TVT: On midurethral tape positioning and its influence on continence

All known original and Subsequent publications describing the treatment of stress urinary incontinence by means of tension-free vaginal tape (TVT) assert that fixing the tape in a midurethral position is an absolute requirement for restoring continence and avoiding bladder voiding disorders. These studies assume that TVT works by replacing defective pubourethral ligaments inserting at the midurethra. In 20 patients we intraoperatively marked the suburethral position of the tape by metal clips and X-ray-proof string, and documented this postoperatively by X-ray images. In most cases the tape was located in the proximal third of the urethra, which did not cause a higher rate of bladder voiding disorders. All 20 patients became continent through the operation. We do not contest the efficiency of the TVT procedure, but we disprove first, that correctly performed operations always result in the midurethral location of the tape, and secondly that the midurethral position is decisive for its success.