Tension-free vaginal tape (TVT) sling

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What is the tension free vaginal tape (TVT) sling?

The tension free vaginal tape (TVT) sling involves placing a tape of mesh underneath the urethra. This tape acts like a hammock to support the urethra.

The use of the tension free vaginal tape (TVT) sling for stress incontinence was paused in 2017, due to safety concerns about mesh and tapes. A mesh review has been carried out and the tension free vaginal tape (TVT) sling for stress incontinence is the only tape that might be approved for use. This awaits further information.

Why do I need a tension free vaginal tape (TVT) sling?

The tension free vaginal tape (TVT) sling is needed for stress incontinence of urine. Surgery is carried out when pelvic floor muscle training has failed.

The operation is intended to support the urethra to avoid leakage of urine on coughing and sneezing.

What can I expect before the operation?

At your pre op assessment and on your admission day the nurse will go through your hospital stay and explain your operation. Please do let us know about any concerns you have or if there is any information you think we should know about that will make your stay with us more comfortable. You will need to make arrangements for your family, children or any other commitments that you have prior to coming in to hospital and to cover the length of your recovery.

You will see an anaesthetist and the doctor performing the surgery before you go to theatre. It is not unusual to feel anxious, the nursing staff will gladly discuss how you are feeling and talk you through your emotions.

If you have not already completed a frequency volume chart and quality of life questionnaire, you might be asked to do so before surgery. You should have already signed the consent form on booking, if not the doctor will go through it with you before you go to theatre.

You will be asked for permission to enter your data on the national database for continence and prolapse surgery. This is a quality control measure to compare the safety and effectiveness of such procedures at the hospital against other units in the country.

Completing a frequency volume chart and quality of life questionnaire at follow up will enable assessing the benefit of surgery for you.

What does the operation involve?

The operation can be done under general, spinal or local anaesthesia. The choice will be made between you, your doctor and the anaesthetist.

A cut is made through the vagina to pass the tape. Two additional cuts are made in the lower abdomen. The bladder may need to be checked with a camera, to ensure it is not injured during the process. The tension of the tape is then adjusted to provide support to the urethra. All wounds are then closed.

If you are having an operation for pelvic organ prolapse at the same time, you may have a temporary pack inserted in the vagina to compress the wounds and to avoid any bruising. A catheter in the bladder may also be required which will be removed within 24 hours.

What are the risks?

There are risks with any operation but these are small.

The main risks associated with mid urethral tape slings are:

Common risks:

• Initial difficulty in passing urine. This is usually managed by having a catheter inserted to drain the bladder and you can go home with a leg bag for few days. Less commonly, patients may need to use clean intermittent self catheterisation for a short period of time. In extremely rare circumstances, the tape may have to be divided to help passing urine
• Postoperative pain

 Uncommon risks:

• Urinary tract infection, which may need antibiotics
• Wound infection, which may need antibiotics
• Wound bruising and delayed wound healing
• Persistence or development of overactive bladder symptoms. (urgency and frequency of passing urine). This usually settles with medication
• Damage to the bladder and / or bowel, which will be repaired during surgery. If such injury is not identified and repaired at the time, there is a risk of fistula, but this is extremely rare
• Late onset difficulty passing urine. This may develop days or even weeks after being able to pass urine smoothly. The management is the same as initial difficulty passing urine, either by using a catheter with a leg bag and / or clean intermittent self catheterisation
• Venous thrombosis and pulmonary embolism (blood clot in leg /  lung). This is extremely rare with such minimally invasive procedures
• Failure to improve or cure stress incontinence, or its recurrence with time. This is rare but will need reassessment and may require further surgery
• Bleeding requiring blood transfusion. Sometimes the bleeding does not become apparent till after leaving theatre, and may require return to theatre
• Tape erosion exposure into the vagina, bladder or bowel. This is rare but may require excision of the exposed tape
• Tape infection. This is very rare but may require removal of the tape
• Pain, which can be associated with intercourse. Usually this improves with time, use of pain killers and / or injection of Local anaesthetics and steroids. In extremely rare occasions, the tape may need to be removed
• Groin pain, in the case of trans obturator tape. Again this is rare, which usually improves with time and the use of pain killers. In extremely rare occasions, the tape may need to be removed

In order for you to make an informed choice about your surgery, please ask one of the doctors or nurses if you have any questions about the operation before signing the consent form

What can I expect after the operation?

As you come round from the anaesthetic, you may experience episodes of pain and / or nausea. Please let the nursing staff know and they will assess you and take appropriate action.

You might have a pack in the vagina and catheter in the bladder.

