Tension-free vaginal tape

This is a minimally invasive surgical procedure to treat urinary stress incontinence (the leakage of urine when coughing, sneezing, moving or exercising). The tension-free vaginal tape procedure (TVT) operation works by supporting the middle of the urethra with a polypropylene mesh tape. This is called a mid-urethral sling procedure.

The TVT procedure was developed in Europe in the mid 1990s to treat female stress urinary incontinence. These slings have been shown in robust studies to be as effective as more invasive traditional surgery but have the advantages of shorter operating and admission times, and a quicker return to normal activities, together with lower rates of complications.

The National Institute for Clinical Excellence (NICE) recommends this procedure in their latest guidelines. It is still considered one of the gold-standard procedures for the treatment of stress urinary incontinence and has a long record of evidence in the highest quality scientific studies of excellent success rates with minimal risks.

The TVT procedure is usually carried out under local anaesthetic and sedation but can also be performed under general or local (spinal) anaesthetics. Two small cuts (0.5 cm) are made just above the pubic bone and a small cut 1 cm in the vagina. Through these cuts a piece of non-dissolvable narrow mesh tape (synthetic polypropylene) is placed below the urethra (the tube through which you pass urine) using a needle. The mesh attaches itself to the surrounding tissues and supports the urethra. This mimics the ligaments that have been weakened by age and childbirth.

A telescope (cystoscope) is inserted through the urethra into the bladder to make sure that there is no bladder injury. Dissolving stitches are placed in the incisions. Most patients do not require a catheter and go home the same day.

The following complications can occur:

Bladder perforation (risk 1–5 in 100 women): During the operation a needle is used to insert the mesh. This needle may accidentally pass through the bladder. The bladder is always checked with a cystoscope to make sure that this hasn’t happened and if it has, the needle will be removed and re-sited. If the bladder has been pierced then the catheter is left in overnight (so you will need to stay in hospital an extra day), but this does not affect the success of the operation.

Voiding difficulty: A lot of women who have TVT find that their bladder is much slower to empty afterwards. This normally improves over time once swelling settles, but women often find that they cannot go for ‘a quick pee’ after a TVT. In rare cases, the bladder doesn’t work properly after the operation, in which case you will be taught to put a catheter into your bladder to empty it yourself (intermittent self-catheterisation). You would not need to wear a urine bag, as you can drain the bladder, if necessary, several times a day. This happens to approximately 1 or 2 in 100 women.

If your urine stream remains very slow or you cannot empty the bladder well even after the swelling has settled, there are possibilities that a further procedure such as cutting or stretching the sling is required.

Urinary urgency: The operation is designed to cure stress incontinence. Urgency (the need to rush to the toilet) and urge incontinence (leakage when you can’t make it to the toilet in time) can sometimes be made better by the operation but occasionally the problem can get worse. About 50% of women notice an improvement in urgency symptoms, but for about 5% the symptoms may worsen following a mid-urethral sling procedure.

Mesh exposure and extrusion (risk 1–5 in 100 women): The vaginal area over the tape may not heal properly or might wear through into the vagina. Symptoms may include vaginal bleeding, vaginal discharge or pain with intercourse for the patient or her partner. Management of this problem would involve either recovering the tape or removing the section of tape that is exposed. This may result in a return to the operating theatre and may result in the operation being ineffective. Very rarely the tape might erode into the urethra (urine pipe) or the bladder, which would require a further operation as well. The risk of exposure is increased by smoking and with certain diseases.

Chronic pain: Long-term pain following sling surgery is unusual. Studies suggest that after the retropubic operation about 1% of women will develop vaginal or groin pain. In most cases pain is short lived and does not last for more than one or two weeks. In rare cases, pain may not settle, and removal of the sling is required.

Damage to bowel or nerve: This very rarely occurs (less than 1 in 1000) and may not be discovered until after the operation.

The procedure usually lasts between 15 and 30 minutes and is carried out under general anaesthetic. Many women can go home on the day of the operation, especially if it is done in the morning.

After the operation and before discharge, you will be asked to measure how much urine you pass when you empty your bladder and an ultrasound scan is normally used to check that your bladder is emptying properly. If you are unable to empty your bladder fully, short-term catherisation may be required.

There will then be some discomfort at the operation site and the patient will need to take painkillers for several days. Paracetamol and/or Ibuprofen (Nurofen) are usually sufficient.

Because major incisions are avoided, recovery is quick. Recovery after a TVT usually takes between one and four weeks. Most patients take two weeks off work. There is no need to wait for a follow-up appointment before returning to work.

You should be able to be fit enough for your usual activities within one or two weeks after surgery. We advise you to avoid heavy lifting and sport for six weeks to allow the wounds to heal and the mesh to settle into place.

We usually advise you to wait for four weeks after the operation before having sex. In the long term there is no evidence that the operation will make any difference to your sex life. If you previously leaked urine during intercourse, the operation often makes this better, but unfortunately this is not always the case.

In the short term this operation is as successful as any major procedure used for controlling bladder leakage, but with a quicker recovery.

In studies, between one and five years after surgery about 75% of women felt their symptoms had improved. However there is a group of women for whom the operation does not seem to work. With time the success of the operation is reduced. The operation is less likely to be a success if you have had previous surgery to your bladder (such as a repair or a previous continence procedure).