stress urinary incontinence ( sui ) is defined as the involuntary leakage of urine on effort , exertion , or coughing . these symptoms always cause a negative impact on quality of life , such as the physical , psychological , and social well - being of the affected women . surgery is the most effective treatment for sui . in 2001 , delorme described an attempt to reduce the morbidity of retropubic needle passage , an alternative approach with a transobturator tape ( tot ) . the tot procedure has been progressively developing to avoid bladder injury , nerve injury , and operation wound complications . with the tot procedure , however , it is difficult to apply the correct degree of tension during surgery . davila et al noted that there was less voiding dysfunction after tot than after the tension - free vaginal tape ( tvt ) procedure . when the tape is too loose , incontinence persists . on the other hand , when the tape is too tight , urinary obstruction occurs . errando et al noted that the remeex system ( mechanical external regulation ) allows the readjustment to be performed 24 hours after the operation . in an initial report on 21 cases at 12 months of follow - up , the procedure was safe and successful , but serious though rare complications have been reported with this technique , including bladder injury and wound infection . thus , the transobturator adjustable tape ( toa ) was developed to reduce these complications . the adjustable transobturator tape has been shown to allow for adjustment of tension for several days after surgical intervention , thus permitting correction of postoperative symptoms . several different midurethral sling systems are commercially available , but the new adjustable sling operation has not been well studied . in this study , we present a retrospective comparison of the results and complications associated with the toa and tot procedures by one urologist after short - term follow - up . we reviewed the files of 103 women referred to our hospital for suburethral tape between june 2008 and june 2009 . each patient underwent one of two techniques ( toa : a.m.i toa sling , agency for medical innovations gmbh , austria ; tot : tension free obturator tape , dowmedics , korea ) in accordance with the scheduling order . all patients were given a routine workup for incontinence , including history , physical examination , stress cough test , standard 1-hour pad test , uroflowmetry , post - void residual ( pvr ) urine measurement , and the complete multi - channel urodynamic study . all medical charts were retrospectively reviewed for certain data , including age , body weight , height , urodynamic study , and type of suburethral tape . our study excluded the presence of any urinary tract infection , urgency incontinence , detrusor overactivity , intrinsic sphincteric deficiency ( isd ) , impaired detrusor contraction , previous anti - incontinence , and pelvic support surgery . we excluded patients who had pelvic prolapse greater than stage i on the international continence society ( ics ) grading system . during the pelvic examination , the severity of the vaginal wall defect was determined by using the pelvic organ prolapse quantification ( pop - q ) system . the stress cough test was performed with the patient in the standing position with 300 ml bladder filling . urodynamic study was performed with the patient in a birthing chair at a 45-degree angle . after catheterization , cystometry was performed by using a laborie 8 fr double - lumen urodynamic catheter at a fill rate of 50 ml per minute . first desire , strong desire , and maximal cystometric capacity were recorded . the valsalva leak point pressure ( vlpp ) , a measurement of the lowest abdominal pressure required to produce urine leakage , was also recorded . the vlpp was obtained with the subject seated when the total infused volume of sterile water reached 300 ml . a vlpp value of less than 60 cmh2o was used as the urodynamic criterion for the diagnosis of isd . routine postoperative follow - up for all patients included office visits at postoperative 7 days and at 3 months . at postoperative 7 days , patients underwent a stress cough test and uroflowmetry and residual urine volume measurement . at the 3-month follow - up sui cure was defined as no leakage of urine during cough stress testing and a pad weight gain of less than 2 g on a 1-hour pad test during the follow - up visit . improvement was defined as a more than 50% reduction of urine weight on a 1-hour pad test and a positive result on the stress cough test . failure was defined as less than a 50% reduction on a 1-hour pad test and a positive result on the cough stress test . patients who checked ' very satisfied ' or ' satisfied ' were placed in the satisfaction group . severe pain was defined as the presence of pain still requiring analgesic therapy 1 week after surgery . the toa tape is situated below the mid - urethra via a small incision in the anterior vaginal wall . two strings on either side are situated 1.5 cm from the midline of the tape , which is externalized via the anterior vaginal wall . when it is pulled down to reduce tension , the toa group is formed of three strings in each branch of the tape situated at the same distance from both thighs . these are externalized via the same orifice through which the mesh is , when pulled up , to increase the tension . the tension is adjusted with minimal tension by placing the scissors between the tape and the urethra . the plastic envelope is removed , and the redundant portion of the mesh is cut . depending on the distance from the urethra to the skin , one or two of the lateral superior strings are also cut . the foley catheter was removed the next day , and the patients underwent studies that included measurements of flow rate and pvr before being discharged home . comparison of baseline patient characteristics as well as baseline uroflowmetric parameters was performed by using the independent t - test and chi - square test . the repeated - measures anova test was used to compare changes in clinical outcomes between the two groups . a total of 103 participants underwent the toa procedure ( n=40 ) or the tot procedure ( n=63 ) . there were no significant differences in preoperative characteristics between patients in the toa and tot groups ( table 1 ) . the meansd operating time was 20.42.5 minutes in the tot group and 22.52.7 minutes in the toa group . 