Normal Vaginal Delivery After a Tension-Free Vaginal Tape Procedure: Case Report and Literature Review

Abstract

Background: Tension-free vaginal tape (TVT) is a widely used method for the surgical treatment of stress urinary incontinence (SUI). TVT is to considered to be a safe and effective procedure, with an enduring high success rate. This article presents a case of a woman, who had an uncomplicated vaginal delivery 3 years after having underwent a TVT procedure. Case: A 41-year-old woman, gravida 4, para 1, with an uneventful pregnancy course was referred to the hospital at 39 2/7 weeks of gestation because of premature rupture of the membranes. Her past history was characterized by an uncomplicated and successful TVT procedure performed 3 years prior, which was inserted after her first delivery to treat severe SUI. One month before the current delivery, a urogynecologist of the hospital visited the patient and considered a vaginal delivery to be possible. No signs of SUI were noted. Results: Five hours after admission to the hospital, this patient had an uncomplicated vaginal delivery of a healthy newborn. Three days later, she was discharged in good condition without any signs of incontinence. The patient had a clinical and sonographic examination 6 weeks after the delivery, and the TVT was still in a correct position without evidence of recurrence of SUI. Conclusions: A vaginal delivery after TVT seems to be possible without an increased risk of recurrence of SUI. Therefore, a TVT procedure, even if childbearing is not completed, can be an interesting therapeutic option. A study with a long term follow-up is needed to confirm this. (J GYNECOL SURG 29:27)

Introduction

Urinary incontinence is a disorder that affects, throughout the lifecycle, ∼26%–57% of women.^1,2 Stress urinary incontinence (SUI) represents ∼50% of people urinary incontinence and is considered to be a condition that is increasing, especially in young women.^1,2 SUI is defined as “the involuntary loss of urine, which occurs when, in the absence of a simultaneous detrusor contraction, the intravescical pressure exceeds the maximum urethral pressure.”³ The diagnosis can be made through an urodynamic examination. The surgical treatment of SUI is a tension-free vaginal tape (TVT), a widely used procedure that is considered to be safe and effective, with an enduring high success rate.⁴ For the development of SUI, the first delivery and high parity are considered as important risk factors, particularly in the ages between 24 and 34 (relative risk [RR] 2.2; 95% confidence interval [CI] 1.8–2.6).⁵ For this reason, to avoid recurrence, many physicians recommend surgical treatment only when childbearing is completed.⁶

Despite this, TVT is considered a minimally invasive surgical procedure that can offer a definitive treatment for SUI. At this time, there is no official guideline for obstetric management of women who have undergone the TVT procedure, but only a tendency not to encourage spontaneous delivery in similar situations. Currently, there are no studies that have evaluated the impact of TVT with respect to pregnancy and delivery; only a few individual case reports exist. This article describes an additional case in which a woman, 3 years after a TVT procedure, had an uncomplicated vaginal delivery. In addition, this article provides some review of the literature about this interesting topic.

Case

A 41-year-old woman, gravida 4, para 1, was referred to the hospital at 39 2/7 weeks of gestation because of a premature rupture of her membranes. Her past history was characterized by an uncomplicated and successful TVT procedure that had been performed 3 years prior to treat SUI (degree: 2–3). The TVT was inserted after the delivery of her first child (3505 g). The actual pregnancy, besides an in-vitro fertilization as a consequence of a second-degree infertility, had an uneventful course. The patient did not not report any urinary incontinence during this last pregnancy.

One month before her current delivery, she came to the hospital's specialist to discuss the mode of delivery. Because of her past TVT operation, a urogynecologist saw the patient and considered a vaginal delivery as possible. No signs of SUI were noted in this patient. The prolene tape of the TVT was seen on sonographic imaging as intact and positioned correctly. The patient was informed about the lack of information about the mode of delivery in such cases, but was also told that, finally, the current authors could recommend that she undego a spontaneous delivery.

Results

Five hours after admission to the hospital she had an uncomplicated vaginal delivery of a healthy newborn with a birthweight of 3135 g. Three days later, the patient was discharged in good condition without any signs of incontinence. The patient had a clinical and sonographic examination 6 weeks after her delivery and the TVT was still in a correct position without any evidence of recurrence of SUI.

Discussion

The mode of delivery, as demonstrated by Rortveit et al., plays an important role in the onset of SUI.⁵ Direct injury of the pelvic floor (episiotomy or up to third-degree tears) after vaginal delivery, as well as neural damage (that may occur with a prolonged second stage of labor), can compromise a patient's fecal and urinary continence. This was confirmed by a large study, which included 27,900 participants, in whom the prevalence of SUI in nulliparous women was 4.7%; in women who underwent only cesarean section, SUI occurrence was 6.9% (odds ratio [OR]: 1.5), and in women after vaginal delivery SUI occurrence was 12.2% (OR: 2.3), respectively.⁵

Despite these results, cesarean section cannot be considered at all as a protective factor against the development of SUI, mainly, because the frequency varies according to the published studies and the prevalence of severe SUI is not associated with mode of delivery.^5,7,8 These controversial data suggest that pregnancy itself can be considered as a risk factor for SUI. During pregnancy, a woman undergoes a profound and reversible anatomical and physiologic change. Her enlarged uterus and increasing weight, as well as the modified biochemical properties in the connective tissue of fascial structures in her pelvic floor, can favor the onset of SUI; these phenomena can explain why SUI already appears fairly frequently during pregnancy. Van Brummen et al. observed that at 12 weeks of gestation 18% of women had a SUI but it increased up to 42% at the end of pregnancy.⁹ An interesting aspect is that women, who develop SUI until the 12th week of gestation have an elevated risk, showing a sort of predisposition, to have urinary incontinence after the birth.⁹

Today, there are several potential ways to treat SUI. The conservative approach includes pharmacologic treatment, use of support devices, and pelvic-muscle training. With respect to the surgical approach, using TVT has become the procedure of choice for primary surgical treatment of SUI.¹⁰ Many studies have shown that this surgical procedure, which is considered to be minimally invasive, has a higher efficacy rate than conservative treatment (90% versus 40%) and very low mortality/morbidity, compared to other operations.^10–12

For this reason it is clear that, in future, we will have more and more young women whose SUI will be cured via a surgical procedure (TVT) at a stage in life when family planning is not concluded.

