University College Hospital at Westmoreland Street. Mid urethral tension-free vaginal tape procedures

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1 University College Hospital at Westmoreland Street Mid urethral tension-free vaginal tape procedures Urology Directorate for women

2 2

3 3 If you would like this document in another language or format, or require the services of an interpreter, contact us on or ext We will try our best to meet your needs. Contents Introduction 5 What does mid urethral tension free vaginal tape mean? 5 How can this procedure help? 6 What are the risks? 6 What are the risks of a general anaesthetic? 7 What will happen if I choose not to have the procedure? 8 What alternatives are available? 8 How should I prepare for surgery? 9 How long does the operation take? 10 Asking for your consent 10 What happens during the procedure? 10 What should I expect afterwards? 11 Frequently asked questions 13 References 14 Where can I get more information? 15 Contact details 16 How to find us 17 Space for notes and questions 18

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5 5 Introduction The aim of this leaflet is to give information on this particular type of surgery for stress incontinence. Stress urinary incontinence (SUI) occurs when the muscles which help to support the bladder, vagina and back passage (the pelvic floor muscles), or those at the opening of the bladder (sphincter muscles), become weak. Because of this weakness urine may leak out when there is a sudden rise in pressure on the bladder such as when coughing, sneezing or laughing. Stress urinary incontinence is the most common form of incontinence for women affecting at least two women in every five. Common causes of stress incontinence include childbirth, hormonal changes after the menopause, chronic straining with constipation, chronic coughing, obesity, or lifting heavy objects repeatedly. What does mid urethral tension free vaginal tape mean? This is a surgical procedure which aims to cure stress incontinence in patients who have been diagnosed with the condition using a type of test called urodynamics. Following your diagnosis your doctor will discuss with you if you are suitable for surgery. The procedure is not suitable for pregnant women. If women become pregnant but have had the procedure then they will have to have a caesarean section to give birth rather than have a vaginal delivery. The procedure has a success rate of 85 to 90 per cent in the short term and 60 to 70 per cent in the long term. The main advantage of this operation is that there is usually minimal postoperative pain, which means less time spent in hospital.

6 6 How can this procedure help? After having this type of procedure between 86 and 90 per cent of patients remain cured of their SUI at a three year follow-up. The benefits of this treatment are: That you will have little post operative pain; You will recover quickly; You will be able to return to normal activities and work soon after. What are the risks? All treatments and procedures have risks and we will talk to you about the risks of TVT. As with all operations, there are risks associated with the insertion of a tension free tape, most being minor. Complications are not common. You may develop a wound infection which can cause irritation around the wound site. We give antibiotics to prevent or treat this. You may notice that you are passing urine more frequently. Up to 15 per cent of women develop the urge to pass urine frequently after the procedure (urgency). This will improve in time for the majority of cases but occasionally it is necessary to prescribe a tablet that will help this symptom. If you have pre-existing urgency or urge incontinence, this could get worse, but it may improve in up to 50 per cent of women. Sometimes bleeding or a bladder (1 per cent risk of bladder perforations) or bowel injury can occur during the operation. If there is any heavy bleeding or bowel injury, you may require surgery to rectify the damage but bladder injury can usually be managed by simply leaving a catheter (a tube that goes up your waterwipe into the bladder to drain the urine) in for a bit longer (three to four days) to let it rest.

7 7 There is a small risk (5 per cent) that over time, the tape/ mesh can erode into the vagina. Surgery may then be required to cover it. You may experience pain when you resume sexual intercourse following surgery. If this happens, and the pain is persistent and sharp then mention this to your GP or practice nurse or to the doctor at the hospital when you return for your outpatient appointment. A few patients (1 per cent of women long term) have problems with emptying the bladder following this procedure. This is usually a temporary problem. It may be necessary to insert a catheter into your bladder to drain off the urine. Resting your bladder will help any swelling to go down which may be making it difficult to urinate. You will be taught how to insert a tube in your bladder to drain off any urine left inside your bladder before you have surgery. This is called intermittent self-catheterisation (ISC). You may have to do this for a few weeks, or for some women a few months until your bladder starts working again properly following the operation. Very rarely some women may have to continue with ISC longer term. 6 per cent of women experience urinary tract infections after the procedure and this can be treated with antibiotics. What are the risks of a general anaesthetic? There are a number of factors that affect the chances of suffering complications from anaesthesia; these may include age, weight, smoking, lifestyle and the general state of your health. Your anaesthetist and/or your surgeon can provide further details. The following information on risks is provided by the Royal College of Anaesthetists. Very common (one in 10) and common (one in 100) side effects: Feeling sick and vomiting after surgery, sore throat, dizziness, blurred vision, headache, itching, aches, pains, backache, pain during injection of drugs, bruising and soreness, confusion or memory loss.