3.0 days in the tot group and 3.2 days in the toa group . there was no significant difference . table 2 shows the objective and subjective outcomes of both groups 3 months after surgery . the overall cure rate was 90% at 3 months in the toa group vs. 85.7% in the tot group . the satisfaction rate was higher in the toa group than in the tot group ( 95.0% vs. 85.6% ) . lee et al noted that the cure rate of the tot procedure was 92% and the satisfaction rate was 98% . four patients in the toa group ( 10% ) needed loosening of the mesh because of urinary obstruction ( flow < 10 ml / s and/or residual urine>50 ml ) after postoperative day 1 . in 2 patients ( 5.0% ) in the toa group , the tension of the mesh was tightened because of a certain degree of continuing incontinence after postoperative day 1 . uroflowmetry tests performed before and after surgery showed that flow in the tot group ranged from 22.61.5 ml / s to 18.91.9 ml / s , whereas that in the toa group ranged from 32.110.4 ml / s to 30.06.2 ml / s ( table 3 ) . the change in residual urine volume was significantly lower in the toa group than in the tot group ( 7.8 ml vs. 43 ml , p=0.01 , repeated - measures anova test ) . there was no definite difference in voiding volume or maximal urine flow between the two groups . vaginal wall injury occurred in 3 patients ( 4.8% ) in the tot group and urethral perforation occurred in 1 patient ( 2.5% ) in the toa group . we promptly repaired the vaginal wall injury , and the patient with urethral perforation was catheterized for 3 days . there were no cases of wound infection , tape erosion , or urinary tract infection ( wbc>5 in urine analysis ) in either group . five patients ( 12.5% ) in the toa group tended to still have continuing groin pain 3 days after surgery . the incidence of such pain was 6.3% of the tot group compared with 5% of the toa group 7 days after surgery . the cause of these results may have been that with the toa procedure the strings remained until the end of the adjustment period . three patients in the toa group had improved pain 1 week after surgery , but two patients ( 5% ) had persistent groin pain until 1 week after surgery . four patients ( 6.4% ) in the tot group had thigh pain , and we continued to order analgesic agents 1 week after surgery . postoperative urinary obstruction was seen in 8 patients ( 12.8% ) in the tot group . three patients ( 4.8% ) in the tot group had persistent obstructive voiding symptoms ( flow rate<10 ml / s and/or residual urine>50 ml ) at the 3-month follow - up visit . these patients still showed no improvement , so we performed urethrolysis at 3 - 5 months after surgery . one patient ( 2.5% ) in the toa group had a complication of urethral obstruction at 3 months after surgery ; this case required urethrolysis at 5 months after surgery . we retrospectively reviewed the data for 103 women referred to our hospital for suburethral tape operation only . the mean age , parity , height , body weight , preoperative clinical parameters , and preoperative urodynamic parameters were similar in both groups . the patients did not have pelvic organ prolapse ( pop : stage2 ) , isd , bladder outlet obstruction , or impaired detrusor muscle contraction . the cure rate of the tot procedure varies from 51% to 97% , depending on the definition used for success , the outcome instruments , and discrepancies in the studied populations [ 5,12 - 15 ] . maroto et al noted in their results of the toa procedure that 90% of the patients were objectively stress continent , 6.5% of the patients had considerable improvement , and 3.5% of the patients experienced failure during the mean follow - up period of 24.7 months . in the present study , the cure rate associated with the toa procedure was 90% and was comparable to the 85.7% cure rate associated with the tot procedure . the high cure rate of the toa procedure resulted from the adjustable system after the immediate postoperative period . we noted a higher satisfaction rate for the toa group ( tot : 85.6% ; toa : 95% ) . the two most frequent problems after stress incontinence surgery are persistence of incontinence and voiding dysfunction , both of which are related to how loose or how tight the tape is implanted . despite all the improvements achieved with synthetic slings , stanton et al said as follows : " thus the ideal sling should be of consistent strength , readily available , adjustable and removable . " readjustment was easily performed under local anesthesia . for the toa sling operation , loosening of although most urinary retention resolves with conservative treatment including medication , urethral dilation , or intermittent catheterization , refractory urethral obstruction ultimately requires midline or lateral excision of the tape . davila et al found de novo voiding symptoms after the tot procedure in 6.7% of their operation cases , and in 7% , the preoperative voiding symptoms worsened . tape cutting or tape adjustment were necessary in up to 5% after the tot procedure . in the present study , eight patients ( 12.7% ) in the tot group