TVT or TOT - What is the Difference?

Jane Akre
February 16, 2021

Mesh Medical Device News Desk, February 16, 2021 ~ What is TOT? TVT? What questions you need to ask if you are told you need a pelvic mesh repair.

The difference between a TOT and TVT placement

If you are new to the terms used to describe transvaginal tape, you will need to understand the difference between TVT and TOT.

The differences are important. Surgeons are still offering women both choices as treatment for stress urinary incontinence (SUI).

If you have been diagnosed with SUI you have experienced a leakage of urine. That occurs when pelvic tissues that support the bladder and urethra become weak which allows the bladder “neck” to be out of alignment which blocks the flow or urine.

SUI can also happen when the muscles that control the urethra weaken and cannot stop the flow of urine when there is abdominal pressure. Aging is one cause of SUI as is childbirth, obesity, smoking, and pregnancy.

TVT stands for tension-free vaginal tape.  It’s also known as a synthetic mid-urethral tape or sling (MUS) because of the mid mark on the urethra where the device will be placed.

Most TVTs are made of polypropylene, a polymer plastic also used in the top of Tic-Tac boxes and on the back of indoor-outdoor carpet. 

It is a cheap plentiful plastic that was determined to be, according to a Johnson & Johnson researcher, “the best of a bad lot” when it came to creating plastic implantable incontinence treatments.

TVT resembles a “sling” or a “ribbon” and your doctor may use those terms when discussing your options.  Understand that a “tape,” a “sling,” or a “ribbon” are the same as transvaginal mesh that you have heard about. Don’t let the soft sell words, including “minimally invasive,” fool you.

YES! This is the mesh you’ve heard about from pelvic mesh lawsuits and trials. 

Also, doctors today tend to tell their patients that today’s mesh is “different.”  What are those differences you might ask.  Your editor has heard from people who receive answers such as “it’s not the same as the lawsuits”, or “the bad mesh has been taken off the market.”   For a Canadian woman, she was told by her doctor “We don’t have that bad mesh in Canada, just the States. It’s cloth here.”

None of these things is true. Any differences they might be referring to could be pore size, but the basic components of polypropylene mesh remain the same.

AGAIN Ask- what is this “new” mesh made of? 

[TAKEAWAY:  Ask your doctor what it’s made of.  He or she may not know the word polypropylene.  Ask your doctor if he can do a native tissue repair using your own fascia harvested from your leg or abdomen, generally a much safer alternative even though it involves two surgeries and is less lucrative for the doctor’s practice. If he can’t, you might find someone who can.]

The transvaginal placement calls for a slice through the vagina. In a blind placement, the doctor feels his way, placing the sling under the urethra for support so urine can more easily flow from the bladder. Please watch a YouTube video of the procedure here.

Dr. S. Raz, TVT image

The Placement

The placement of TVT is called retropubic mid-urethral because the TVT tape exits in the abdomen. TOT has an entirely different placement.

TOT stands for TVT-Obturator, referring to its placement. It’s also referred to as TVT-O.  The TVT-O passes through the obturator foramen and exits through the groin. 

The TVT-O procedure was developed because of complications associated with the TVT procedure such as postoperative voiding (urinating) difficulties, and the potential for bladder, bowel and vascular injury, a result of being a blind procedure.

Passing through the obturator foramen avoids the pelvic organs in the retropubic space. Groin pain is reported to be higher among the women with an obturator placement.

The TVT-O has been found to be defectively designed in a court of law.


Twice the Risk of Reoperation


According to Danish researchers in a 2017 published study, TOT used to treat incontinence has twice the risk of reoperation when compared to transvaginal tape. 

TOT mesh was introduced in Denmark in 2003 and in the U.S. two years earlier. The Danish study involved a total of 8,671 women who had undergone surgery to treat urinary incontinence between 1998 and 2007. None had prior surgeries.

The retropublic TVT had a 6% reoperation rate, the lowest of reoperation. Burch colposuspension was 6%, while the transobturator tape was 9%.

The study is notable because it looked at reoperation rates within five years. Most mesh was tested for one year before being marketed.

And according to a July 2019 Mayo Clinic study by Dr. Emanuel Trabuco, MD, transobturator surgery has a higher failure rate (11.2 percent) compared to 5.2% for the retropubic sling.

And with a failure rate higher generally defective product lawsuits follow. 

Dr. Greg Vigna, JD MD

Here is a news release announcing a newly filed case where medical malpractice is included in a TVT-O defective product lawsuit filed by Dr. Greg Vigna, Ben Martin and Laura Baughman of Dallas.

Dr. Vigna (who advertises on MND) specializes in neurological injuries believes any device with a transobturator component can cause nerve damage.

“From the POP (pelvic organ prolapse) devices, which are banned, to the transobturator slings, any devices that have a transobturator component can cause obturator and pudendal neuralgia.
“We believe the manufacturers knew this and didn’t disclose this to doctors. And to this day the manufacturers are not being forthcoming providing open education to doctors on the severity of injuries.  So why wouldn’t the manufacturers tell doctors? If you are going to do a sling, do the retropubic sling because the rate of surgical complications over 8 years is 2.5 times less than TOT.”
Autologous Sling, U Penn Medical

Autologous Sling

The other option for a "sling" is autologous, meaning that your own tissue will be harvested, fashioned into a ribbon or sling and used to cradle your urethra. This is the safest procedure which your body will likely not reject because no foreign tissue has been used.

Problem- Not all doctors can do an autologous sling.  Here is a YouTube video on how it's done.

TAKEAWAY: Ask your surgeon if he/she can harvest your own fascia to make a sling.  

So why is TOT still done?

This story will continue in PART TWO.


MND, January 11, 2017, TOT has Twice the Risk of Reoperation of Transvaginal Tape, American Journal of Obstetrics & Gynecology, September 2015,

Mid-urethral sling operations for stress urinary incontinence in women, Cochrane Database Syst Rev, July 2015

MND, August 6, 2019, Doctors Could be Held Responsible for Mesh Implants Gone Wrong

Mayo Clinic, July 15, 2019, Study shows advantages for stress urinary incontinence surgery

New England Journal of Medicine, June 3, 2010, Retropubic versus Transobturator Midurethral Slings for Stress Incontinence

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