8 8 Uncommon (one in 1000) side effects and complications: Chest infection, bladder problems, muscle pains, slow breathing (depressed respiration), damage to the mouth, an existing medical condition getting worse, awareness (becoming conscious) during operation. Rare (one in 10,000) or very rare (one in 100,000 or less) complications: Damage to the eyes, serious allergy to drugs, nerve damage, death. Death from anaesthesia is very rare, and is usually caused by a combination of four or five complications together. In the UK there are approximately about five deaths for every million anaesthetics. All treatments and procedures have risks and we will talk to you about the risks of TURBT. What will happen if I choose not to have the procedure? This type of surgery is usually recommended when it is felt this would be the best option for your particular type of incontinence. Surgery is usually only an option when other non-surgical treatments have been tried and have not been successful. There are other surgical options which your doctor will discuss with you. They have similar success rates to TVT but are bigger operations so patients take longer to recover. What alternatives are available? Pelvic floor exercises You should have already completed a course of pelvic floor exercises before being offered tension-free tape to treat your stress urinary incontinence. This is usually a structured programme of exercises for three months, provided by the continence advisors. Pelvic floor exercises are the most effective non-surgical treatment for stress urinary incontinence. They can also be effective in preventing incontinence from worsening. The exercises have to be performed daily and a cure rate of up to 70 per cent may be expected in mild SUI.

9 9 Electrical stimulation This is usually only offered to women who are physically unable to perform a pelvic floor contraction and isn t routinely offered to all who have stress urinary incontinence. Bladder neck bulking This involves injecting a material such as silicone paste into the neck of your bladder to help improve your continence/bladder control. The results of this operation tend to not last very long and it is not suitable for all patients. This procedure may be 65 per cent successful at first, but can become less effective (20 per cent) with time and you may have to have the procedure repeated in nine months to one year. This should be considered if your family is not complete. Other surgical procedures Conventional major surgery (colposuspension) may achieve a similar success rate, but there is usually a four to six day stay in hospital and you will need to take six weeks off work. How should I prepare for surgery? Before your visit, we will invite you to a pre-operative clinic where you will be assessed for surgery. You will be seen by a member of the nursing staff who will ask questions about your previous medical history and will arrange for some tests i.e. blood test. You may also have a chest X-ray. You will also be told if you need to stop taking your medications or not on the day of the operation. You should not have any food for six hours before surgery but you are allowed to drink water for up to two hours beforehand. You need to have a bath or shower before you come into the hospital. Please leave any jewellery at home. If you are unable to remove any piece of jewellery, a protective tape will be placed over it.

10 10 When you arrive on the ward, the nurse will check your details and will show you to your bed and help you to change into a gown and give you an identity wristband. It you are wearing any nail varnish or make up you will be asked to remove this. We will take some basic tests such as pulse, temperature, blood pressure and a urine sample. You will also need to remove contact lenses, glasses, glass eyes and false teeth. Please bring into hospital any tablets or medicines you may be taking. How long does the operation take? The operation usually takes about thirty minutes. However, you will stay in recovery for monitoring after the operation. Asking for your consent We want to involve you in all the decisions about your care and treatment. If you decide to go ahead, with treatment by law we must ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please don t hesitate to speak with a senior member of staff again. What happens during the procedure? You have a condition called stress incontinence. This means that when you put stress on your bladder e.g. by coughing or sneezing, the bladder valve is too weak to hold in the urine and you leak. The procedure involves two small incisions (cuts) to the abdomen (lower tummy) and another in the vagina just below the urethra (the tube through which the urine flows down when you empty your bladder). This will be performed under a general anaesthetic (you are asleep). A piece of mesh tape (made of prolene, a synthetic material) is inserted through the cut in the vagina and passed under the urethra.

