneouslywithin 30 to 60 minutes.RESULTSAll 15 subjects tolerated theTOT urethral sling procedureunder local anesthesia very well,with no pain or intraoperative/postoperative complications.They were all highly satisfiedwith the procedure and its result.DISCUSSIONThis initial study suggests that the TOTurethral sling procedure for urinarystress incontinence can be performedsuccessfully in an office setting underlocal anesthesia. An increasing numberof surgical procedures are being performedunder local anesthesia in anoffice setting to accommodate patients’FOCUSPOINTAll 15 subjectstolerated theTOT urethral slingprocedure underlocal anesthesia verywell, with no painor intraoperative/postoperativecomplications.The Female Patient | VOL 33 APRIL 2008 71

CASEREPORTTransobturator Tape Urethral Sling ProcedureFOCUSPOINTIt would not bepossible to performthe procedure asdescribed withoutusing the Kleintumescent techniquefor localanesthesia.desire for safe, more affordable procedureswith a faster recovery time. TheTOT urethral sling procedure has traditionallybeen performed in the hospitalunder level 2 or 3 general anesthesia orspinal anesthesia. The author’s objectivewas to perform this procedure in anoffice setting under local anesthesiawith no sedation. After appropriateexplanation, most patients welcomed theidea of undergoing the procedure underlocal anesthesia.There are reports of the TOT urethralsling procedure being performed underlocal anesthesia with IV sedation (level 2general anesthesia) in a hospital setting.To date, there has been no literaturedescribing this procedure performedunder total local anesthesia inan office setting. Local anesthesiahas several advantages overgeneral and spinal anesthesiafor the TOT urethral sling procedure.The most important advantageis the ability to perform astress test during the procedureto promote more accurate placementof the sling, as opposed toarbitrary use of scissors or aHegar dilator below the urethra.The voiding and stress tests canbe performed immediately afterthe procedure to confirm accurateplacement of the tape. Inaddition, postoperative urinaryretention is a common setbackfollowing general anesthesia. Underlocal anesthesia with postoperative testing,none of these subjects needed anindwelling postoperative catheter, andall but one were able to void adequatelyafter the procedure. Immediate adjustmentof the sling resolved the voidingdifficulty in that case; this correctionwould not have been possible with generalor spinal anesthesia. Clinically, allpatients were comfortable enough toreturn to work on the following day.However, further study is required toconfirm this result. At this time, theauthor recommends 5 to 7 days’ restuntil the follow-up visit.It would not be possible to performthe procedure as described withoutusing the Klein tumescent technique forlocal anesthesia. The total lidocaine doserequired is well below the safety limit of40 mg/kg. Blood loss for all 15 subjectswas less than 50 mL per patient. 4 Anotheradvantage of this technique is the antisepticproperty of lidocaine, which mayhelp to reduce the chance of infectionunder local anesthesia. 7Another concern many surgeons mayhave is the possibility of an increased riskof infection when a foreign substance(ie, the sling) is introduced in an officesetting. However, a series of 240 breastaugmentation procedures using artificialimplants with local anesthesia in anoffice setting demonstrated no increasedrisk of infection. 7It appears that performing the TOT urethralsling procedure under local anesthesiain an office setting is a reasonableoption in experienced hands. Further studiesshould confirm this. Benefits includereduced cost, patient comfort and convenience,more accurate placement of thesling, and faster recovery.CONCLUSIONHealth care providers and patients willboth welcome the TOT urethral slingprocedure if it can be performed safelyunder local anesthesia in an office setting.As this is a minimally invasive surgicalprocedure, 2 local anesthesia isappropriate if administered carefullyand correctly. Experience with shiftingprocedures such as endometrial ablation,microinsert tubalocclusion sterilization,and liposuction from general tolocal anesthesia in an office setting hasproven that it may be possible to performmany surgical procedures safely outsidethe hospital. The benefits include immediateambulation, minimal pain, fasterrecovery, and possibly less morbidity. Asmore minimally invasive gynecologicsurgeries are performed in the office setting,it is hoped that the TOT midurethralsling procedure will become a partof this trend.72 The Female Patient | VOL 33 APRIL 2008

