What is TOT Surgery? Recovery Process and Risks

TOT (transobturator tape) surgery is a minimally invasive surgical method used to treat stress urinary incontinence in women—especially when it occurs during coughing, sneezing, laughing, or heavy lifting. By placing a special supportive tape (mesh) through the vagina, the urinary tract is supported much like a hammock. This helps prevent involuntary urine leakage during moments of increased intra-abdominal pressure, offering a highly effective, long-term solution with success rates typically ranging between 90 and 95 percent. Urinary incontinence is not a natural, inevitable consequence of aging or childbirth that you simply have to endure; with this reliable method offered by modern medicine, you can regain your social life and self-confidence.

At a Glance:

TOT surgery is recognized worldwide as one of the gold standards for treating stress urinary incontinence.
The procedure is completed in a short time, averaging 15 to 30 minutes.
It is usually performed under spinal anesthesia (numbing from the waist down) or general anesthesia.
Since the incisions are made inside the vagina, there are no visible surgical scars from the outside.
Patients are typically discharged the day after surgery and can quickly return to their daily routines.
For a full recovery, it is necessary to avoid heavy lifting and strenuous physical activities for the first 6 weeks.

What is Urinary Incontinence in Women and the Transobturator Tape (TOT) Method?

Urinary incontinence is the involuntary leakage of urine beyond a person's control. Much more common in women than in men, this condition arises from the weakening of the pelvic floor muscles or the over-sensitization of the bladder nerves. The pelvic floor muscles are a group of muscles that support the bladder and the urinary tract (urethra) from below. When these muscles weaken, the urinary tract loses its normal anatomical position and cannot remain closed under pressure.

Transobturator tape, commonly known as TOT surgery, aims to artificially rebuild this weakened anatomical support. During the surgical procedure, a synthetic, biocompatible polypropylene tape is placed under the middle section of the urinary tract. This tape does not lift the bladder neck; instead, it creates a solid foundation that prevents the urinary tract from sagging downward when intra-abdominal pressure increases. Thus, when a patient sneezes or laughs, the urinary tract rests against this tape and closes, preventing urine leakage.

Types of Urinary Incontinence and Their Main Causes

To determine the correct treatment method for patients presenting with urinary incontinence, identifying the type of the problem is crucial. This is because the mechanism and treatment of each type of incontinence are different. If you would like more detailed information about the different types of the condition, you can also review our article titled Urinary Incontinence: Causes, Types, and Treatment Options.

Stress Urinary Incontinence: This is the leakage of a few drops or more of urine during physical actions that increase intra-abdominal pressure (coughing, sneezing, laughing, exercising, climbing stairs). This is the group for which TOT surgery is most frequently applied and most successful.
Urge Urinary Incontinence: This is the condition of leaking urine before reaching the toilet, accompanied by a sudden, intense urge to urinate. It is generally associated with overactive bladder syndrome and is treated with medications rather than surgery.
Mixed Urinary Incontinence: These are cases where both stress and urge types are seen together. The treatment plan is shaped according to which type is more dominant.
Overflow Urinary Incontinence: This is the continuous leakage of urine as a result of the bladder's capacity being exceeded due to incomplete emptying.

The main causes and risk factors, especially for stress urinary incontinence, include having multiple normal (vaginal) deliveries, giving birth to large babies, obesity, chronic constipation, chronic cough due to smoking, and menopause. With menopause, the decrease in the estrogen hormone leads to the weakening of the vaginal tissues and the muscles around the urinary tract, significantly increasing this risk.

Urinary incontinence usually begins with mild symptoms. Initially, it may only be seen as a few drops during very severe coughing fits or when lifting a heavy object. However, over time, as the weakening of the pelvic floor muscles increases, it can reach a level that requires the use of a pad even during a slight smile or a walk down the bustling streets of Istanbul.

Beyond the physical aspect of this condition, the psychological and social damage it creates is much heavier. Patients constantly feel the need to look for a toilet when they go out, hesitate to enter crowded environments for fear of odor, and have to carry spare clothes with them at all times. Quitting exercise, withdrawing from sexual life, and social isolation are the most common consequences of untreated urinary incontinence.

How Does the Diagnostic Process Work at the Hospital?

A comprehensive evaluation is performed before treating urinary incontinence in women. Your physician will first listen in detail to your medical history, the number of births you have had, the medications you use, and the situations in which your complaints arise. Then, a gynecological and urological examination is performed. During this examination, a stress test is applied where the patient is asked to cough or strain to observe any urine leakage.

To confirm the diagnosis and rule out any other underlying infection, a urinalysis and urine culture are requested. Ultrasonography may be performed to see how much the bladder empties after urination. If there is a suspicion of mixed urinary incontinence in the patient or if there is a history of a previously unsuccessful surgery, urodynamic tests that measure bladder pressure and capacity are utilized. All these tests are meticulously evaluated to clarify whether surgery is the right option for you.

Urinary Incontinence Treatment in Women: Stages of TOT Surgery

If pelvic floor exercises (Kegel exercises) and lifestyle changes (losing weight, quitting smoking) have not provided sufficient benefit, surgical intervention comes to the forefront. TOT surgery stands out with its high success rate and comfortable recovery process.

Preoperative Preparation Period

Once the decision for surgery is made, standard surgical preparation procedures are applied. If you are using blood thinners, you may need to pause these medications a few days before the surgery under your physician's supervision. You will be asked to fast (no food or water) for at least 6-8 hours before coming to the hospital on the day of surgery. Additionally, if there is an existing urinary tract infection, it is absolutely ensured that it is treated with antibiotics before the surgery.

