Nghiên cứu ứng dụng và kết quả phẫu thuật đặt dải băng qua lỗ bịt (trans obturator tape TOT) điều trị tiểu không kiểm soát khi gắng sức ở phụ nữ tt tiếng anh

1
MINISTRY OF EDUCATION AND
TRAINING

MINISTRY OF NATIONAL
DEFENSE

VIETNAM MILITARY MEDICAL UNIVERSITY

MAI TRONG HUNG

RESEARCH ON THE APPLICATION AND OPERATIVE
OUTCOMES OF THE TRANSOBURATOR TAPE (TOT)
FOR FEMALE STRESS URINARY INCONTINENCE
(SUI)

Majority: Surgery
Code: 9720104
ABSTRACT OF THESIS OF DOCTOR OF MEDICINE

HANOI, 2020


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The study was complete at VIETNAM MILITARY
MEDICAL UNIVERSITY

Instructors:
1. M.D., Ph.D., Assoc. Prof Vu Huy

Nung

2. M.D., Ph.D., Assoc. Prof Le Anh

Tuan
Debator 1
Debator 2
Debator 3

: M.D., Ph.D., Assoc. Prof Trieu Trieu Duong
: M.D., Ph.D., Assoc. Prof Nguyen Ngoc Minh
: M.D., Ph.D., Assoc. Prof Nguyen Phu Viet

The thesis will be dabated and protected in front of the
University-level Dissertation Council of Vietnam Military
Medical University
At……………………………………….….. year

For further information:
1. National Library
2. Library of Vietnam Military Medical
University
3. Library of Central Medicine Information


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LIST OF RELEVANT STUDIES OF THE AUTHORS
UNDER THE PUBLICATION
1. Mai Trong Hung, Vu Huy Nung, Le Anh Tuan (2020)
“Assessment on the female SUI treatment outcome by
the Transoburator Tape (TOT) surgery”, Vietnam
Journal of Medicine and Pharmacy, Edition 1, p.1;

2. Mai Trong Hung, Vu Huy Nung, Le Anh Tuan (2020)
“Some indication factors related to the Transoburator
Tape (TOT) surgery in the female SUI treatment”,
Military Journal of Medicine and Pharmacy, Edition 2,
p.127;
3. Mai Trong Hung, Vu Huy Nung, Le Anh Tuan (2020)
“Factors related to indications of trans - Obturator tape
surgery for the treatment of female stress incontinence”.
Journal of military pharmaco - Medicine N02-2020


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INTRODUCTION
Urinary incontinence (UI) is “the involuntary leakage of
urine”. Urinary incontinence is more common with an estimated 2535% to suffer from it, among them, Stress Urinary Incontinence
(SUI) accounted for 53%.
In 1996, Ulmsten introduced a technique named the Tensionfree Vaginal Tape (TVT) and in 2003, De Lorme developed
Transobturator tape (TOT) which the tape is introduced through the
obturator foramen, made a big change in the strategy of treating
Stress Urinary Incontinence. Up to now, it has become the firstpriority technique in the treatment effort of SUI because the method
is easy to implement, less intrusive, safe and highly effective.
In Vietnam, the surgery of Stress Urinary Incontinence by the
method of Transobturator Tape (TOT) has only been applied in recent
years. It is required to carry out further studies to evaluate the longterm outcome of the surgery, and to reduce the rate of complications
of surgery being a practical requirement as well. Resulted in the
afore-said matter, I carried out this research thesis: “Research in
application and surgical outcome of Transobturator Tape (TOT)
in the treatment of female Stress Urinary Incontinence (SUI)”
with 2 targets:

1. Comment on some relevant clinical and subclinical features to
the technique of sub urethral transobturator tape in female SUI
at Hanoi Obstetrics and Gynecology Hospital.

2. Assessment of surgical outcomes of the Transobturator vaginal
tape (TOT) in female patients.


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Necessity of the thesis
Rates of UI accounted for 25 - 45% of the population, in
which SUI is made up for 53%. The demand for surgical treatment of
female SUI has been increasing rapidly in Vietnam. The method of
TOT is considered to be the first priority treatment for such patients.
The safety and effectiveness of the method in the application to
Vietnamese patients become an urgent and practical matter that
required to be studied further.
New contribution of the thesis

-

Carry the technical procedure with 12 simple and easy-toimplement steps.