MuzzammelLETTER TO THE EDITORREFERENCES1. Pelosi MA II, Pelosi MA III. New transobturatorsling procedure reducesinjury. OBG Management. 2003;15(7).www.obgmanagement.com/article_pages.asp?AID=3168&UID=. Accessed December27, 2007.2. Delorme E. [Transobturator urethralsuspension: mini-invasive procedure inthe treatment of stress urinary incontinencein women.] Prog Urol. 2001;11(6):1306-1313.3. Wang AC, Lin YH, Tseng LH, Chih SY, LeeCJ. Prospective randomized comparisonof transobturator suburethral sling(Monarc) vs suprapubic arc (Sparc) slingprocedures for female urodynamic stressincontinence. Int Urogynecol J PelvicFloor Dysfunct. 2006;17(5):439-443. Epub2005 Dec 3.4. Chandra Singh J, Kekre NS. Stress urinaryincontinence: TVT or TOT? Indian J Urol.2005;21(2): 127-128.5. deTayrac R, Deffieux X, Droupy S, Chauveaud-LamblingA, Calvanèse-Benamour L,Fernandez H. A prospective randomizedtrial comparing tension-free vaginal tapeand transobturator suburethral tape forsurgical treatment of stress urinaryincontinence. Am J Obstet Gynecol. 2004;190(3):602-608.6. Mourtzinos A, Maher MG, Raz S. Transobturatorversus retropubic suburethraltapes for stress urinary incontinence. NatClin Pract Urol. 2006;3(2):62-63.7. Kaplan B. Breast augmentation underlocal anesthesia. Am J Cosmetic Surgery.2004;21(2):69-72.TO THE EDITOR:I read your article, “Breast Cancer and Risk: A ClinicalTranslation” with interest. 1 I noticed the absence of electiveor induced abortion as a risk factor for breast cancer. Thelatest information published out of Great Britain usingnational cancer registration data shows that abortion is amajor risk factor in the development of breast cancer. 2 Certainly,this needs to be taken seriously and at least a mentionof abortion as a risk factor is warranted.Byron C. Calhoun, MD, MBACharleston, WVTHE AUTHOR REPONDS:Thank you for your letter and for pointing out the recent articlefrom Great Britain. 2 The issue of induced abortion and itsrelationship to breast cancer is not new. Indeed, in 2003,ACOG published a Committee Opinion on the subject, concludingthat studies have been inconsistent and are difficult tointerpret because of methodology. 3 They also note that themore rigorous studies argue against a causal relationship. Thestudy by Carroll is a retrospective analysis of data on bothabortion and breast cancer. 2 While the “n” is significant, andthe numbers intriguing, this is still an observational study andtherefore, can only raise a hypothesis that must then be testedwith a prospective trial. In the absence of such data, all we cansay, based on the Carroll study, is that while there may be anassociation, causality has not been proven. Until those dataare clear, I feel it to be neither prudent, nor scientifically valid,to include induced abortion as a risk factor for breast cancer.Given the ongoing interest in this issue, I am sure that weall will continue to follow the literature and use our bestscientific judgment when counseling women.Vivian M. Dickerson, MDEditor-in-ChiefThe Female PatientREFERENCES1. Dickerson, VM. Breast Cancer and Risk: A Clinical Translation. The FemalePatient. 2008;33(1):18-25.2. Carroll, PS. The Breast Cancer Epidemic: Modeling and Forecasts Based onAbortion and Other Risk Factors. Journal of American Physicians & Surgeons.2007;12(3):72-78.3. American College of Obstetricians and Gynecologists. ACOG CommitteeOpinion No. 285, August 2003: Induced abortion and breast cancer risk.Obstet Gynecol. 2003;102(2):433-435.The Female Patient | VOL 33 APRIL 2008 73