You may have a drip to give you fluids, though you will be able to eat and drink.

Your nurse will be checking your blood pressure, pulse, breathing and temperature and monitor the wounds across your abdomen or in the groin, depending on the operation, and any vaginal bleeding.

You will be asked to move from side to side and to do leg and breathing exercises once you are able to. This will help prevent any pressure damage, deep vein thrombosis or chest infection.

What about going home?

You will be able to go home when you are passing urine without difficulty. You will be asked to pass urine in a jug and will have a scan to measure how much urine is left in the bladder.

If you have a pack in the vagina, then the catheter will only be removed when this pack is removed.

Most patients go home on the day but patients having prolapse surgery at the same time may stay over night.

To ensure you have a good recovery you should take note of the following:

Rest

During the first two weeks at home it is common to feel tired, exhausted and emotional. You should relax during the day gradually increasing the number of things you do each day. Avoid crossing your legs when you are lying down.

Vaginal bleeding

You can expect to have some vaginal discharge / bleeding for few days after surgery. This should be light and red or brown in colour. Sanitary towels should be used, rather than tampons, to reduce the risk of infection.

Stitches

The wounds across your abdomen or in the groin as well as inside the vagina will be closed by dissolvable stitches. We advise that you shower daily and keep the wounds clean and dry. There is no need to cover the wounds with a dressing.

Housework:

Weeks 1 to 2

We recommend that you do light activities around the house and avoid any heavy lifting (not more than 1.5kgs in each hand).

Weeks 3 to 4

We recommend that you gradually introduce lighter household chores, dusting, washing up, making beds and ironing. You may begin to prepare food and cook, remembering not to lift any heavy items.

Weeks 4 to 6

By this time you should resume normal daily activities, but continue to refrain from straining till 3 months after surgery, to ensure good healing of the tape.

Exercise

Exercise is important and it is advisable to go for short walks each day, increasing the distance gradually. You may return to light exercise, like gentle swimming and cycling, after 4 to 6 weeks. You should avoid straining or heavy exercise for 3 months, to ensure good healing of the tape. You will be able to manage the stairs on your arrival home. We encourage you to do pelvic floor exercises, to enhance muscle tone.

Diet

A well balanced nutritious diet with high fibre content is essential to avoid constipation. Your bowels may take some time to return to normal and you may need to take laxatives. You should include at least 5 portions of fruit and vegetables per day. You should aim to drink at least 2 litres of water per day.

Intercourse

You should usually allow 4 to 6 weeks after the operation to allow the vagina to heal. If you experience vaginal dryness, you may wish to try a vaginal lubricant from your local pharmacy. If after this time you are experiencing pain or any problems with intercourse then you should see your GP.

Returning to work

This will depend on the nature of your work. If you work in an office base environment, you will need 4 to 6 weeks off work. If your work involves lifting and exertion, you will need 3 months off work. The hospital doctor will provide a sick note for this period.

Driving

It is usually safe to drive after 6 weeks but this will depend on your level of concentration, ability to perform an emergency stop and your car insurance policy.

What about follow up?

You will be invited for follow up, usually about 8 weeks after surgery. If you have any problems before this you can either contact your doctor or contact the hospital to bring the appointment forwards. During this follow up appointment, your symptoms will be reviewed and you will be examined to assess wound healing. The frequency volume chart and quality of life questionnaire will be checked.

Are there any alternatives to having a mid urethral tape slings?

You will have been offered and tried conservative measures, including fluid advice, pelvic floor muscle training, smoking cessation as well as weight loss, before being offered surgery.

Alternative procedures for stress incontinence of urine include:

• Autologus sling, an operation to support the urethra using a strip from the abdominal wall.
• Colposuspension, an operation to support the area around the bladder neck to the back of the bone in the lower abdomen.
• Injection of a bulking agent at the bladder neck.

 These can be discussed with your doctor.

You should contact your doctor or the hospital if you notice increased temperature, smelling wound discharge and / or pain.

Who can I contact with any concerns or questions?

If you have any problems or questions, use the contact numbers below to contact us.

Further sources of information:

British Society of Urogynaecology patient information leaflets

Patient.info: stress incontinence

NHS.uk: treatment for urinary incontinence

This patient information leaflet was prepared by Dr. Sharif Ismail, Consultant Subspecialist Urogynaecologist.

This information leaflet has been approved at the Clinical Governance and Safety and Quality Meetings of the Department of Obstetrics and Gynaecology as well as Brighton and Sussex University Hospitals NHS Trust Carer and Patient Information Group (CPIG).

Ratified April 2017 Women’s Safety and Quality Committee.