-

Implement the long-term research and follow-up, further
assessment on post-surgical results up to 24 months.

-

Indicate some relevant factors to surgical results such as over-50
age, BMI> 23; pelvic organ prolapse grade II, urinary
incontinence grade II and group of patients with Stress Urinary
Incontinence grade III.

Thesis’ layout
The thesis consists of 115 pages, including the
following parts: introduction (2 pages), overview (33 pages),
objectives and research method (24 pages), result (23 pages),
discussion (28 pages), conclusion (2 pages), petition: 1 page.
The thesis includes 34 tables, 22 figures, 7 diagrams and 124
references (English and Vietnamese).
CHAPTER 1
OVERVIEW

1.1.

Definition and classification of Urinary Incontinence (UI)


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1.1.1. Definition of UI
According to the International Continence Society-ICS,
“Urinary incontinence (UI) is defined as any involuntary leakage of
urine and their symptoms, as a social and hygienic matter that related
to complaint of quality of life”.
1.1.2. Classification of Urinary incontinence

In the clinical perspective, urinary incontinence is classified
into 3 main types:

- Stress Urinary Incontinence (SUI): It happens when the
patient exerts pressure on his/ her abdomen by some movements as
lifting something heavy, coughing, climbing in a stair, workouts,
dance, etc. SUI results from the failure of the support system of the
pelvic floor or urethral sphincter deficiency.
- Urge urinary incontinence (UUI): You have such a sudden,
intense urge to urinate that you cannot stop the demand even in some
minutes, that resulted in an involuntary loss of urine (involuntary loss
of urine)
- Mixed incontinence: You experience a combination of SUI
and UUI.
1.2. Surgical treatment of Stress Urinary Incontinence (SUI)
* Pubovaginal sling (PVS):
The pubovaginal sling (PVS) is a technique using strips of
rectus fascia are looped below the bladder neck. It is indicated in case
that the previous surgical methods failed, or SUI with urethropexy
and kinodynamic tests shows low urethral closure pressure or low
urinary incontinence (UI) when experiencing the Valsalva maneuver.
* Burch procedure:


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The technique of hanging the bladder on Cooper's ligament.
This was considered the “gold standard” in the treatment of SUI until
the late 1990s. Research Michael E.A. compared the effectiveness of
the Burch procedure and the Fascial Sling procedure, the findings
showed that after 24 months, female patients who experienced the
Fascial sling procedure had higher successful rate than those who
experienced the Burch procedure ; however, the Burch group was
less Urinary tract infections (UTI), dysuria, SUI than the Fascial

Sling group.
* Mid-urethral slings
Mid-urethral slings are considered the gold standard surgical
procedure. This procedure is more effective than the Burch, featured
by shorter operation time and fewer postoperative complications.
In 2001, Delorme initially reported his research, using a passage to
support the urethra via the obturator fossa (the method of TOT). This
method also uses artificial needle passage such as The tension-free
vaginal tape (TVT) to support the urethra, but it is not placed in the back
of the pubis, but through the obturator fossa, aiming to avoid
complications such as bladder perforation, intestinal perforation.
1.3. Researches to assess the treatment outcomes of SUI by the
TOT surgery domestically and internationally
1.3.1. Researches to assess the treatment outcomes of SUI by the
TOT surgery internationally
In Around the world, many studies mainly compared the
outcomes of SUI treatment using the passage TVT and the TOT
surgery. A number of studies with long-term follow-up period (73
patients within 12 years) indicated that the TOT surgery was a


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highly-effective technique for the SUI treatment (82,2%). Moreover,
there were a number of studies reporting a medium-rate of recovery
after treatment with the TOT surgery (64,1%).
1.3.2. Assessments on the outcomes of the TOT in Vietnam
Le Si Trung (2006) followed the treatment of 15 patients at
Viet Phap Hospital in Hanoi: the mean operation time was 20 mins
(15-35 mins). The mean hospitalization time was 23,6 hours (12-36
hrs). There were no complications during the operation time. There

were no abnormal complications after the surgery except for one
patient of delayed wound healing. The rate of full recovery reached
93,3% (14/15); improvement by 6,7% (1/15).
Le Phuc Lien et al. (2011) reported the findings of treatment
of 22 patients: The mean operation time was 47,3 minutes, the onemonth follow-up was by 81,8%.
Nguyen Ngoc Tien (2012) reported the findings of the SUI
treatment by the TOT surgery on 126 patients at FV Hospital. It showed
that a year after hospital discharge and follow-up, the success rate was
really high (96.8%), rate of postoperative complications was made up
for 19.8%.
Nguyen Van An et al. (2012) reported the findings : the TOT
surgery results on 46 patients at Binh Dan Hospital monitored during an
mean of 23.6 months ; the success rate accounted for 97%, operative
complications consist of a case of bladder perforation and 2 cases of
vaginal perforation ; postoperative complications include a case of groin
pain, 2 cases of newly-relapsed urgency and a case of prolene mesh
extrusion.


