title: [Trans-obturator urethral sling for surgical correction of female stress urinary incontinence: Outside-in (Monarc) versus inside-out (TVT-O). Are both ways safe?].
abstract: BACKGROUND
  The originally described outside-in procedure for the trans-obturator route was later turned inside-out. We wanted to demonstrate the safety of the two techniques through personal and published experience.
  
  
  METHODS
  Non-randomized, prospective, observational, open-label, longitudinal study of 100 female patients (50 TVT-O and 50 Monarc). All the female patients presented with isolated stress urinary incontinence. Only 4 patients presented with mixed incontinence in the Monarc (MON) group. Sphincter incompetence was observed 4 times in the MON group and 3 times in the TVT-O group. All the patients underwent surgery under assisted local anesthesia in a day-hospital setting. Only those patients presenting with patent established urinary incontinence, corrected by the TVT test, underwent surgery. Post-operative control was conducted at 3 months and 1 year.
  
  
  RESULTS
  The duration of hospitalization was 10 h for 48 patients in the MON group and 49 in the TVTO group. The only per-operative complication was a vaginal perforation in the lateral angle of the vagina for a MON patient. Early post-operative complications were observed in the MON group: 3 cases of urinary tract infection, 1 of transient urine retention, 3 of pain in the thighs spontaneously resolving within 4 days and 1 of permanent pain in one leg at time 1 year, which remained bearable. For the TVTO group the post-operative complications consisted in: 1 case of urinary tract infection, 1 of transient retention and 4 of pain in the thigh. No hematoma was reported in either group. Among the late complications, the de novo symptoms included 1 case of imperious urges to urinate in the TVTO group and objective dysuria in 2 cases in the MON group vs. 7 in the TVTO group. There was no statistically significant between-group difference in the complications. No tape exposure was observed. Overall, the recovery rate was 90% at 1 year for MON vs. 94% for TVTO (p = NS) with 2 cases of recurrence between 3 months and 1 year in that series. Mixed incontinence was corrected at time point 1 year in 75% of cases for MON, with 1 case of recurrence in the year. For the patients presenting with sphincter incompetence, competence was maintained at 3 months and 1 year in all cases in the MON group. The 3 TVT-O were cured at 3 months, but 2 recurrences were observed at 1 year. All patients, except one, were satisfied at time point 1 year and those who had sexual relations (54%) did not report any disorder at time point 1 year.
  
  
  CONCLUSIONS
  The cadaveric studies by advocates of the outside-in technique show a vascular and nervous risk which has received little attention in terms of complications in the literature. Post-operative leg pain is encountered with both techniques and usually is transient.
  
  
  CONCLUSIONS
  Our experience, like that reported in the literature, shows that the two trans-obturator access routes are equally safe. The clinical results would appear to be equivalent, in terms of recovery, to the rates obtained with retropubic TVT.
authors.affiliation: Service de Gynécologie Obstétrique, CH de Dunkerque, rue des Pinsons, 59430 Saint-Pol-sur-Mer. ph.debodinance@wanadoo.fr
authors.forename: P
authors.initials: P
authors.lastname: Debodinance
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007431:Intraoperative Complications; D007902:Length of Stay; D008137:Longitudinal Studies; D008593:Menopause; D008875:Middle Aged; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012008:Recurrence; D016896:Treatment Outcome; D014550:Urinary Incontinence, Stress / Q000601:surgery*; D014552:Urinary Tract Infections / Q000453:epidemiology; D013520:Urologic Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D014621:Vagina / Q000293:injuries