Surgical Process and Anesthesia Methods

TOT surgery is generally performed under spinal anesthesia, where the lower half of the body is numbed, or under general anesthesia, where the patient is completely asleep. The anesthesiologist will determine the most suitable method for your health condition together with you. The procedure takes an average of 15-30 minutes.

The surgeon makes a small incision of about 1.5 to 2 centimeters on the front wall of the vagina. A polypropylene tape, passed through the inner part of the groin area (obturator foramen) with the help of special needles, is placed under the urinary tract. The tension of the tape is delicately adjusted so that it does not compress the urinary tract but provides support during moments of pressure. The incision sites are closed with self-dissolving stitches, so there is no hassle of having stitches removed later.

TOT Surgery Recovery Process and Home Care

To rest the bladder after surgery, a urinary catheter is usually inserted for one day. The next day, the catheter is removed, and after it is observed that the patient can urinate comfortably on her own, the discharge process is carried out. The recovery process for TOT surgery is quite promising, but paying attention to your home care is critical for the permanence of the result.

For the first few days, mild groin pain or vaginal spotting-type bleeding is considered normal; these conditions are controlled with simple painkillers. The first 6 weeks are crucial for complete healing and for the inserted tape to integrate with the tissues. During this period, you must not lift objects heavier than 5 kilograms, and you should strictly avoid heavy sports, doing sit-ups, and sexual intercourse. In addition, it is of great importance to protect yourself from constipation by consuming high-fiber foods and drinking plenty of water to prevent straining.

Potential Risks and Side Effects of the Surgery

As with any surgical intervention, TOT surgery has some potential risks and side effects. Mild bleeding and urinary tract infections may occur during or after the procedure. In rare cases, if the inserted tape provides too tight support to the urinary tract, the patient may have difficulty urinating after surgery or may not be able to empty her bladder completely. This situation is generally temporary, but if it persists, a minor intervention may be required to loosen the tape.

Another rare complication is mesh erosion. In the event that the synthetic tape is exposed outwards from the vaginal wall over time, vaginal discharge, bleeding, or pain during sexual intercourse may be experienced. In such cases, your physician will resolve the issue by repairing the exposed part. However, when performed by experienced surgeons, the incidence of these complications is quite low.

When to See a Doctor and Emergencies

If you are forced to use pads in your daily life, hesitate to drink water for fear of leaking urine, or restrict your social activities, you should consult a urology or gynecology specialist without delay.

However, if you experience any of the following symptoms while recovering at home after TOT surgery, you should call 112 emergency services or apply to the emergency department of the nearest hospital without losing time:

A high fever exceeding 38 degrees Celsius (100.4°F) that does not go down,
Sudden, fresh, red bleeding from the vagina heavy enough to fill pads,
Inability to urinate at all at home after the catheter is removed, or a feeling of severe swelling in the bladder,
Foul-smelling, dark-colored, and thick vaginal discharge,
Severe pelvic or groin pain that progressively increases and does not ease despite painkillers.

A Safe Treatment Process at BHT CLINIC

BHT CLINIC İstanbul Tema Hastanesi provides services to our patients presenting with urinary incontinence complaints with a multidisciplinary approach carried out jointly by urology and gynecology specialists. In our hospital, every stage from diagnosis to postoperative follow-up is carried out in accordance with international JCI quality standards, keeping patient privacy at the forefront. Thanks to our advanced technology diagnostic devices and fully equipped operating rooms, your treatment process is managed in the safest way possible.

Many of our patients experiencing urinary incontinence may also have underlying systemic conditions such as diabetes. Diabetes can both affect the bladder nerves, leading to urinary problems, and seriously threaten eye health. For this reason, you are evaluated with a holistic approach in our hospital; in addition to your urological treatment, you can safely have your general health screenings done by getting support from our Ophthalmology (Eye Diseases) department when necessary.

We are always by your side with our emergency service and expert staff, providing 24/7 care for unexpected situations. Do not postpone your health; to laugh and move freely again, you can take the first step by contacting us through our BHT CLINIC online appointment page or by calling our call center at 0850 811 34 00.

Frequently Asked Questions

How long does TOT surgery take?

When performed by an experienced surgical team, TOT surgery is a very short and practical procedure that generally takes between 15 and 30 minutes. The total time spent in the operating room, including the patient receiving anesthesia and the waking-up process, can take about 1 hour.

Can urinary incontinence recur after surgery?

The success rate of TOT surgery in stress urinary incontinence is around 90-95 percent, and the results are mostly permanent. However, if conditions that strain the pelvic floor develop in the following years, such as excessive weight gain, severe chronic cough, or having a new normal delivery, complaints may recur, albeit rarely.

When does sexual life return to normal after TOT surgery?

It is a medical necessity to avoid sexual intercourse during the first 6 weeks after surgery so that the incisions made vaginally can heal completely and the inserted mesh can fully attach to the tissues. Following your doctor's check-up at the end of the sixth week, if no problems are detected, you can return to your normal sexual life.

Does this surgery prevent getting pregnant?

No, since TOT surgery is not a procedure that damages the reproductive organs, it absolutely does not prevent you from getting pregnant. However, since having a normal (vaginal) delivery in a pregnancy that occurs after the surgery can disrupt the structure of the inserted tape and cause urinary incontinence to recur, a cesarean delivery is generally recommended.

Will there be a surgical scar?

The small incision of about 2 centimeters made during the procedure is located completely inside the vagina and cannot be seen from the outside. Therefore, there will be no aesthetically disturbing surgical scars left on the abdominal area or in the groin.

This article is for informational purposes only; please be sure to consult your physician for diagnosis and treatment.

Overcoming Urinary Incontinence in Women: Up to 95% Success with TOT Surgery