TVT-hybrid sling : a unique combination for effective treatment of stress incontinence in complex urological patients

Hypothesis / aims of study: Stress urinary incontinence (SUI) is a prevalent, debilitating condition affecting women worldwide. Since its introduction by Ulmsten et al., the Tension-free Vaginal Tape (TVT) procedure has become a cornerstone in SUI treatment, demonstrating high cure rates in both short- and long-term outcomes. (1) However, the synthetic slings carry a risk of complications (erosion, bladder injury, voiding dysfunction and potential postoperative acute urinary retention (AUR)). Furthermore, literature suggests de novo OAB may develop after TVT placement, raising safety concerns despite proven SUI resolution. (2) TVT surgery for SUI patients requiring intermittent self-catheterization (ISC) also has a higher risk of post-operative erosion. Hybrid sling techniques, combining central autologous fascia with lateral synthetic mesh arms are developed to minimize complications while maintaining efficacy with its tension free fixation around the mid-urethra. This case series presents short-term outcomes of TVT-hybrid sling surgery in this complex patient population. Study design, materials and methods: In a retrospective, monocentric study, data was analysed from 13 women undergoing TVT-hybrid sling surgery for SUI. Patient characteristics are visible in Figure 1. The TVT Hybrid sling procedure was performed using a 4 × 2 cm segment of tensor fascia lata muscle tendon, harvested from the lateral thigh through a 4 cm incision made approximately 10 cm above the lateral condyle of the tibia. The graft was attached to a synthetic TVT-mesh with 4 non-absorbable polypropylene sutures creating the hybrid sling. (Figure 2) This sling was positioned following the standard TVT technique, adjusted to a tension-free position and ensuring the fascia lata portion being placed at the urethral side. (3) Post-operative treatment success of the incontinence surgery was defined as resolution in self-reported SUI complaints (Urinary Distress Inventory) or an objective reduction in incontinence pads needed per day. Results: Peri-operative outcomes are reported in Figure 1. 3 cases used left leg fascia grafts and 10 cases used the right leg. Median operating time was 75 minutes (IQR 60-101), median catheterization duration was 1 day (IQR 1–3) and median hospital stay 2 days (IQR 2–2). A summary of the postoperative outcomes are visible in Figure 1. At a median follow-up of 4 weeks (IQR 4–5), 10 patients reported complete resolution of SUI symptoms, 9 patients reported a decrease in incontinence pads usage per day with a median use of 0 incontinence pads per day (IQR 0–3). The postoperative median ISC frequency decreased from 6 (IQR 3-7) to 4 times per day (IQR 3–5). Postoperative pain was reported in 2 cases and postoperative bleeding was observed. Residual lower urinary tract symptoms (LUTS) were reported in 7 patients, all of whom already reported urge-urinary incontinence (UUI) preoperatively. Additional procedures were needed in 3 patients, including 2 cases of AUR for which a suprapubic catheter was placed. One patient received intravesical onabotulinumtoxinA injections because of pre-operative therapy resistant overactive bladder (OAB) symptoms. Interpretation of results: The TVT hybrid sling technique results in a reduction in SUI symptoms and a decreased need for ISC. Three patients needed to start ISC after surgery, although these patients were counselled preoperatively for an increased risk of postoperative acute urinary retention (AUR) because of previous TVT erosion. Mean operating time in this cases series is slightly longer than in synthetic TVT-sling placement. Nevertheless, operating time decreased from 95 minutes to 50 minutes in recent cases of this series, highlighting the fast learning curve of this technique. Concluding message: The TVT-hybrid sling appears to be a promising treatment option for SUI in patients with a higher risk for post-operative ISC. Differentiation on pre-operative urodynamic findings between urethral hypermobility and intrinsic sphincter deficiency (ISD) remains important. Prospective studies with longer follow-up periods are needed to confirm these findings and further optimize patient selection.