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CHAPTER 2
RESEARCH OBJECTIVES AND METHODS
2.1. Research objectives
The research targeted the diagnosed female SUI cases, had a
positive Bonney test, undergone the transobturator tape (TOT)
surgery at the Hanoi Obstetrics and Gynecology Hospital.
Criteria for patient selection

-

Female patients are diagnosed with simple or mix stress urinary
incontinence SUI, among them, the mix SUI was prominent.

-

Carried out the TOT surgery at Hanoi Obstetrics and Gynecology
Hospital for the first time.

-

Had an adequate medical records with data to conduct some
research analysis.

-

The patients agree to participate in the research.
Criteria of patient exception

-

Female SUI mixed with severe pelvic organ prolapse (Grade
III).

-

Female SUI within 12 month after their deliveries, from the
date of surgery.
Research period
The research was conducted during the period of January 1, 2013
and May 2018.

2.2. Research methods
2.1.1. Study design
Apply the Cohort studies performed cross-section observations at
intervals through time.
2.1.2. Scope of study sample


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Apply the formula of sample size calculation for descriptive
research to a calculated ratio, n = 48.98 patients. There were 59 cases
eligible for sampling in the research.
2.3. Transobturator Tape (TOT) at Hanoi Obstetrics &
Gynecology Hospital
It means the “Inside-out” approach (TVT-O), including 12
steps:
Step 1: Lying patient position
Step 2: Hang two minor slips into thigh creases
Step 3: Insert a urinary catheter
Step 4: Position the wayout of the bilateral groin’s brackets
Step 5: Incise the vaginal wall

-

Vaginal wall incision of 1.5 cm and underneath the
meatus of 1.5 cm.

Step 6: Separate vagina and tissue around the urethra:
Step 7: Dissect by Metzenbaum dissecting scissor:
Step 8: Place the TOT needle:

Place the guiding tool for the TOT needle with the bracket.
Take a rotation from a modified handle clockwise (to the right) or
counterclockwise (to the left). All maneuvers both rotate and bring
the handle in the middle of the vertical axis. Place the cord-tipped
needle end of the urethra to the the previously defined point on the
skin. Next, remove the cord and take the TOT needle out toward the
opposite direction.
Repeat the same maneuvers to dissect the vagina and place the
needle on the opposite side.
Step 9: Insert the bracket into the urethra:


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Place the straightened bracket into the urethra without twisting
it. Use Babcock clamp between the bracket’s middle section, to fold
the bracket about 2-3 mm to insert just underneath the urethra.
Step 10: Check the gap between the urethra and the bracket
Pull the two ends of the bracket out of the skin until Babcock
clamp exposes the urethra.
Take out the Babcock clamp and leave a gap between the
urethra and the bracket; check the gap by the tip of Metzenbaum
dissecting scissor.
Step 11: Cut the brackets off the skin
Step 12: Sew the vaginal incision and inguinal skin incision
billaterally
2.4. Research criteria
2.4.1. Clinical and subclinical indicators related to surgery
indications

-

Age : classified into the [< 50 age] and [≥ 50 age]
Body Mass Index (BMI)
Time of illness.
Medical history of UI treatment
Obstetric history : number of delivery ; number of caesareans
; infant’s weight ; history of intervention on perineum

+

Combined systemic pathology
Combined Urological - genital diseases
Assessment on the level of UI:
Level of SUI in the check-up:
. Grade I: wet lingeries
. Grade II: wet outer pants


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+ Level of SUI [82]:
. Grade I : leak urine when coughing or exerting harder
. Grade II : leak urine in daily physical movement or
activities as standing up, walking, climbing in a
staircase

. Grade III : regulary even the lying position
-

Interpretation of positive urine culture in case of suspicion of
bacterial infection: BC positve (+) and positive nitrite (NIT

(+))

