title: Trans-obturator-tape procedure--"inside out or outside in": current concepts and evidence base.
abstract: OBJECTIVE
  Surgical treatment of female stress urinary incontinence has become very popular as a consequence of the good results given by the minimally invasive tension-free vaginal tape. This has attracted great attention from industry, resulting in a proliferation of new slings and different implantation techniques. This review focuses on published literature on the two trans-obturator procedures, outside in or inside out, recently described.
  
  
  RESULTS
  Tension-free vaginal tape was originally reported as a very safe procedure. However, analyses performed in Scandinavia and Austria and several clinical case reports have emphasized the risk of serious complications, related to the penetration of the retropubic space. Two new surgical approaches have been introduced maintaining the position under the mid-urethra of the tension-free vaginal tape but reducing or even eliminating complications related to the penetration of the retropubic space by placing the tape between the two obturator foramens, from outside to inside or from inside to outside.
  
  
  CONCLUSIONS
  Efficacy reported results are very close to those reported in most of the observational series of tension-free vaginal tape. Both trans-obturator procedures have been reported with very few complications. Anatomical dissections have shown that these two procedures can be very safe, but that the tip of the tunneller could injure the bladder, the urethra or the obturator pedicle. Surgeons have to respect the key points of the procedures. No evidence-based conclusion can yet be drawn on these two procedures. Long-term follow-up trials and tracker studies including very large cohorts of patients are needed.
authors.affiliation: Department of Urology, Academic Hospital Caremeau, Place du Pr Debré, 30029 Nîmes Cedex 9, France. pierre.costa@chu-nimes.fr
authors.forename: Pierre
authors.initials: P
authors.lastname: Costa
authors.forename: Vincent
authors.initials: V
authors.lastname: Delmas
mesh_terms: D005260:Female; D006801:Humans; D018482:Muscle, Skeletal; D010388:Pelvis / Q000033:anatomy & histology; D019736:Prostheses and Implants; D014550:Urinary Incontinence, Stress / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*