In the literature there were only case reports, which are summarized in Table 1, concerning pregnancy and the mode of delivery after TVT.^13–19 Arunkalaivanan et al. published the results of a questionnaire, distributed in the United Kingdom, about pregnancy after TVT procedure.²⁰ In this survey, 23% of the gynecologists who were questioned, considered the desire for future childbearing in patients who had received TVT not an absolute contraindication for it. However, 91% of these gynecologists recommended cesarean section as a mode of delivery in women who are continent during pregnancy.²⁰ Table 1 shows only the cases found in the literature with complete data sets. Most cases reported (10/13) had a vaginal delivery after TVT without any problems. Two of 3 patients reported that they had incontinence after vaginal delivery, but had presented with SUI also during pregnancy. All the other women—the current case included—had no problems after giving birth. This result was probably obtained because of good suburethral support established by tape-induced fibrosis in these cases.

Table 1.

Case Reports in the Literature About Urine Incontinence in Pregnancy and Mode of Delivery After Mid-Urethral Sling Procedure

Authors	Age	Para	Time of surgery before pregnancy	Continent status during pregnancy	Mode of delivery	Continence After delivery
Iskander et al.¹³	34	2	9 months	Continent	CS	Continent after 6 months
Gauruder-Burmester et al.¹⁴	39	4	3 months	Continent	CS	Continent after 2 months
Vella et al.¹⁵	42	2	4 years	Continent	CS	Continent after 3 years
Panel et al.¹⁶	36	2	9 months	Continent	CS	Continent after 22 months
Panel et al.¹⁶	37	4	3 months	Continent	CS	Continent after 13 months
Panel et al.¹⁶	28	2	24 months	Continent	CS	Continent after 18 months
Panel et al.¹⁶	31	1	36 months	Continent	CS	Continent after 4 months
Panel et al.¹⁶	32	2	24 months	Continent	CS	Continent after 38 months
Panel et al.¹⁶	39	3	36 months	Continent	CS	SUI
Groenen et al.¹⁷	28	1	2 years	Continent	CS	UI
Seeger et al.¹⁸	37	1	1 month	Unknown	Vaginal delivery	Continent after 5 months
Vella et al.¹⁵	42	1	3 years	Continent	Vaginal delivery	Continent after 2 years
Hassan et al.¹⁹	36	1	3 weeks of gestation (TOT)	Continent	Vaginal delivery	Continent after 2 months
Panel et al.¹⁶	31	2	4 months	Continent	Vaginal delivery	Continent after 15 months
Panel et al.¹⁶	39	1	5 months	Continent	Vaginal delivery	SUI
Panel et al.¹⁶	32	2	36 months	Continent	Vaginal delivery	Continent after 14 months
Panel et al.¹⁶	36	3	7 months	MUI	Vaginal delivery	Continent after 8 months
Panel et al.¹⁶	38	3	27 months	Continent	Vaginal delivery	Continent after 3 months
Panel et al.¹⁶	20	1	18 months	SUI	Vaginal delivery	SUI
Panel et al.¹⁶	38	1	7 months	Continent	Vaginal delivery	Continent after 5 months
Panel et al.¹⁶	34	4	51 months	Continent	Vaginal delivery	Continent after 3 months
Groenen et al.¹⁷	33	2	4 months	SUI	Vaginal delivery	SUI
Schryba et al.	41	1	3 years	Continent	Vaginal delivery	Continent after 2 months

CS, cesarean section; TOT, trans-obturator tape; SUI, stress urinary incontinence, UI, urge incontinence; MUI, mixed urinary incontinence.

In another group of women who underwent cesarean section (Table 1), 2 of 10 had recurrence of SUI. However, in those cases no recurrence of SUI presented during pregnancy.

All the cases found in the literature are not enough to provide statistical relevance for recommending vaginal or a cesarean delivery after TVT, but these cases seem to indicate that vaginal delivery can be a good, practical option without the potential surgical risks of a cesarean delivery.

In the current case, as well as those in some reports, the prolene tape of the TVT remained intact in the same position before, during, and after pregnancy. In addition Riachi et al. described 2 patients with recurrent SUI during pregnancy in which a repeated TVT procedure was performed successfully.²¹ The previous sling was not removed in each of these 2 patients, and no intraoperative or postoperative complications occurred.²¹ Another study demonstrated that a TVT performed for SUI after a previous failed surgical procedure had a success rate of 82%. In this study the follow-up was 4 years, and only 9% of the patients had significantly reduced SUI.²²

Conclusions

A vaginal delivery after TVT seems to be possible without an increased risk of recurrence of SUI. Therefore, a TVT procedure, even if childbearing is not completed, can be an interesting therapeutic option. A study with a long-term follow-up is needed to confirm this.

Footnotes

Disclosure Statement

None of the authors of this article have financial interests connected with this case report.

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