- Measure the postvoid residual volume
2.4.2. Assessment criteria of operative results of TOT in the
treatment of female SUI
-

Operative time

-

Treatment time

-

Time of Postoperative Urinary Catheterization

-

Pain Assessment : Visual Analog Scale (VAS)

-

Operative and Postoperative complications

-

Assessment on operative results:
+

Early result : postoperative recovery, hospital discharge,
days of postoperative hospitalization

+

Outcomes after 1, 3, 6. 12, 18 and 24 months

+

Relapses: the re-appearance of SUI that the patient
complained previously

-

Assessment criteria of treatment outcomes

+ Patients were considered successfully treated when the
SUI completely terminated at the assessment time;


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+ Patients were considered to be clinically unsuccessfully
treated when they still had UI at the assessment time.

-

Review some factors related to treatment failure

2.5. Data management and analysis
All information obtained from the patient medical record

was entered into the variables table of the STATA 14.0 software.
CHAPTER 3
STUDY RESULTS
3.1. Clinical and subclinical characteristics related to the
indicated Transobturator Tape (TOT) surgery
- The patient age on average was 54,7 ± 10,42 years. The
youngest was 30 and the eldest was 83.
- 100% of patients were pregnant and child-bearing. The
mean number of birth in the research group was 2,6 ± 0,9 children, of
which there were at least a child and 7 children for the most crowded
family.
- 32 patients with vaginal delivery from 3–4 times, accounted
for 54,2%; The number of patients with vaginal delivery > 4 times
was 16, accounted for 27,1%.
- 56 patients with pelvic organ prolapse, of which the
majority number was Prolapse Grade I by 76,2%, Prolapse Grade II
was 23,8%.
- Level of SUI: Grade I: 2 patients, occupied 3,3%; Grade II:
14 patients, by 23,8%; Grade III: 43 patients, by 72,9%.


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Table 3.10. BMI and Pre-operative SUI classification (n=59)
Simple SUI

BMI

Mix SUI

Total

Q’ty

%

Q’ty

%

< 18,5

3

11,5

3

9,1

6 (10,1%)

18,5 – 22,9

16

61,5

20

60,6

36 (61,0%)

≥ 23

7

26,9

10

30,3

17 (28,8%)

Total

26

44,1

33

55,9

59

Rate of the simple SUI accounted for 44.1%; Rate of the mix
SUI accounted for 55.9%. The BMI difference was not statistically
significant between the simple SUI and the mix SUI (p > 0,05).

Table 3.11. Postvoid residual volume (n=59)

Postvoid residual volume

Quantity

Rate (%)

≥ 100 – 150 ml

54

91,5

> 150 ml

5

8,5

 ± SD (Min – Max)

131,7 ± 19,6 (100 – 170)

3.2. Assessment on the technical outcomes of TOT in the
treatment of female SUI
- Mean operative time: 66,4 ± 21,9 (45 – 180) mins
- There were 2 bleeding cases during the operative time, as
Patient No.4 and Patient No.17 (3,4%). Successful hemostasis with
the 2-0 Vicryl thread.

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- Mean pain level (VAS): 4,8 ± 0,93 (3 – 7) points
- Mean hospitalization time: 4,6 ± 1,8 (1 – 10) days. The shortest
term was a day and the longest term was 10 days.
3.3. Assessment on the treatment outcomes of TOT in the
treatment of female SUI
3.3.1. Postoperative results and post-hospitalization results
- After withdrawing the urinary sonde, 58 patients could urinate
normally. It was required to place Foley Catheters
- On the 6th day of post-operation, all 59 cases had no longer the
SUI symptoms, test of Valsava maneuver and (-) coughing test.
3.3.2. Treatment results of 1-month hospital discharge
Table 3.23: Results of Pre-op treatment and 1-month Postoperative
treatment
Pre-op
Rate %
100
100
100
131,7 ± 19,6
(100 – 170)
13 ± 2,3
(10 - 18)


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3.3.3. Outcomes of 4 months after hospital discharge
- All 59 patients (100%) had no longer any symptom of SUI.

