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Autologous TOT - A step towards “foreign body free” SUI surgery

Updated: Jan 8

By Dr. Pawan Vasudeva, Safdurjung Hospital, Delhi

Midurethral sling surgery using a macroporous, monofilament polypropylene mesh, over the years, had become the “go to procedure” in the surgical  management of women with stress urinary incontinence (SUI). As a result, a  much lesser number of the equally efficacious alternative, autologous bladder neck slings were being performed since the midurethral route has the added advantages of shorter operative time and hospital stay. However, after a 2008 FDA warning and subsequent communications, the synthetic mesh procedure from a modern marvel suddenly became a medical menace in the public eye leading  to more than a million lawsuits in the United States alone with settlement amounts going into hundreds of millions of dollars. Several countries banned the meshes while some others “paused it”.

The “route” was right, but since the synthetic mesh came into disrepute, using autologous tissue instead, for mid urethral sling surgery looked like a reasonable option and this procedure has gained momentum. (1)  The procedure of autologous transobturator tape (TOT) is almost similar to that described for synthetic mesh TOT, except that instead of the synthetic mesh, a strip  of autologous tissue (1.5 cm width x approx 6 cm length) is used and non-absorbable sutures are tied at all 4 corners and instead of a single pass of the needle, 2 passes are required on each side to bring the corner stitches out of the obturator foramen, which are then tied at the level of obturator foramen. The autologous tissue being used is either rectus fascia or tensor fascia lata, each with its own pros and cons. Several recent reports have evaluated the midterm efficacy of autologous TOT and a recent randomised comparative trial showed that at 24 months of follow-up, the dryness rate (92.4% vs 94.6%) as well as the complication rate (8.3% vs 6.6%) of autologous vs synthetic mesh TOT were similar. (2) Besides, there is some evidence that the sexual function outcomes of autologous TOT are superior to that with synthetic TOT, with the only downside being the harvest site related complications such as wound hematoma noted in a few patients in the rectus fascia group. (3)

Autologous TOT retains the ease, simplicity and efficacy of the TOT procedure with encouraging mid term results, while avoiding the complications of a synthetic mesh. Whether it would emerge as an equally efficacious long term alternative to the current standard of care, only time will tell.

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