الفهرس 
Anatomy of Female Pelvic FloorOnly 14 pages are availabe for public view
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Abstract
U
rinary incontinence (UI) is a common condition among women, and most studies report aprevalence in the range of 25–45 %. Stress urinary incontinence (SUI) is the most common cause of urine leakage, accounting for approximately 50% of incontinence in women. The prevalence of MUI among women suffering from urinary incontinence varies from 29 to 69 %.
UI is associated with a negative impact on a woman’s social, physical, and psychological well-being, leading to embarrassment, low self-esteem, and negative effects on the productivity of working women. In extreme cases, patients reported avoiding employment; 60% avoided going away from home, and 50% avoided sexual activity. Women with MUI are twice as likely to be bothered by their symptoms as compared to those with SUI alone.
Management of women with MUI is relatively more difficult, as it involves addressing both the SUI and overactive bladder (OAB) symptoms. Conservative management is usually the first line, including pelvic floor muscle training, bladder retraining, and pharmacological treatment. If the above fails, surgery for SUI may be contemplated in women with predominant SUI symptoms; a number of options are usually discussed with the patient including mid-urethral slings (MUS).
Corrective surgery can be grouped into four categories: 1) slings, 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters.
One of the developments in the treatment of female SUI is the minimally invasive tension free vaginal tapes (TVT). It involves recreating urethral support with a polypropylene mesh with blind passage of TVT needle in retrobubic space, which makes the vascular, visceral and vesical injuries possible in TVT technique.
For this reasons, new surgical approaches has been introduced maintaining the position of the tape under the mid-urethra. The original design of this technique, called transobturator tape (TOT), was to place the tape between the two obturator foramina from outside to inside after an extensive suburethral finger dissection.
Another transobturator technique developed which allows the passage of the tape from inside to outside, with no need for more finger dissection, so minimize the risk of urethral, vaginal or bladder neck injury, with the use of newly designed specific surgical instruments is the Gynecare TVT obturator system technique which uses a non-absorbable monofilament polypropylene tape in plastic sheath.
The aim of our study was to evaluate the safety and efficacy of TOT for the treatment of MUI. The study was performed in a prospective randomized study of 20 female patients who suffered from MUI full- filling the inclusion criteria and had none of the exclusion criteria (detrusor overactivity, detrusor underactivity, associated pathology that may induce similar symptoms e.g. urinary tract infections, central or peripheral neurological pathology, Presence of other gynecological pathology that needs hysterectomy, advanced pelvic organ prolapse (≥ stage 2), pregnancy, patients who are surgically unfit).
We treated 20 female patients using T.O.T set by outside to inside technique. All procedures passed smoothly without adverse events, lasted for 15 minutes ±3.5 minutes. All patients had minimal blood loss less than 100 cc, hence they did not need blood transfusion, all patients stayed at the hospital for 24 hours without occurrence of fever and then all were discharged. at 2 weeks post-operative clinical examination revealed two patients with vaginal infection (10%), that responded to medical treatment.
The study showed that there is no significant difference in the cure rate between patients who had less than or more than three urge inc. episodes. Patients who had less than three urge inc. episodes (13 cases, 65%) showed cure rate 53.8% (7 cases), while patients who had urge inc. episodes three or more than three, they were 7 cases (35%) which showed cure rate 71.4% (5 cases).
The study showed that no significant difference between patients who had less than or more than three incontinence episodes on the cure rate of SUI. Patients who had less than three stress inc. episodes (11 cases, 55%) showed cure rate 81.81% (9 cases), while patients who had stress inc. episodes three or more than three, they were 9 cases (45%) which showed cure rate 88.88% (8 cases).
Our study showed no statistically significant difference in the cure rate depending on the age factor by dividing the patients into two groups group below forty (11 cases) and group above forty (9 cases).
Postoperative follow up for six months after T.O.T. fixation showed statistically significant cure rate for urge component 12 cases (60%), and also significant cure rate for stress component 17 cases (85%).
The limitations in our study were small number of patients and short time of postoperative follow-up.
We advocate that the T.O.T procedure should always be tried in the management of mixed urinary incontinence in female population as it is an effective and simple procedure.