- Mean Postvoid residual volume: 56,2 ± 14,5 ml, which
was a statistically significant decrease with p <0,05 compared to the
Pre-op data, but there was no significant difference with the period of
a month after surgery. (p > 0,05).
3.3.4. Outcomes of 6 months after hospital discharge
- 100% of patients had no longer SUI.
- Mean frequency of urination per day was only between 5 –
8 times.
- Mean Postvoid residual volume: 49,5 ± 10,7 ml.
3.3.6. Outcomes of 12 months after hospital discharge
- A patient relapsed into SUI, accounted for 1,7%.
- Mean Postvoid residual volume: after the urination, it still
remained stable at <50ml. However, there were other 6 patients with
the postvoid residual volume >50ml, a patient reached the highest
level of 110ml, increased compared to the data of 9 months after the
surgery.
3.3.7. Outcomes of 18 months after hospital discharge
- 5 patients relapsed into SUI, accounted 8,5%. Mean
frequency of urination per day: 6,9 ± 0,9 (6–10).
- Mean Postvoid residual volume: 54,9 ± 22,9 (20 – 130) ml.
3.3.8. Outcomes of 24 months after hospital discharge


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Table 3.30. Treatment outcome of Pre-op and 24 months after
hospital discharge
Rate %
100
100
100

0

There was a newly relapse case appeared at 24-month postoperation, use Bonney test (-). There is no indication of repeating the
TOT techniques.

Table 3.31. SUI Relapse and Operative Indications

Features

Relapse
(n = 6)

Nonrelapse (n =

P

53)

Mean age

58,2

51,6

0,03

BMI

23,5

20,4

0,04


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Normal Birth ≥ 3

3/6

45/53

0,000

Infant's weight > 4kg

1/6

4/53

0,000

With TSM

1/6

6/53

0,31

Simple

2

24

Mix

4

29

Pelvic organ

Grade I

0

42

prolapses

Grade II

6

8

Grade I

0

8

Grade II

6

45

Grade I

0

2

Grade II

0

14

Grade III

6

37

Types

0,186

0,000

complex
Level of UI

Level of
SUI

0,000

0,000

Relevant indicative factors to the postoperative relapse of SUI, BMI>
23; number of vaginal deliveries ≥ 3, infant’s weight > 4kg,
combined with the prolapse Grade II and Stress Urinary Incontinence
Grade III, 4/6 cases of relapses with BMI> 23.
CHAPTER 4
DISCUSSION
4.1. Clinical and subclinical characteristics of indications of
transobturator tape (TOT) surgery
4.1.1. Age and index of BMI
The studied patient age on average was 54,7±10,42 years, of
which the youngest was 30 and the eldest was 83. Our findings were
higher than those of Ho Nguyen Tien in the SUI treatment by


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Bandelette underneath the urethra was 51,8±11,9 (the youngest was

39 and the eldest was 67) and the research of Nguyen Tan Cuong in
the female UI treatment by TVT surgery was 49,8±7,2 (the youngest
was 33 and the eldest was 69). Nguyen Van An et al. Introduced a
study evaluating the medium-term outcome of the female UI
treatment by the TOT surgery on 46 female patients with an average
age of 52,0±1,4 years, the youngest was 38 and the eldest was 76.
According to Table 3,10, the study group had both slim
(10,2%), normal (61,0%) and fat (28,8%). Compared with the results
of Nguyen Thi Tan Sinh, there was a relationship between BMI ≥ 22
and the UI status. The risk of UI in patients with BMI ≥ 22 was
higher than those with BMI <22 with OR = 1,77, 95% CI: 1,31 - 2,4).
When reviewing the simple SUI and the mix SUI in relation to BMI,
there was no statistically significant difference with p>0,05 between
UI and BMI level (Table 3,10). Nevertheless, when reviewing each
group of the simple SUI and the mix SUI, most patients had a BMI
of 18,5 or higher. Our results were also consistent with Ho Nguyen
Tien with a BMI ≥ 23, accounted for 32%. Explanatorily, there were
some reasons as overweight that cause frequent abdominal pressure,
more pressure on the bladder and urinary incontinence (UI).
4.1.2. Gynecological factors
The number of pregnancies and abortions, the number of
delivery, the infant’s weight at birth, the vaginal delivery or
caesarean delivery as well all have an influence on the female UI.
Our findings are also consistent with Nguyen Tan Cuong (mean
delivery rate accounted for 2,5 times and the highest to 10 times of
pregnancy) and Ho Nguyen Tien (mean number of children was 3,4