had undergone urethral pull - down after postoperative 1 day . in urethral pull - down , a hegar dilator is inserted in the urethra and pulled down with the aim of moving downward and loosening the tape in the tot group . if the maximum flow rate is less than 10 ml / s or there is more than 50 ml of residual urine after the toa procedure , tension is released from the mesh by pulling down on one side only of the vaginal strings , approximately 1 cm . the patients were checked again by uroflowmetry and residual urine volume after 3 hours . if the patients showed sui in the cough stress test , then we immediately pulled up the strings on each side , approximately 0.5 cm ( fig . continence was tested , and the procedure was repeated until the patient was continent with a maximum flow rate equal to or greater than 10 ml / s and when there was less than 50 ml of residual urine . we rechecked the results of the cough test and uroflowmetry and residual urine at postoperative 1 week and 3 months . in another study , the tension was adjusted in 44% of patients : in 34% , the tension was increased , and in 10% , the tension was decreased . in the present study , 10% of the patients in the toa group needed a decrease in the tension and 5% of the patients needed an increase in the tension due to a certain degree of continuing incontinence . after tightening or loosening of the mesh , the patients had higher satisfaction and continence and a higher flow rate . a randomized study from finland revealed that 16% of the tot patients had groin pain compared with 1.5% of the tvt patients , which led to an increased need for analgesia in the transobturator group . three cases of vaginal wall injury in the tot group were encountered , indicating that the needle passed through the dissection space between the vagina and the urethra . we performed surgical implantation of the tape with a view of avoiding urethral injury , so the needle passed close to the vaginal surface . urethral injuries are believed to occur because of poor surgical technique , which damages the integrity of the urethral tissue or its blood supply ; because of excessive tension placed on the tape ; or as the result of local infection . the transobturator sling procedure has been shown to have a lower incidence of bladder injury ( 0.5% ) , urethral injury ( 0.5% ) , and lower urinary tract injuries ( 1% ) than does the tvt procedure . we think the recommendation for cystoscopy after passage of the trocars can not be overemphasized , even if the rate of urethral injury was very low , because these complications can be treated promptly in the operation field . we conclude that toa is an effective and simple procedure because the procedure had minimal complications and a high success rate . our results show that the persistence of stress incontinence and the development of obstruction after surgery depend largely on the tension applied to the mesh , looser or tighter , during the procedure . toa allows for postoperative adjustment of tension , thus permitting correction of postoperative incontinence or obstruction . the present study was limited in that the results were recorded until only 3 months after surgery . hence , the study may not properly indicate long - term prospective outcomes . clearly , further follow - up is required , and more comparative studies are warranted to evaluate the outcome and safety of these novel procedures for the treatment of sui . the toa procedure allowed postoperative readjustment of the suburethral sling pressure for a number of days after surgical intervention , which resulted in good short - term results . these data suggest that better objective and subjective results and residual urine volume can be obtained with the toa procedure than are achieved with the traditional non - adjustable mesh and without significant postoperative complications . however , these data had a short postoperative follow - up period and excluded women with sui with co - morbid status . long - term follow - up will be required to fully evaluate the results and safety associated with these procedures .
purposethe transobturator adjustable tape ( toa ) sling operation is a new procedure that allows for the adjustment of tension after surgical intervention , thus permitting correction of postoperative incontinence or obstruction . 
 the aim of this study was to compare the efficacy and safety of toa with that of the transobturator tape ( tot ) procedure.materials and methodsbetween 2008 and 2009 , women with stress urinary incontinence ( sui ) underwent tot ( n=63 ) or toa ( n=40 ) . 
 the preoperative evaluation included history taking , physical examination , voiding diary , stress and 1-hour pad tests , and a comprehensive urodynamic examination . 
 postoperative evaluation was performed at the 1-week and 3-month postoperative follow - up visits.resultsthe overall cure rate was 90.0% for the toa group and 85.7% for the tot group . 
 the rate of satisfaction was higher in the toa group than in the tot group ( 95.0% vs. 85.6% ) . 
 four patients in the toa group needed reduced tension as the result of urinary obstruction . 
 the tension of the mesh was tightened in 1 patient because of a certain degree of continuing incontinence . 
 the residual urine volume was significantly lower in the toa group than in the tot group ( 7.8 ml vs. 43 ml , p=0.01).conclusionstoa allowed postoperative readjustment for a number of days after surgical intervention , which allowed for good short - term treatment outcomes . 
 these data suggest that better subjective and objective results and residual urine volume can be obtained in the toa group than those achieved with the traditional non - adjustable mesh and without significant postoperative complications .