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Marc Laniado
MD FRCS(Urol) FEBU
CONSULTANT IN UROLOGY
- What is a transobturator tape?
- How likely is it that a transobturator will cure incontinence?
- How long does it take for the transobturator tape to work?
- How is a transobturator tape placed in the body?
- Are there alternatives to a transobturator tape?
- When can I have sex after the transobturator tape?
- When can I start dancing, heavy lifting or rigorous exercise?
- What are the side-effects or the risks of a transobturator tape?
- Can I become incontinent again after a transobturator tape?
What is a transobturator tape?
This is a narrow strip of synthetic material placed in your body to support the urethra. The 'Monarc subfascial hammock' is a brand name for such a tape made by a company called American Medical Systems (AMS). The hammock cradles your urethra and gives it a solid point to rest on and press against. This helps the urethra close more tightly at times of stress.
You can download documents from NICE (National Institute for Clinical Excellence) and the companies that make the product from here.
- NICE advice to patients on the transobturator tape for incontinence
- AMS (American Medical Systems) Monarc patient information 1
- AMS (American Medical Systems) Monarc patient information 2
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How likely is it that a transobturator tape will cure incontinence?
In women who have incontinence due to weakness in the pelvic floor and poor support of the urethra (i.e. "genuine stress incontinence"), 8 or 9 out of 10 women should be completely dry or much better after surgery than before. Nine out of every 10 women are able to be as active as they like after placement of a transobturator tape e.g. lift children, dance or exercise. As a result, 19 out of every 20 women are satisfied by the results of the procedure.
No-one can guarantee that everyone will be cured and about 1 in 20 women are not satisfied by the operation. If the bladder is overactive as well, then the success rate is less and fewer women are satisfied. In addition, side-effects are always possible and it is important to think carefully about the advantages, alternatives and risks of any procedure before going ahead.
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How long does it take for a transobturator tape to work?
In general, you will be dryer once the catheter is removed. The full improvement may take several weeks to be noticed.
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How is a transobturator tape placed in the body?
You have either a general anaesthetic so you are asleep or the lower half of the body is made to feel numb by a spinal anaesthetic. A small incision (about 1 to 1.5 inches, 3 cm) is made in the vagina just below the opening of the urethra (water pipe), and two 1/4 inch (0.5 cm) incisions in the inner thigh. The tape (e.g. Monarc) is positioned under the urethra and the incisions are the closed with stitches. These stitches will dissolve spontaneously. During the procedure, a telescope may also be passed through the urethra (water pipe) to examine the inside of the bladder (cystoscopy). The whole operation takes about 30 minutes.
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Are there alternatives to a transobturator tape?
In general, it is wise to try simple remedies as these may be successful and make surgery unlikely. Pelvic floor exercises can help in many cases. When taught by a physiotherapist, these can work very well. Like any exercise programme, it is necessary to keep doing them for them to work.
In addition, it is possible to try a drug called duloxetine. The trade name for this drug is "Yentreve". It needs to be taken twice a day indefinitely. It may be used in combination with physiotherapy. It is not as effective as a surgical procedure, needs to be taken twice a day and has side-effects. In some situations, it may be preferable in some cases.
Another operation was used in the past. This was called the Burch colposuspension and to many is still the gold standard by which all other procedures are judged. As it involves an incision made in the lower belly and requires several days in hospital, many people have chosen not to have this procedure because newer procedures require less time in hospital and are equal effective.
More recently, the TVT has been introduced as an innovative procedure for incontinence. The original TVT was placed behind a bone (pubis) in front of the bladder felt in the lower abdomen. As the approach required the passage of needles behind this bone, injuries that occurred from time to time to the bladder or bowel. The newer transobturator approach is much less likely to cause such problems and is preferable.
There are different forms of the transobturator tape. I prefer to use the Monarc, because it appears to be safer (click here).
What happens after the transobturator tape has been placed?
When you return to the ward, there may be a catheter present. This is a tube draining the bladder. If there is a catheter, this is usually removed after a few hours. If your bladder does not empty properly, it may be necessary to have a catheter for a longer period of time, but this is unusual. After you have passed urine, you can leave the ward and go home. This may be the same day, or sometimes the day after the operation. If the operation has been combined with a procedure for prolapse, you will probably be in hospital for a longer period of time.
You may need to take antibiotics for a while to prevent infection, and apply oestrogen cream (e.g. Vagifem tablets) to the vagina to promote healing.
The stitches present in the vagina and thigh dissolve spontaneously over a few weeks.
After 4 to 6 weeks, you should be reviewed by your doctor who may want to test the rate at which you pass urine and how effectively you empty your bladder. These tests are simple and are not invasive. After that you will probably be reviewed between 6 and 12 months after the operation.
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When can I have sex after a transobturator tape and will it be different?
You should not have sex for four to six weeks after the operation. Some women may experience discomfort with sexual intercourse after the procedure.
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When can I start dancing, heavy lifting or rigorous exercise?
Again, you should avoid such activities for about 4 to 6 weeks.
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What are the side-effects or risks of a transobturator tape?
Every operation has risks and these need to be weighed against the advantages. Fortunately, the side-effects are relatively uncommon:
- Of every 10 women, about one may experience difficulty passing urine, the urinary flow is slower and it takes longer to empty the bladder - this is usually transient and gets better over several weeks. Rarely, this requires temporary use of a catheter or another operation
- Of every 10 women, two may experience bleeding. Usually, this can be controlled relatively easily, but rarely this may need additional treatment
- Of every 10 women, two might have a urine infection that would require antibiotics
- Of every 10 women, one could develop new symptoms such the need to pass urine more frequently during the day and night, or have to rush to the toilet to pass urine when they feel the need to empty their bladder
- of every 100 women, one or two may have damage to the urethra (water pipe) or bladder. This may need a specific repair by further surgery
- of every 100 women, about 2 may have damage to the vagina ("erosion"). The chance of this is less if antibiotics are taken. After the menopause, oestrogen cream in the vagina before and after surgery can also make this less likely. If damage to the vagina is substantial, the tape may have to be removed either partially or completely by another operation.
- of every 100 women, about 2 might have severe pain felt in the vagina or thigh that might last one week
- of every 100 women, a severe infection is possible - this is avoided and treated by giving antibiotics. If it is extremely severe, a further operation may be necessary.
In general, these risks are greater in women who are obese, diabetic or with lung disease.
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Can I become incontinent again after a transobturator tape?
If you become pregnant, it is possible that incontinence can return. Therefore, it is preferable to wait until your family has been completed before undergoing the procedure.
Incontinence can also occur later in life after such procedures. About 7 out 10 women will still be dry 5 to 10 years after surgical procedures. Failure is more likely if the bladder is overactive. This can often be treated successfully by medication.
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Over what period of time will the benefits of a transobturator tape last?
Transobturator tapes have been in existence for about 3 years. The materials used for the procedure have been in existence for considerably longer. What is relatively new, is the technique for inserting the tapes beneath the urethra. It is thought that continence will be preserved for many years after insertion of the tape. Until there are people who have had transobturator tapes for that long, this will not be known.
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