TOT Surgery

What Is TOT Surgery? How Does Its Mechanism Work?

TOT is the abbreviation for "Transobturator Tape." This is a mid-urethral sling surgery developed to correct stress urinary incontinence. The "tape" (band or sling) used in the surgery is a narrow strip (mesh) made of a biocompatible, permanent, synthetic material, generally called polypropylene.

Mechanism of Action: The basic principle of the surgery is to create an artificial support to replace the weakened natural support. Through a small incision made via the vaginal route, this synthetic tape is passed just beneath the mid-portion of the urethra and directed outward on both sides through anatomical openings in the groin region called the obturator foramen. Lying beneath the urethra like a hammock, the tape prevents the urethra from dropping downward and opening at moments when intra-abdominal pressure increases (coughing, sneezing, etc.). What matters is that the tape does not compress the urethra, but only provides it with support (a "backboard"). This way, normal voiding function is not affected, while urine leakage during stress is prevented.

Transobturator Approach: This method is called "transobturator" because the tape is passed through the obturator openings in the groin region. This approach may offer certain potential advantages over TVT (Tension-free Vaginal Tape – retropubic approach), another commonly used sling method (for example, a theoretically lower risk of bladder injury), but both methods are reliable techniques with high success rates. The choice of method may vary depending on the surgeon’s experience and the patient’s condition.

Who Is a Suitable Candidate for TOT Surgery? (Indications)

The most suitable candidates for TOT surgery are as follows:

• Primary Indication: Women with pure stress urinary incontinence (SUI) that affects quality of life and does not respond adequately to conservative treatments such as pelvic floor exercises.
• Mixed Urinary Incontinence (MUI): May also be considered in patients who have both stress and urgency-type symptoms but in whom the stress component predominates. However, the patient must be informed that the surgery will only correct the stress-type leakage, and that urgency-type symptoms may require additional (usually medical) treatment.
• SUI Together with Pelvic Organ Prolapse: In patients scheduled for uterine or bladder prolapse surgery, if occult or overt stress urinary incontinence is also present, TOT surgery can be performed in the same session as the prolapse surgery.
• Patient Factors: It is important that the patient’s general health status is suitable for anesthesia and surgery, that she is not planning a future pregnancy (pregnancy can disrupt the position and effectiveness of the sling), or that she understands the possible effects of pregnancy on the outcome.

Your doctor (Prof. Dr. Nuray Bozkurt) will determine, following a detailed evaluation (history, examination, and urodynamic testing if necessary), whether TOT surgery is a suitable option for you.

How Is TOT Surgery Performed? Step-by-Step Surgical Process

TOT surgery is generally a short (average 20-30 minutes) procedure performed via the vaginal route:

1. Anesthesia: The surgery is usually performed under regional (spinal or epidural) or general anesthesia. In some cases, local anesthesia with sedation may also be sufficient.
2. Position: The patient is placed on the operating table in the gynecological examination (lithotomy) position.
3. Preparation: The surgical area (vagina and groin) is sterilized. A temporary catheter may be inserted to empty the bladder.
4. Vaginal Incision: A small, approximately 1-1.5 cm vertical incision is made in the anterior vaginal wall, just below the mid-portion of the urethra.
5. Tunnel Creation and Tape Passage: From this vaginal incision, a tunnel is created through the obturator foramen toward the groin skin on both sides (usually the inner thigh fold) using specially designed needles or trocars. The synthetic tape (sling) is attached to these instruments and placed beneath the urethra by passing it through the tunnels.
6. Tape Adjustment: The surgeon ensures that the tape lies tension-free beneath the urethra. The goal is not to lift or compress the urethra, but simply to support it from below. The ends of the tape are brought out through the small skin incisions in the groin area and are usually cut so as to remain under the skin, without being fixed to any structure.
7. Cystoscopy (Usually Performed): At the end of the procedure, the bladder is examined with a camera (cystoscope) to check for any injury to the bladder or urethra.
8. Closure: The vaginal incision and the small skin incisions in the groin are usually closed with self-dissolving sutures.

What Are the Advantages of TOT Surgery? Why Is It Frequently Preferred?

TOT surgery offers many advantages in the treatment of stress urinary incontinence:

• High Success Rate: The long-term rate of correcting or significantly reducing urinary leakage is quite high, at around 85-95%.
• Minimally Invasive: Performed via the vaginal route with small incisions. There is no large incision in the abdominal area.
• Short Operating Time: Usually completed in a short time of about 20-30 minutes.
• Short Hospital Stay: Most patients can be discharged the same day or the following day.
• Fast Recovery: The time to return to normal daily activities and work is much shorter than with open surgery.
• Less Pain: Postoperative pain is generally mild and easily controlled.
• Reliability: It is generally a safe surgery when performed in suitable patients and by experienced hands.
• No Entry into the Retropubic Space: Unlike the TVT method, because the retropubic space behind the bladder is not entered, risks such as bladder injury or major vessel injury are considered to be theoretically lower.

