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Midurethral Sling Trocars (TVT / TOT)

Device-specific passers used to place a midurethral sling through a retropubic (TVT) or transobturator (TOT) route, or to deploy a single-incision sling. These are different implant-and-passer systems, not one interchangeable tape that can be routed with any trocar. "Tunneller" appears in the early Petros / Ulmsten literature; this page uses trocar for the relevant passers while distinguishing the Raz-Pereyra, Stamey, and suprapubic catheter devices.[1][2][14]

For the procedure-level page (indications, outcomes, AUA/SUFU positioning), see the Female SUI database.

Trocar Family​

Trocar / passerApproachTrajectoryDirectionDesign note
TVT EXACT (Gynecare/Ethicon)RetropubicAlong the posterior pubic bone through RetziusVaginal → suprapubic in this product's IFUSingle steel-shaft/plastic-handle trocar loaded sequentially into two implant-connected sheaths[14]
IVS tunneller (Petros / Ulmsten, 1990s)RetropubicVerticalBottom-to-top90° with delta-wing handle and blunt wedge tip
TOT trocar (Delorme, outside-in)TransobturatorHorizontal through obturator membraneSkin → vaginaHelical / curved
TVT-O trocar (de Leval, inside-out)TransobturatorHorizontalVagina → skinHelical / curved
Single-incision mini-sling inserterSingle-incisionDevice-specific anchor deploymentVaginal approachInserter and fixation vary by product; follow its IFU. Its comparative trial evidence is separate from full-length route comparisons.[5]
Stamey needle (reported non-kit TOT passer)TransobturatorUsed in a historical, self-prepared-mesh seriesFollow the described technique, not a generic directionSuture carrier used as a passer; not an interchangeable commercial-kit trocar[3]

Design Notes​

Retropubic (TVT) trocar​

  • TVT EXACT specifically. One polypropylene mesh implant held between two white trocar sheaths; a single-use steel-shaft and plastic-handle trocar is inserted into each sheath in turn. Its separately available rigid catheter guide is reusable. Do not extrapolate these components or reprocessing rules to another kit.[14]
  • The IVS and later TVT designs differ in curvature and handling, but an asserted 90° to 120° change is not established here as a causal explanation for bladder perforation.[1]
  • Bleeding has been reported with TVT EXACT; a device-specific complication reduction cannot be inferred from shaft dimensions or a two-case report.[4]
  • The retropubic pass is not directly visualized. Cystoscopy after both passes and before positioning the implant is specified in the TVT EXACT IFU; EAU 2026 gives a strong recommendation for cystoscopy to check for bladder perforation when inserting a synthetic midurethral sling, and a strong recommendation to inform women that long-term outcomes are superior with the retropubic route.[14][15]

Transobturator (TOT) trocars​

  • Curved / helical to traverse the obturator membrane horizontally.
  • Outside-in (Delorme). Enters at the groin incision and exits the vaginal dissection. In a small cadaver study, the tape was farther from the obturator canal (2.3 cm) but closer to the ischiopubic ramus (0.04 cm); these are anatomic measurements, not patient complication rates.[6]
  • Inside-out (de Leval / TVT-O). Exits the skin from the vaginal entry. The same cadaver study measured 1.3 cm to the canal and 0.39 cm to the ramus. A mixed-design review found fewer vaginal-angle injuries with inside-out (OR 0.14); its groin-pain trend was not statistically conclusive.[6][7]

Reconstructive-Urology and Urogyn Uses​

The trocar is the procedure-defining instrument for:

  • Retropubic TVT. An established synthetic MUS option for selected women with primary SUI.
  • TOT / TVT-O. An alternative route where retropubic passage is less suitable, after counseling about route-specific benefits and harms. UK NICE guidance is more restrictive: do not offer transobturator MUS unless specific clinical circumstances make the retropubic approach unsuitable.[16]
  • Selected higher-risk SUI populations (including ISD, obesity, recurrent SUI or concomitant POP). A mixed-design meta-analysis favored retropubic over transobturator MUS for objective and subjective cure; this does not prove benefit in every subgroup or dictate device choice for an individual.[8]
  • Historical self-prepared mesh series. Zyczkowski and colleagues used a Stamey needle for both their branded and modified TOT cohorts. Their sequential, nonrandom cohorts also differed by mesh preparation; the study does not establish Stamey-versus-helical-trocar equivalence or safety.[3]

Tape-to-Urethra Distance — Tensioning Technique​

The pass is only part of the operation; suburethral tensioning depends on the system and technique. Examples from the literature are not interchangeable IFUs:

  • Ulmsten original. 16 Fr Foley intraurethral plus Metzenbaum scissor blade (3–5 mm) between tape and urethra.[9]
  • TOT 8/4 (Ludwig 2016). Hegar 8 intraurethral plus Hegar 4 suburethral during placement. In two small, nonrandom, single-center cohorts using a specified PVDF TOT, a postoperative 3–5 mm tape–urethra distance was observed in 29/35 (83%) versus 13/46 (28%); this is a positioning observation, not proof of superior continence or safety with other kits.[9]

Complication Profile by Trocar​

ComplicationRetropubic trocar (TVT)Transobturator trocar (TOT / TVT-O)
Bladder perforationHigher: TOMUS observed 15/298 retropubic vs 0/299 transobturator; cystoscopy required by TVT EXACT IFULower, not zero; EAU still recommends cystoscopy for all synthetic MUS[10][14][15]
Vascular / bowel injuryUncommon but potentially seriousUncommon; risks vary with route, anatomy and device
Postoperative voiding dysfunctionHigherLower
Groin / thigh painLower in pooled route comparisonsHigher in pooled route comparisons; rate depends on outcome definition and follow-up[2]
Vaginal-sulcus perforationN/AHigher with outside-in vs inside-out (OR 0.14 for inside-out)[7]

