The TOT (Trans Obturator Tape) method is used in surgical treatment of stress urinary incontinence in women. It is performed with trans-obturator access. Through these openings a urological tape (sling) is passed, which aims to create a kind of hammock supporting the middle and rear part of the urethra. With trans-obturator access the sling lies in the anterior section of the urethra.
After administering anaesthesia (usually local or spinal) and inserting a Foley catheter, a approx. 2 cm incision at the vaginal vestibule is made, creating a tunnel towards the obturator foramen. Then, the palpable identification of bone elements of the obturator foramen is performed; the surgeon makes a small cut on the vulva skin (ca. 0.5-1 cm) slightly above the clitoris and 1.5-2 cm aside towards the genitofemoral sulcus. A needle applicator is fed into the incision sliding it on the upper part of the pubic bone until the obturator membrane gives flexible resistance. The surgeon specifies the piercing place of the obturator membrane with an index finger. After piercing the obturator membrane, the pelvis fascia is pierced and the applicator is fed. It is directed with a finger until the needle appears between the dissected vaginal wall and the index finger separating the urinary bladder. The urological tape is fixed at the tip of the applicator and passed with the needle through the previously prepared tunnel. The whole procedure shall be repeated on the opposite side. After inserting the whole tape, it is stabilised under the middle part of the urethra. The adjustment is always performed without tension. The vaginal wall and skin incisions shall be sewn, disinfected and the Foley catheter shall be removed.