Tension-Free vaginal tape: Follow the rules. (Technical Errors Cause Complications).

CHICAGO -- Precise adherence to the tension-free vaginal tape procedure outlined in 1996 should minimize the chance of complications, Dr. Carl G. Klutke said at a Gynecare-sponsored satellite symposium held during the annual meeting of the American Urogynecologic Society.

The original article in the International Urogynecology Journal of Pelvic Floor Dysfunction (7[2]:81-85, 1996) is a mustread for anyone who is considering using Gynecare's TVT Tension-Free Support for Incontinence. But that's just the first step. "You can't learn it from a videotape or a presentation. You must learn it at the hands of an experienced surgeon," said Dr. Klutke, a urologic surgeon at Washington University St. Louis.

Although relatively rare, vascular injury is one of the most frequently mentioned complications, and it causes great concern when it does occur. It is caused by the needle being inserted too laterally or by excess flexion of the legs when the patient is positioned on the operating table. Patients' legs should be brought forward and out, and attention to proper trocar placement is essential, he said.

If vascular injury results in only minor bleeding from the retropubic vessels or the vessels close to the urethral neck, treatment is simply the expeditious completion of wound closure and tamponade--using finger or pack pressure--along with local diathermy. On the other hand, major bleeding from the iliac or obturator vessels requires immediate resuscitation and open intervention intraoperatively, with immediate postoperative arterial embolization under radiographic control.

Retropubic hematomas can arise during TVT if the needle is inserted too laterally or if there is excess leg flexioning. Patients typically will feel discomfort 1-2 days after the procedure, but the problem is usually limited. Detection is by ultrasound. Aspiration or open drainage is only necessary if symptoms persist, Dr. Klutke said at the meeting, cosponsored by Loyola University Chicago.

Mesh protrusion is the most common TVT complication. It's a technical error, often due to inadequate suturing, improper passage of the tape through the anterior vaginal wall, or premature resumption of sexual activity Careful technique in needle passage and wound closure should prevent most cases of this. Treatment includes antibiotics and a minor plastic surgery procedure ...