Midurethral Sling (TVT / TOT)
5728851840wRVU: 11.08 — Anterior vesicourethropexy (Burch colposuspension), open51841wRVU: 13.34 — Burch colposuspension, complicated (with prior surgery)51990wRVU: 13.03 — Laparoscopic urethral suspension (laparoscopic Burch)
Stress urinary incontinence, urodynamic [/ clinical] diagnosis, refractory to conservative management
Same
[Retropubic midurethral sling (TVT) / Transobturator midurethral sling (TOT)]
[Attending name], MD/DO
[Resident/PA name]
[General endotracheal / spinal / MAC]
The patient is a [age]-year-old [female] with stress urinary incontinence presenting with [leakage with cough / sneeze / lifting / exertion]. [Urodynamic studies confirmed urodynamic stress incontinence with [urethral hypermobility / intrinsic sphincter deficiency].] [Q-tip test demonstrated urethral hypermobility.] Conservative measures including [pelvic floor physical therapy / pessary] were [failed / declined] after [X months]. The risks, benefits, and alternatives including Burch colposuspension were discussed. Informed consent was obtained.
Examination under anesthesia confirmed [urethral hypermobility / intrinsic sphincter deficiency]. The vaginal epithelium was [well-estrogenized / atrophic]. [No significant anterior compartment prolapse was noted.] [Concomitant [cystocele / vault prolapse] was present and addressed — see additional procedure note.]
The patient was positioned in the dorsal lithotomy position with the legs in [Allen / candy cane] stirrups. A Foley catheter was placed and the bladder drained. The vaginal introitus was prepped with [Betadine / chlorhexidine]. A surgical timeout was performed.
The anterior vaginal wall was hydrodissected with [10 mL of 0.25% bupivacaine with 1:200,000 epinephrine] at the level of the midurethra bilaterally.
A [1.5-cm] midline vaginal incision was made at the level of the midurethra. [TVT: Lateral dissection was carried in the paraurethral space hugging the posterior surface of the pubic bone on each side. The endopelvic fascia was perforated with the tip of the introducer, entering the space of Retzius. The TVT needle was passed on the right, then the left, from the vaginal incision suprapubically, maintaining contact with the posterior pubic bone throughout. The bladder was deflected to the contralateral side during each needle pass.] [TOT: The introducer was passed through the obturator foramen on each side using the [inside-out / outside-in] technique, avoiding the obturator neurovascular bundle medially.]
The polypropylene tape was positioned tension-free beneath the midurethra. Tension was adjusted with the Foley catheter in place to allow passage of a [right-angle clamp / Metzenbaum scissors] between the tape and the urethra at rest, with the tape resting flat without indentation of the urethral lumen.
Cystoscopy was performed with [300 mL] of sterile water distending the bladder. [TVT: The bladder was inspected in full — no tape perforation was identified. Both ureteral orifices were visualized with bilateral efflux of urine confirmed.] The bladder mucosa was intact.
The tape tails were trimmed at skin level [suprapubically / at the groin]. The sheath introducers were removed. The vaginal incision was closed with [2-0 Vicryl] absorbable suture.
None
None
Minimal
Foley catheter; voiding trial performed [prior to discharge / on postoperative day 1]
The patient was taken to the PACU in stable condition. [A voiding trial was performed — the patient voided spontaneously with a post-void residual of [X] mL.] [The patient was discharged home same day.]
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Stress urinary incontinence, refractory to conservative management
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Retropubic TVT / Transobturator TOT] midurethral sling
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with SUI, urethral hypermobility/ISD. Failed/declined conservative management. Consent obtained.
FINDINGS: Urethral hypermobility ***. Vaginal epithelium ***. No significant prolapse/concurrent prolapse addressed separately.
PROCEDURE:
Dorsal lithotomy. Foley placed, bladder drained. Hydrodissection midurethra bilaterally. 1.5 cm midline vaginal incision at midurethra. [TVT: Lateral paraurethral dissection, posterior pubic bone. Endopelvic fascia perforated. Needle passed right then left, suprapubically, hugging pubic bone. Bladder deflected.] [TOT: Inside-out/outside-in through obturator foramen bilaterally.] Polypropylene tape positioned tension-free at midurethra. Tension set with Foley in — clamp passes freely. Tails trimmed at skin level. Sheaths removed. Vaginal incision closed 2-0 Vicryl.