What Are the Risks and Possible Complications of TOT Surgery?

Like every surgical procedure, TOT surgery also carries potential risks and complications, although these are generally rare:

• Bleeding: Significant bleeding may rarely occur during or after surgery. A hematoma (collection of blood) may form.
• Infection: Infection may develop at the vaginal incision site, in the urinary tract, or rarely in the pelvic region.
• Bladder or Urethral Injury: The risk of injury to these organs during the procedure is low (<1-2%) and is checked with cystoscopy.
• Temporary Voiding Difficulty or Inability to Urinate: Difficulty urinating or incomplete bladder emptying may be seen in the early postoperative period (5-10%). This is usually temporary and resolves on its own, but occasionally a temporary catheter or self-catheterization may be required. Permanent voiding difficulty is very rare.
• New or Worsening Urgency-Type Symptoms (De Novo Urgency): In some patients, a sudden sensation of urgency or urgency-type leakage may develop after surgery, or pre-existing symptoms may worsen. This can usually be treated with medication.
• Groin Pain: Temporary or, rarely, persistent pain (2-5%) in the obturator region where the tape passes. It generally decreases over time.
• Painful Intercourse (Dyspareunia): May rarely occur.
• Mesh-Related Complications: Very rarely, problems such as the synthetic tape protruding from the vagina (erosion/exposure), becoming infected, or causing chronic pain have been reported. The quality of the materials used and the surgical technique affect these risks. With current macroporous monofilament polypropylene meshes, these risks are quite low.
• Failure or Recurrence: Rarely, urinary leakage may persist despite surgery or may recur over the years.

Before the surgery, Prof. Dr. Nuray Bozkurt will explain the possible risks and complications specific to you in detail.

Recovery Process After TOT Surgery and Points to Consider

Recovery after TOT surgery is generally fast and uneventful:

• Hospital Stay: Usually the same day or at most 1 night.
• Pain: Usually mild and controlled with simple oral pain relievers. Mild tenderness in the groin area may last a few days.
• Catheter: Usually removed after surgery, but may sometimes remain in place for one day.
• Activity: Light activities can be started the day after surgery. It is recommended to rest for the first 1-2 weeks, then gradually return to normal activities. It is very important to avoid heavy lifting (over 5 kg), straining, strenuous exercise (running, jumping), and sexual intercourse for generally 4 to 6 weeks. This period is necessary for the tape to fully integrate into the tissue and for healing to be complete.
• Hygiene: Vaginal discharge or slight spotting may last a few days. It is recommended to keep the area clean and dry, and to take only external showers. Vaginal douching or tampon use is not recommended.
• Preventing Constipation: A high-fiber diet and adequate fluid intake are important to avoid straining.
• Follow-up: Follow-up examinations are usually performed 1-2 weeks and 4-6 weeks after surgery. Healing and urinary control status are assessed.

TOT Surgery in Ankara: Safe and Effective Treatment with Prof. Dr. Nuray Bozkurt

Prof. Dr. Nuray Bozkurt offers modern and effective treatment methods in Ankara for resolving stress urinary incontinence in women:

• Accurate Diagnosis and Patient Selection: She accurately determines the type of urinary incontinence (stress, urgency, mixed) and carefully selects suitable patients for TOT surgery.
• Priority to Conservative Treatment: Before surgery, she always evaluates and recommends conservative treatment options such as pelvic floor exercises.
• Minimally Invasive Surgical Expertise: She is experienced and knowledgeable in performing minimally invasive surgical techniques such as TOT surgery (or refers patients to specialists who can safely perform this surgery).
• Safe Surgical Environment: She performs (or coordinates) surgeries in Ankara in sterile and safe hospital conditions with the necessary equipment.
• Patient Information: She openly and clearly shares all the details of the surgery, its benefits, possible risks, and the postoperative process with her patients.
• Postoperative Follow-up: She closely follows her patients’ recovery process and provides the necessary support.
• Focus on Quality of Life: Her primary goal in treatment is to resolve her patients’ urinary incontinence problem and restore their quality of life. Easy accessibility is important (0538 983 18 78)(0312 284 00 12).

If you experience urinary leakage (stress type) during activities such as coughing, sneezing, laughing, or exercising, and this is negatively affecting your quality of life, TOT surgery may be a permanent and effective solution for you. To learn more about this modern, minimally invasive surgical method, find out whether it is suitable for you, and plan your treatment process, you can consult Prof. Dr. Nuray Bozkurt at our clinic in Ankara. To make an appointment, please contact us at 0538 983 18 78.