Outcomes Summary​

  • TOMUS trial (Richter 2010). Its prespecified objective composite met equivalence at 12 months (80.8% retropubic versus 77.7% transobturator); its subjective composite did not meet the equivalence criterion (62.2% versus 55.8%).[10]
  • Five-year outcomes vary by trial, endpoint and population; consult the specific study rather than applying one 80–90% cure estimate to both routes.[8][11]
  • Operative time and hospital stay slightly shorter with TOT.[12]
  • Guideline context. AUA/SUFU includes synthetic MUS among surgical options for appropriately selected patients; EAU recommends intraoperative cystoscopy; NICE limits transobturator use in the UK. These are jurisdiction-specific recommendations, not a single universal route preference.[13][15][16]

Limitations​

  • Blind retropubic passage. The trajectory is not directly visualized; follow the device-specific IFU and inspect the lower urinary tract intraoperatively.[14]
  • Vascular and obturator-canal proximity. The few centimeters between safe and unsafe trocar trajectories are anatomically tight, particularly in the obese pelvis and the patient with prior retropubic surgery.
  • Regulatory and guideline differences require country-specific consent and device checks. In particular, NICE's transobturator and single-incision restrictions differ from US route options; vaginal prolapse mesh policy must not be silently substituted for SUI sling policy.[13][15][16]

References​

1. Petros P, Abendstein B. "The mechanics of urethral closure, incontinence, and midurethral sling repair. Part 3 surgical applications (1990–2016)." Neurourol Urodyn. 2019;38(2):818–24. doi:10.1002/nau.23840

2. Ford AA, Taylor V, Ogah J, et al. "Midurethral slings for treatment of stress urinary incontinence review." Neurourol Urodyn. 2019;38 Suppl 4:S70–5. doi:10.1002/nau.24030

3. Zyczkowski M, Nowakowski K, Kuczmik W, et al. "Tension-free vaginal tape, transobturator tape, and own modification of transobturator tape in the treatment of female stress urinary incontinence: comparative analysis." Biomed Res Int. 2014;2014:347856. doi:10.1155/2014/347856

4. Masata J, Svabik K, Martan A. "Bleeding complication with the TVT-Exact procedure: a report of two cases." Int Urogynecol J. 2015;26(2):303–5. doi:10.1007/s00192-014-2494-7

5. Abdel-Fattah M, Cooper D, Davidson T, et al. "Single-incision mini-slings for stress urinary incontinence in women." N Engl J Med. 2022;386(13):1230–43. doi:10.1056/NEJMoa2111815

6. Zahn CM, Siddique S, Hernandez S, Lockrow EG. "Anatomic comparison of two transobturator tape procedures." Obstet Gynecol. 2007;109(3):701–6. doi:10.1097/01.AOG.0000255662.79008.18

7. Madhuvrata P, Riad M, Ammembal MK, Agur W, Abdel-Fattah M. "Systematic review and meta-analysis of 'inside-out' versus 'outside-in' transobturator tapes in management of stress urinary incontinence in women." Eur J Obstet Gynecol Reprod Biol. 2012;162(1):1–10. doi:10.1016/j.ejogrb.2012.01.004

8. Kim A, Kim MS, Park YJ, et al. "Retropubic versus transobturator mid urethral slings in patients at high risk for recurrent stress incontinence: a systematic review and meta-analysis." J Urol. 2019;202(1):132–42. doi:10.1097/JU.0000000000000222

9. Ludwig S, Stumm M, Mallmann P, Jager W. "TOT 8/4: a way to standardize the surgical procedure of a transobturator tape." Biomed Res Int. 2016;2016:4941304. doi:10.1155/2016/4941304

10. Richter HE, Albo ME, Zyczynski HM, et al. "Retropubic versus transobturator midurethral slings for stress incontinence." N Engl J Med. 2010;362(22):2066–76. doi:10.1056/NEJMoa0912658

11. Laurikainen E, Valpas A, Aukee P, et al. "Five-year results of a randomized trial comparing retropubic and transobturator midurethral slings for stress incontinence." Eur Urol. 2014;65(6):1109–14. doi:10.1016/j.eururo.2014.01.031

12. Huang ZM, Xiao H, Ji ZG, Yan WG, Zhang YS. "TVT versus TOT in the treatment of female stress urinary incontinence: a systematic review and meta-analysis." Ther Clin Risk Manag. 2018;14:2293–303. doi:10.2147/TCRM.S169014

13. Kobashi KC, Vasavada S, Bloschichak A, et al. "Updates to surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline (2023)." J Urol. 2023;209(6):1091–8. doi:10.1097/JU.0000000000003435

14. Ethicon. GYNECARE TVT EXACT™ Continence System and Reusable Rigid Catheter Guide: Instructions for Use. LAB0012869v7; February 2021. English pp. 4–7.

15. European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS: Disease Management, surgical-treatment recommendations (accessed September 2026).

16. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management (NG123), Recommendations, recommendations 1.5.10 (transobturator approach) and 1.5.11 (top-down retropubic and single-incision slings only within a clinical trial); accessed September 2026.