TOT Sling and Groin Pain
Transobturator sling or TOT sling is a known as a second-generation sling and is a type of transvaginal mesh which can cause vaginal, groin and leg pain and can be removed in experienced hands. It was made for the treatment of stress urine incontinence and was introduced into the United States in 2002 in an attempt to minimize intra operative complications associated with the first generation TVT sling including: bleeding, bladder injury and bowel injury. It predecessor the TVT or the tension free vaginal tape sling also known as the retropubic TVT sling was introduced only 4 years earlier in 1998 in the U.S.
 Tension Free Vaginal Tape Sling |
 Transobturator Sling |
Studies have shown the TVT and TOT slings have equivalent cure rates however comparative trials have shown that the TOT slings have more groin pain. This makes sense because this is the pathway of the synthetic mesh of the TOT sling. The TOT sling is placed through a single incision in the vagina just under the urethra and then exits through the groin (the crease between the leg and pelvis) on each side of the vagina. However most of the studies suggesting that the TOT sling can create greater amount of groin pain than the TVT sling which exists at the pubic area are short term studies and claim the pain is most often temporary. Though this might be true in the majority of patients there are still many patients who will have persistent groin, leg and vaginal pain.
Drs Miklos & Moore have learned from listening to patients from all over the world that sometimes the pain is not temporary but instead chronic, severe and potentially permanent. Medical manufacturers and key opinion leaders or thought leaders in the field of urine incontinence surgery have neglected to study or take heed of these patients’ complaints. Slings of any type including: synthetic TVT, synthetic TOT, traditional (using cadaver, cow or pig tissue) or single incision slings (SIS) can cause pain. Most patients who complain of pain usually will describe the pain as vaginal pain with or without intercourse. However, many patients will also complain of a pulling or pain in the groin after a TOT sling procedure.
Drs Miklos & Moore have personally had more than one of “their own” TOT sling placement patients do exceptionally well after the surgery but suffered from complications years later. These patients were cured of urine leakage and were without pain for 5-10 years after surgery and then suddenly they returned to Drs Miklos & Moore with complaints of vaginal and groin pain. This delayed presentation of pain, years after surgery, is consistent with the healing process of synthetic mesh in the human body. It is well known and understood that the synthetic mesh creates a chronic inflammatory reaction which creates scar tissue. The longer there is an inflammatory reaction the greater the scar tissue. The more scar tissue is manufactured by the human body the greater chance the sling contracts, increases tension and pulls on the points of anchoring inside the body. The TOT anchors via scar tissue from the obturator muscles, membrane and leg muscles on each side of the body and as scar tissue increases the sling becomes a rope in a tug of war between the pelvis and groin from each side of the body.
It is not understood why some patients do very well with the TOT sling surgery and others will have pain problems. What is important is if you have a pain problem after a TOT sling find a surgeon who can address your problem. Don’t trust all surgeons to make the correct diagnosis as most surgeons do not believe a TOT sling can cause pain. Choose a surgeon who has a history of making the diagnosis and one who has experience in removing the mesh.
Drs Miklos & Moore have removed hundreds of TOT type slings and remove the portions of the sling which are responsible for the patients’ painful condition. Drs Miklos & Moore attempt to minimize surgical complications and unnecessary morbidity by only removing the mesh which is affecting the patient.
 TOT sling – normal |
 TOT sling – tension |
If a patient only presents with vaginal pain or pain with intercourse and the exam confirms the pain is consistent with the vaginal portion of the TOT sling, Drs Miklos & Moore would recommend a removing only the vaginal portion of the sling. The removal of the vaginal portion of the the TOT sling usually results in a 30 minute surgery and the removal of 5-6 cm (1 inch = 2.54 cm) of mesh. If the patient complains of groin pain and has vaginal pain after the placement of the TOT sling, Drs Miklos & Moore would recommend a complete TOT sling removal which is a much more aggressive surgery and can take as much as 4 hours.
 Partial TOT Removal |
 Complete TOT removal |
The complete TOT removal is one of the most difficult and tedious surgeries which Drs Miklos & Moore perform. If a person is suffering from both vaginal and groin pain and Drs Miklos & Moore’s exam confirms the TOT sling is the cause of her pain then the surgery is recommended.
The surgery is performed through a single vaginal incision (2.5 cm) and two groin incision (6-8 cm). The surgery is meticulous and tedious and it often requires 2-4 hours to remove the whole sling. The patient is usually discharged the very next day and pain rarely exceeds the pain she was experiencing prior to surgery.
The complications of the surgery include: injury to the urethra (<1%), bladder (<1%) or ureters (<1% Drs Miklos & Moore have not had this complication), obturator nerve damage resulting in gait disturbance or difficulty walking (<1% Drs Miklos & Moore have not had this complication), bleeding requiring a blood transfusion (<1% Drs Miklos & Moore have not had this complication), and recurrent stress urine incontinence (> 95%). It is estimated that removal of the whole sling will result in an improvement or cure of pain in 60% of patients, 30% of patients the pain remains the same and in approximately 5-10% the pain gets worse.
Because the TOT sling has rare but devastating complications such as groin and leg pain yet has cure rates equivalent to the TVT sling, single incision sling and the laparoscopic Burch procedure, Drs Miklos & Moore believe the TOT sling should be used as “last resort” treatment for stress urine incontinence or perhaps should not be used at all.
So if you suffer from vaginal, groin or leg pain after a Trans obturator sling ie TOT sling and you want a surgeon with experience, expertise and one who can offer you the best results see Dr Miklos for your evaluation and potential surgery. Do not have a surgeon remove a portion of the sling as this lessens the chance that Dr Miklos can find the sling once it has been cut and or partially removed. The best chance at surgical success is the first attempt at TOT sling removal.