11 11 The middle part of the tape supports the urethra and the two ends are threaded through the two incisions in the abdomen or through one small cut in each inner thigh, to support the bladder like a hammock. The mesh remains in place permanently to support the urethra. You can t see the tape once it is in position. The wounds are sutured (stitched). You will have a urinary catheter (tube into your bladder) draining your urine; this will be removed the day after your surgery or one week later in clinic. This will depend on the outcome of the surgery and your surgeon s preference. A vaginal pack (a long piece of gauze) may also be inserted during the operation to absorb any bleeding, which will be removed the next day. What should I expect afterwards? On your return to the ward, the nurses will check your blood pressure and your temperature regularly. If you are experiencing any pain or are feeling sick, please tell the nurse looking after you who can give you some painkillers and/ or anti-sickness tablets. You will be allowed to eat and drink when you return to the ward after your operation. The procdure can be done as a day case or you may be kept in overnight. On the day after your operation, if you have a pack in your vagina it will be removed. Your catheter (the small tube inserted in your bladder) may also be removed or if you are discharged with the tube still in place you will come to clinic one week after surgery for this to be removed. You will need to try to drink 1.5 to 2 litres of fluids within the first 24 hours (six to eight cups). Please do not drink more than this or you may put unwanted pressure on your bladder. You will need to pass urine in a jug/ disposable bedpan for the nurse to measure. The nurse will need to check that you are emptying your bladder properly using a special bladder scanner. She will move a small probe around on top of your tummy just over where your bladder is. This will measure the amount of urine left in your bladder after you have been to the toilet. Once you are passing 200 ml of urine or more at a time

12 12 and leaving less than 100 ml in your bladder, you should be able to go home. The nurse looking after you will explain this to you in more detail once your catheter has been removed. You will be encouraged to get out of bed, wash at your bedside and walk around the ward on the day after your operation. If you are having problems emptying your bladder properly following the removal of the catheter, then one of the following will happen: You will go home with a catheter for up to a week, to let the bladder rest after the surgery, and then to come back in to have the catheter removed again and try to pass urine. If unsuccessful you will be asked to start emptying your bladder using intermittent self catheterisation. You will be taught how to do this before your surgery by the continence advisors. If you have not been referred to them before surgery please contact the PA and she will arrange an appointment for you. You may have to do this for a few weeks, or for some women a few months until your bladder starts working again properly following the operation. Very rarely some women may have to continue with ISC longer term. There will be stitches in the lower part of your abdomen (tummy) just above your pubic bone and these normally dissolve by themselves, 10 to 14 days after the procedure. The stitches in the vagina are also dissolvable and after a few weeks you may notice them as they come out in small pieces. Good hygiene is important, try to have a shower rather than a bath. Keep the wounds and vaginal area clean to allow the incisions in the vagina to heal properly and prevent infection. Do not douche your vagina or use tampons till four weeks after surgery. Drink lots of fluids and eat fresh fruit and vegetables to avoid constipation and straining to open your bowels. Any constant cough is to be treated promptly. Please see your GP as soon as possible.

13 13 Frequently asked questions Will I feel any pain? You may experience a moderate amount of pain the first 24 to 48 hours after surgery. Simple pain relief such as paracetamol can control your discomfort and will be offered regularly. You will also have painkillers to take home with you when you leave hospital. If you have had two cuts in your inner thighs when the tape was inserted, your thighs may feel sore for slightly longer. When can I play sport? Usually after four to eight weeks. This will give you plenty of time to the wounds to heal and the mesh to settle into place. When can I have intercourse? After four to six weeks. Pain during intercourse is one of the rare complications of this surgery (see above, under possible complications). When can I drive? Usually within one week of surgery What follow up can I expect? You will have a telephone or outpatient review one week after surgery. Your GP will review your progress four weeks after surgery. You will be reviewed in outpatients after four months to check on how the surgery has affected your continence problem. What if I have problems after discharge? If you are unable to pass urine after discharge or have severe vaginal bleeding, abdominal distension or pain you need to attend the Accident and Emergency Department (A and E) immediately.

14 14 Remember: Contact your GP if you have other problems such as: Foul smelling discharge from the wound; High fever; Pain when passing urine or blood in the urine; Difficulty opening your bowels; Pain or swelling of the legs References Anaesthetic information provided by the Royal College of Anaesthetists ( Guys and St. Thomas s patient information leaflet Mayday Hospital patient information leaflet Addenbrooks Hospital patient information leaflet

15 15 Where can I get more information? Prodigy Website: NHS Direct Telephone: Website: Patient UK Website: Please also see our UCLH Surgery video information by going to: UCL Hospitals cannot accept responsibility for information provided by other organisations.

16 16 Contact details University College Hospital Switchboard: Website: Julie Jenks, Nurse Practitioner Direct telephone: ext PA Mr Ockrim, Miss Greenwell Direct telephone: Switchboard: ext 79210

17 How to find us 17

18 18 Space for notes and questions

19 19

20 First published: June 2012 Last review date: June 2012 Next review date: June 2014 Leaflet code: UCLH/S&C/SURG/UROL/TAPE/1 University College London Hospitals NHS Foundation Trust Created by Medical Illustration RNTNEH Unique Code: 29055

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