Development of a Retropubic Tension-free Vaginal Tape (TVT) Simulation Model and a Clinical Teaching

Presented By
Dr. Jayesh Tigdi
Dr. Naomi Reaka
Dr. Carolyn Best
Dr. Ola Malabarey

Affiliations
McMaster University

See full transcript here: https://cansagevideos.com/development-of-a...

In this video from myself and colleagues at McMaster University we describe the development of a retropubic TVT simulation model and its use via a clinical teaching video for OBGYN residents.

The objectives of this video are to provide background clinical information on the relevance of TVT insertion skill learning and the benefits of simulation for this surgery. We will demonstrate the use of the TVT simulation model in a teaching video directed for OBGYN residents as a part of our future research study.

Stress urinary incontinence is the involuntary leak of urine with increased intraabdominal pressures such as when coughing, laughing, or sneezing. Prevalence estimates range between 10 to 55% among females aged 15 to 64 years old. Risk factors include those that weaken the pelvic floor.

Evaluation for SUI includes a focused history, physical examination, and ruling out voiding dysfunction with a post-void residual. As this is a quality-of-life issue, acceptability of various treatment options depend on the risk, benefit profile for the patient.

Expectant management, pelvic floor physiotherapy, pessaries, and various surgical managements are available. The number one surgical standard of treatment of SUI, given in large part due to its high success rate and shortened OR time requirements, is the TVT.

As the TVT insertion process relies on passage through pelvic spaces where there is an intricate condensed network of blood vessels and organs, there is a risk of haemorrhage and a 0.5% risk of iliac artery injury. Bladder and urethral injury are also possible risks. Listed here are possible postop complications.

The importance of proper movement of the TVT insertion trochar is essential as this is a blind skill. Preceptors watching cannot see the path of the trochar and learners may not be familiar with the path the trochar is supposed to take. This can create heightened anxiety and discomfort for both the preceptor and learner.

We know from an abundance of literature that simulation can help with surgical skills. Also, discomfort with surgical skills has been shown to be associated with perceived inferiority and performance, resulting in less confidence in the skill.

Practitioners therefore may not offer this skill to patients placing the burden on those patients waiting for this surgery for specifically trained surgeons.

We therefore sought to develop a TVT simulation model that was both affordable and easy to assemble. The total cost was under $100 with the majority arising from infrastructure materials such as the pelvic model. Expired TVT kits were donated to us, and the tissues were simulated with modelling clay that could be reformed and reused.

In this simulation we demonstrate the surgical steps to residents using the created model. We start by demonstrating how to handle the trochar and insert the sheath, followed by proper placement and motions for placement of the sheaths. Confirmation of appropriate placement and tensioning will also be discussed. Tips will be given along the way from an expert surgeon.

So, this patient’s already had her counselling done. She’s in the operating room under an anaesthetic. She is in lithotomy position and her bladder is empty with a Foley catheter in place. You could use the catheter introducer to deviate the urethra and the bladder away from the site of insertion. So, we’re assuming that the tunnels are already created.

So, we will start on the right side of the patient with the urethra and the bladder deviated to the opposite side holding the TVT on top with a proper grip to avoid having the tissues try and push your hand sideways. So, you’re in full control.

So, we’ll start by going into the right tunnel of the bisection. Throughout the insertion your index of your nondominant hand is pinching the tip of the trochar between the patient and your finger. So, you’re holding it tight and guarding it, making sure you’re not perforating through the vaginal tissue.

As soon as the tip is right under the inferior pubic rami you keep your finger there pinching your trochar so it doesn’t go any further and you immediately drop your hand to change the angle.

The idea is hugging the bone with the TVT insertion. The closer you hug the bone, the less likely you are to perforate the bladder which is represented here with the Styrofoam.

 And you can see that the trochar is really hugging the bone. You’re not aiming lateral because then you can get blood vessels or nerves. And you’re basically aiming towards the patient’s ipsilateral shoulder.