Christopher P. Steidle, MD

MR imaging is     helping radiologists and surgeons plan and monitor a novel surgical     procedure developed to treat stress urinary incontinence. The     transobturator tape approach uses a different pathway than previous     approaches, thereby reducing the risk of serious complications such as     bowel and bladder perforation.  

	Beginning in the 1930s, various procedures have been     designed to treat stress incontinence, all fraught with poor long-term     success rates.

 Tension-free tape (TVT) and other midurethra sling     approaches have been successful at treating genuine stress urinary     incontinence. Unfortunately, some extremely dangerous complications,     such as bowel or bladder perforation, have been associated with the     treatments.		

The TVT is positioned either transvaginally or     transabdominally over and behind the pubic bone. The procedure     thus-unnecessarily and dangerously-perforates the     endopelvic fascia, exposing the pelvic viscera and     increasing the possibility of postoperative complications and     infection. Among the safety precautions required for a TVT are     catheterization, inpatient hospitalization, and cystoscopy.

  		Transobturator tape, or TOT, the newest sling approach, uses     the obturator foramen, a lesser known anatomical area that     obviates the dangers of damage to abdominal viscera during pelvic surgery     due to its location below the endopelvic fascia.     

 This area   had not been described until 1998, when Dr. Emanuel Delorme     pioneered a technique for placing a midurethral sling through this space.

 Since then, MR     imaging has been used to describe the pelvic anatomy.	

The TOT approximates a more natural U shape, rather than the V shape seen with the TVT,     thus yielding better postoperative urinary flow rates (Figure 1). The TOT     approach avoids the risk of bladder or bowel perforation, so cystoscopy is     often considered unnecessary, saving the surgeon much time. Almost all TOT     patients leave the hospital soon after the surgery without any     catheterization or postoperative discomfort. Early postoperative     complications have been minimized by woven polypropylene slings that resist     erosion and infection while promoting tissue in-growth. 

At our facility, we have undertaken an ongoing study     to identify the anatomy of this area and correlate it with cadaver     specimens and with MR images of patients, both pre- and postoperatively. We     examined patients undergoing TVT, TOT, or a combination of either procedure     with concomitant pelvic prolapse surgery via MRI. Those undergoing TOT were     imaged both preoperatively and three to six weeks postoperatively. Those     undergoing TVT were imaged only postoperatively. MR images, performed with     a 1.5T scanner, were obtained in sagittal and axial orientations using     a body coil, first with the patient at rest and then again during maximum     pelvic strain. The scans were downloaded onto	a dedicated workstation for radiologist review.	

Preoperative MR images of a patient complaining     of stress urinary incontinence at rest and during the Valsalva     maneuver clearly show cystoceole (Figure 2). Cystoceole is caused by     weakening of the levator ani muscles and stretching of the associated     connective tissues, usually due to pregnancy and     vaginal delivery. Genuine stress urinary incontinence is the major     symptom of cystoceole because of the weakened support. A     midurethral sling can be used to reconstruct urethral support and     aid in reestablishing continence. A postoperative MR image     confirms the placement of the TOT (Figure 3).

	The surgery is performed entirely below the endopelvic     fascia. Unlike  TVT, the TOT approach keeps a safe distance from     important vessels and nerves. The sling passes through the obturator     foramen at a distance of 3 to 4.5 cm from the obturator vessels and nerve     and approximately 8 cm away from the great saphenous vein. TOT has been     successfully performed in conjunction with a wide variety of pelvic organ     repairs, but combination TOT anterior-posterior repair surgeries are     complex and have the possibility of unforeseen complications. 

MRI allowed us to successfully discern the anatomy of     the pelvic diaphragm, pelvic viscera, and associated conditions such     as nabothian cysts (Figure 4) and cystoceole. MRI was also able to confirm     the position of the TOT as being midurethral and below the pubococcygeal     line. The TOT approach seems to be the most logical and appropriate     surgical treatment option for genuine stress urinary incontinence. Clinical     trials have been under way for years, and preliminary results have been     promising. It will be interesting to study the long-term patient     satisfaction and economic relief attributed to TOT and see if these     measures of success reflect its anatomical and surgical benefits. 

Mr. Regan is a senior medical student at the Indiana     University School of Medicine and Dr. Steidle is medical director of     Northeast Indiana Urology Research and a clinical associate professor of     urology at the Indiana University School of Medicine in Indianopolis.


I would like to thank Dr. David Janizek of MD     Imaging (Fort Wayne, IN) for his quick preparation and interpretation     of the MR images. I also want to thank Northeast Indiana Urology for     funding this project through the Midwest Alliance for Health Education in     cooperation with Indiana University School of Medicine-Fort     Wayne Center. -SMR

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MR imaging is helping radiologists and surgeons plan and monitor a novel surgical procedure developed to treat stress urinary incontinence.

Christopher P. Steidle, MD

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