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±1,6, a child at min and 6 at max). According to Krue et al. 1997,

rate of SUI increased from 6,9% before pregnancy to 30,6% after the
delivery. Giving birth to a heavy baby was also considered as a factor
to increase the risk of UI, particularly the infant’s weight of over
4,000g. The study of Ebbesen et al. evaluated the risk of UI for each
delivery as follows: OR = 1.37 (95% CI: 1.04 - 1.79) for a delivery,
OR = 1.28 (95% CI: 1.03 – 1.61) for two deliveries and OR = 1.56
(95% CI: 1.26 – 1.95) for three deliveries or more.
Research findings indicated that patients with the vaginal
deliveries of 6 times at maximum (a patient) and also a patient who
had not yet delivered but pregnant. However, according to S. Shirish
Sheth, this technique can be carried out in patients who have not
given birth yet. According to S. Shirish Sheth, the TOT surgery has
been made on 220 patients who had not yet given birth with the same
indications. The number of deliveries may be a risk of SUI and did
not affect the indications of TOT surgery. The matter of number of
deliveries has influence on the treatment outcome will be discussed
in the following chapter.
Pelvic Organ Prolapse is the most mentioned disease topic in
the study of indications and the SUI treatment outcomes by the TOT
surgery as well.
According to the research’s finding, among patients who was
indicated to the TOT surgery, 96,0% of patients had pelvic organ
prolapse, 89,8% had cystocele. Most of these diseases were treated
before surgery but were ineffective and we found a clear influence of
the disease on the decision to apply the TOT surgery.


21
No patients with pelvic organ prolapse Grade III were
indicated to the TOT surgery in the research. Pelvic organ prolapse

Grade III was not a contraindication of the TOT surgery, but only
placing a TOT would not bring benefits to the patients, even it would
not be effective and the TOT surgery could cause injuries due to
pelvic organ prolapse.
4.1.3. Postvoid residual volume
According to our findings, most of pre-op cases, 91,5% of
patients with postvoid residual volume from 100 – 150 ml and 8,5%
of patients with postvoid residual volume > 150 ml. In no case did
urine residue <100ml. Hence, 100% of cases after urination were still
required to urinate but difficult to urinate. Our research findings were
also suitable for other authors such as Nguyen Tan Cuong and Le Si
Trung.
4.1.4. Clinical patterns of the SUI, and UI Grade
There were 33 cases of urinary incontinence, combined with
the SUI in our study, accounted for 55,9%. It showed that the
diversity in clinical characteristics of female SUI in our country.
Patients often have chronic diseases of the bladder as cystitis, or
chronic stress on the bladder causing the urgency.
To assess the severity of urinary incontinence, many authors
relied on the number of sanitary pad that were required by patients
within 24 hours. We cannot assess the criteria, because many patients
did not sanitary pads. We relied on the simple assessment that some
authors applied, which were based on the wetness of lingeries and


22
outerwear. The evaluation method was not really scientific but easyto-implement in Vietnam.
Among the patients with UI most of the cases were at Grade
II and Grade III, those were the patients with severe and moderate
SUI. Only 2 patients were at Grade I (3,4%); up to 96,6% of patients

at Grade II and Grade III, and Grade III accounted for 72,9% (Table
3.9). The characteristic was consistent with the research findings of
Ho Nguyen Tien et al. rate of UI Grade I by 12%, Grade II by 52%
and Grade III at 36%.
4.2. Treatment outcomes of female SUI by the TOT surgery
4.2.1. The relevant results of the transobturator tape (TOT)
The process of TOT surgery at Hanoi Obstetrics and
Gynecology Hospital was divided into 12 steps including: 1) Lying
patient position; 2) Hang two minor slips with a nylon thread into
thigh creases; 3) Insert a urinary catheter CH16; 4) Position the
wayout of the bilateral groin’s brackets; 5) Carry out the vaginal
incision; 6) Separate vagina and tissue around the urethra; 7) Carry
out the dissection; 8) Place the TOT needle; 9) Place the bracket into
the urethra; 10) Check the gap between the urethra and the bracket;
11) Cut the brackets off the skin; 12) Vaginal incision and skin
incision. This is a simple and easy-to-implement technique. We
divided into such 11 minor steps for the surgeons to apply easily.
In terms of operative hour, our findings indicated that, it took
66,4 minutes to place the suburethral transobturator tape (TOT) into
the uretha while Ho Nguyen Tien’s the findings of 20,7 minutes and
Nguyen Tan Cuong’s findings of 59 minutes. Our operative hour was