Cystoscopy: [No tape perforation. Bilateral ureteral jets confirmed.] Bladder intact.
EBL: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: Foley; voiding trial ***.
DISPOSITION: PACU. Discharged same day/POD 1 after voiding trial.
Signed: .ME, .MYDEGREE
.TODAYVariants
Transobturator Sling (TOT) — Key Differences
The transobturator approach was selected [given prior retropubic surgery / retropubic scarring / patient anatomy / surgeon preference]. Instead of passing through the space of Retzius, the needle traverses the obturator foramen bilaterally, following the curve of the obturator from the vaginal incision to a small stab incision at the inner thigh [inside-out technique], or in reverse [outside-in technique]. The obturator neurovascular bundle runs superior to the path — the tape passes below the horizontal ramus of the pubis. Bladder perforation risk is lower than TVT (~1% vs. 5%); obturator/thigh pain is the characteristic complication (typically resolves within weeks). Cystoscopy is still mandatory. TOMUS trial (NEJM 2010) showed equivalent subjective cure rates to TVT at 12 months; TVT shows marginally higher objective cure in some series, particularly for intrinsic sphincter deficiency.
Burch Colposuspension (Concomitant with Sacrocolpopexy)
Burch colposuspension was performed concomitantly with laparoscopic sacrocolpopexy for coexisting stress urinary incontinence, avoiding placement of a second mesh implant. Following sacrocolpopexy, the space of Retzius was entered laparoscopically. The bladder was mobilized medially. Two [0-Ethibond] permanent sutures were placed on each side, passing through the full thickness of the anterior vaginal wall lateral to the urethra at the level of the bladder neck, and fixed to [Cooper's ligament (iliopectineal ligament)] on the ipsilateral side. Sutures were tied without tension, elevating the bladder neck without compressing the urethra. The space of Retzius was not closed. Burch colposuspension is most commonly used in this setting to avoid concurrent mesh sling placement; as a standalone procedure for SUI it has largely been replaced by midurethral slings. Bill 51990 (laparoscopic, 13.03 wRVU) or 51840 (open, 11.08 wRVU).
Charting Tips
- Cystoscopy is mandatory after TVT — document explicitly. The TVT needle passes through the space of Retzius blind, adjacent to the bladder. Bladder perforation occurs in approximately 5% of TVT cases; a missed perforation results in tape erosion into the bladder presenting as recurrent UTIs and hematuria months later. Document: no tape perforation visualized, bilateral ureteral jets confirmed, bladder mucosa intact.
- Document tension setting. The most common cause of postoperative urinary retention is an overtightened sling; the most common cause of failure is an undertightened one. Document the method used to set tension (instrument test, cough test with partial fill) and the intraoperative result.
- For TVT, document the direction of bladder deflection during needle passage. The bladder should be deflected to the contralateral side during each pass. If the drainage bag turns pink during needle passage, bladder entry has occurred — withdraw, repass more laterally, and re-scope before proceeding.
- Document intrinsic sphincter deficiency (ISD) vs. urethral hypermobility if urodynamics were performed. ISD (low leak point pressure <60 cmh2o failure for given has higher in isd li low mucp) or over prefer rates rates; retropubic sling some subgroup.< success surgeons this tot tvt>
Billing Tips
- Bill 57288 for sling operation for stress incontinence (11.83 wRVU, 90-day global). This code applies to both retropubic (TVT) and transobturator (TOT) midurethral sling approaches — document which approach was used in the operative note. Note: midurethral mesh slings were explicitly exempted from the 2019 FDA withdrawal order for transvaginal mesh; they remain the standard of care for surgical SUI.
- If a concomitant anterior colporrhaphy or posterior repair is performed, bill the additional code with modifier -51. If performed at the same time as sacrocolpopexy (57425), the sling (57288) is separately billable with -51 — document both indications (prolapse and SUI) preoperatively.
- Burch colposuspension (51840, 11.08 wRVU open; 51990, 13.03 wRVU laparoscopic) is most commonly performed concomitantly with sacrocolpopexy when a sling-free approach is desired. As a standalone procedure for SUI it is infrequently performed but remains billable. Document the indication and approach.
- 90-day global: voiding trials, catheter management, and routine follow-up are bundled. Urethrolysis for postoperative obstruction requiring OR return uses modifier -78.
- Cystoscopy (52000) performed at the time of sling placement is bundled — do not bill separately.