I was interested to read the communication from Morton and Hilton1 describing their tertiary referral experience of urethral injuries following the insertion of various mid-urethral tapes. The occurrence of urinary tract injury with tension-free vaginal tape (TVT), led in part to the development of the obturator tapes (i.e. TOT), with a suggestion that routine cystourethroscopy was not required with TOT in uncomplicated procedures. Meta-analyses of studies comparing TVT with TOT (in its various forms) have subsequently suggested a reduced urinary tract perforation rate with the TOTs,2 and in many parts of the UK, a TOT is now the first line surgical treatment of stress urinary incontinence, in place of TVT, with this as the suggested justification.

In my personal series of TVTs, the bladder perforation rate has been 0.3% (2 in 650), mainly due, I believe, to routine transvaginal, retropubic hydrodisection with 100 ml of 0.5% prilocaine solution. With care, the perforation rate can be very much less than the IQR of 3–7%. We should therefore be reluctant to change from conventional retropubic TVT to an obturator tape to reduce what can be a tiny incidence of bladder perforation, in view of the longer efficacy data available for TVT. (5-year follow up from comparative controlled trials3 and now 11 years in the Scandinavian cohort study).4 I do insert TOTs in randomised controlled trials, and in patients with previous retropubic surgery with scarring. Despite my low bladder perforation rate, however, I will continue to recommend routine cystoscopy during TVT or TOT placement, to avoid the serious consequences of any missed bladder or urethral perforation. Because of the small risk of urethral trauma with TOTs, it may also be sensible to urethroscope with a 0° scope for the urethra, and a conventional 70° scope for the bladder.

Primum non nocere.


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