23
longer than the afores-said authors due to the different method of
operative hour calculation.
There was no cases of bladder damage in our findings. There
were 2 cases of internal bleeding during the dissection, accounted for
3,4%. Both cases had pelvic organ prolapse Grade II, with much of
urethritis around the urethra. Using the dissecting scissors, there was

excessive bleeding from the obturator. There was no damage to large
blood vessels. Just put the diluted adrenaline-soaked meche for 10
minutes and it was self-hold, that could proceed to surgery.
The mean number of hospitalization after surgery in our
study findings was 4,6±1,8 days, a day at min and 10 days at max.
Our results were also higher than that of Ho Nguyen Tien with an
mean hospitalization day of 2,1 ± 1,1 days, that of Nguyen Tan
Cuong was 1,3 days (a day at min and 5 days at max).
4.2.2. Ssessment on the female SUI treatment outcomes by the TOT
surgery
4.2.2.1. Postoperative outcome
When monitoring patient's progress after surgery until
discharge (from the first day to the fifth day after the surgery), the
research findings indicated that after the urinary catheterization, on
the first day the number of patients with UI accounted for 10,2%
drop to 1,7% on the second day. From the 3rd day, 100% of patients
had no symptoms of UI.
According to Hermieu J.F analysis over 150 studies with
1,000 cases of TOT and TVT surgery, 85% were completely effective
and the treatment effects of both methods were similar but including
some different operative complications. Postoperative complications


24
of TOT was lower than TVT that was the Hematoma in the Space of
Retzius (<1% vs 1%), bladder damage (1-2% vs 5-10%), urethral
damage (<1% vs 1 %) and the TOT surgery hour was short, but had
higher incidence of inguinal groin pain (15,9% after surgery and
droped to 1,9% one week after the surgery).
Assessing the postvoid residual volume after the surgery, our

findings showed a clear improvement in urination status of
postioperative patients. 100% of patients had normal urination
conditions.
According to our research, in five consecutive days after the
surgery, 100% of patients had the postvoid residual volume <100ml.
While, at the Pre-op time, the mean postvoid residual volume was
130,3 ml. In particular, the postvoid residual volume tented to
decrease from day 1 to day 5.
4.2.2.2. Follow-ups after hospital discharge
The assessment time was chosen not earlier than but only
started a month after the surgery, to exclude the impact factors, which
may affect the treatment such as patients may still have postoperative
pain and dysuria possibly. On the other hand, there might be edema,
inflammation which were also factors that can affect the results.
We assessed the outcomes through 2 levels: success or
failure. In case of success, the patients completely have no SUI, even
slightly. In case of failure, the patients still have more or less SUI.
Our research findings indicated that there was no patient with
UI after hospital discharge. It means that the method's success rate
was 100%. According to the summary of many studies, the success
rate of TOT surgery in the range of 80,5% - 96%; As for the TVT


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method, the success rate was from 81% - 90%. According to the
American Urological Association’s 2009 Guidelines, the success rate
of method of urethral support using artificial sling grafts was 84%
(78% -89%), while the method of self-tendons and muscles was 90%
(76%-98%). However, these figures were introduced for reference
only, this is because of the different times of research assessment.

Follow-ups of the progress of treatment findings showed that
the UI after a month was 1.7% and dropped to 0% after 3 months, 6
months and 9 months. Hence, the urination immediately after the
surgery can still be improved later. The long-term assessement from
time to time is essential.
Recent studies on the TOT surgery reported by Nguyen Ngoc
Tien (2012) found a relatively high result. According to his study, the
success rate was 96,8%. Complications in this study included vaginal
perforation by 1,6%. hematoma in the surgical area by 1,6%;
Hematoma in the Space of Retzius by 0,8%; thigh pain by 7,1%;
dysuria by 9,5% and urgency by 4,8%.
The study by Nguyen Van An (2012) of the female SUI
treatment by the TOT surgery obtained a highly-significant success
rate (95,7%). Operative complications: a case of bladder perforation
(2,1%), 2 cases of angle vaginal perforation (4,2%), all cases were
detected and treated well right after the surgery. Postoperative
complications: a case of thigh pain (2,1%), 2 cases of urgency (4,2%)
and a case of prolene mesh protrusion (2,1%).
A month after the surgery, our findings indicated that the
failure rate was 1,7% (a patient). Nevertheless, the patient had no
symptoms at 3 months and had no relapse. Thus, we only calculated