A randomized prospective comparison of the needleless mini-sling "hammock" and "U-shape" configurations for management of stress urinary incontinence: 60-month follow-up results

OBJECTIVE

To compare needleless mini-slings placed in a retropubic (U-shape) or trans-obturator (hammock-shape) configuration for treating stress urinary incontinence at 60th month.

METHODS

All surgeries, conducted by a senior surgeon, involved objective and subjective assessments preoperatively and at 6, 12, 18, and 60 months postoperatively using cough-stress tests, ICIQ-SF, PGI-I, and a Likert scale.

RESULTS

After 60 months, no significant differences were found in cure rates, mesh complications, or reinterventions between U-shaped and hammock-shaped groups. However, a significant decrease in cure rates was observed at 18 and 60 months in both groups. Notable differences in ICIQ-SF, Likert scale, and PGI-I scores were seen in the hammock-shaped group, while the U-shaped group showed differences in ICIQ-SF and PGI-I scores, but not in the Likert scale.

CONCLUSION

Given the lack of significant differences, asserting the superiority of either retropubic (U-shape) or transobturatorly (hammock-shape) needleless mini-slings for treating stress urinary incontinence is challenging.

Midurethral Sling Mesh Exposure Confers a High Risk of Persistent Stress Urinary Incontinence

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the relationship between mesh exposure and persistent stress urinary incontinence (SUI) post-midurethral sling (MUS) surgery.

METHODS

Extensive data collection including patient demographics, obstetric history, existing medical conditions, previous surgeries, and surgical outcomes, encompassing both perioperative and postoperative complications.

RESULTS

Out of 456 patients who underwent the MUS procedure within the specified period, the persistence of SUI was noted in 6.4% of cases. Mesh exposure was observed in 8.8% of these cases. Notably, 25% of patients with mesh exposure suffered from persistent SUI, in stark contrast to 4.6% of those without mesh exposure (p < 0.0001). Further, multivariate analysis indicated that patients with mesh exposure had an approximately 6.5-fold increased likelihood (95% CI: 2.71-15.44) of experiencing persistent SUI compared with those without mesh exposure.

CONCLUSIONS

Mesh exposure is a significant independent risk factor for persistent SUI post-MUS surgery. Patients with mesh exposure are about 6.5 times more prone to persistent SUI than those without. Although mesh exposure is typically managed with expectant measures, vaginal estrogen or mesh excision, current evidence does not support surgical revision of MUS affected by mesh exposure or additional incontinence procedures during mesh excision.

Assessment of Urinary Dysfunction After Midurethral Sling Placement: A Comparison of Two Voiding Trial Methods

STUDY OBJECTIVE

Temporary urinary retention after midurethral sling (MUS) surgery requiring indwelling catheter or self-catheterization usage is common. Different methods for assessment of immediate postoperative urinary retention have been described. This study aimed to compare postoperative voiding trial (VT) success after active vs passive VT in women undergoing MUS surgery.

DESIGN

Comparative retrospective cohort study.

SETTING

Female pelvic medicine and reconstructive surgery practice at a university-affiliated tertiary medical center.

PATIENTS

Patients with stress urinary incontinence who underwent surgical treatment during the study period were eligible for inclusion. Excluded were patients younger than the age of 18 years, combined cases with other surgical services, planned laparotomy, and a history of urinary retention and patients for whom their VT was performed on postoperative day 1. The cohort was divided into 2 groups: (1) patients who underwent an active retrofill of their bladder using a Foley catheter and (2) patients who were allowed to have a spontaneous void.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 285 patients met the inclusion criteria for the study. Of these subjects, 94 underwent an active VT and 191 underwent a passive VT. There were no statistically significant differences in immediate postoperative urinary retention (30.8% vs 29.3%; p = .79) or time from surgery end to VT (233.0 ± 167.6 minutes vs 203.1 ± 147.8 minutes; p = .13) between groups. Urinary retention, as defined by a failed VT, increased from 10% to 29.3% when MUS placement was accompanied by concomitant prolapse repair procedure. Multivariate logistic regression analysis revealed that undergoing a combined anterior and posterior colporrhaphy (odds ratio [OR], 5.13; p <.001) and undergoing an apical prolapse procedure (OR, 2.75; p = .004) were independently associated with immediate postoperative urinary retention whereas increased body mass index (OR, 0.89; p <.001) lowered likelihood of retention.

CONCLUSION

The method used to assess immediate postoperative urinary retention did not affect VT success. Concomitant combined anterior and posterior colporrhaphy and apical suspension were correlated with greater likelihood of VT failure whereas increased body mass index decreased odds of retention.

Precision in Practice: The Critical Role of Mesh and Procedure Type Specification in Urogynecological Surgeries and Research

Recently, the debate surrounding the use of mesh in urogynecological procedures has intensified, leading to FDA warnings and heightened safety concerns. This clinical opinion emphasizes the vital need to specify mesh types in these procedures, drawing attention to the risk profiles and clinical outcomes associated with various meshes and the procedures that utilize them. A significant issue identified in contemporary literature is the tendency to group diverse mesh types under the same umbrella, disregarding their unique characteristics and applications. We describe the range of mesh types, their application routes, and associated complications, highlighting the risks of this nonspecific approach to patient safety and informed decision making. We critically examine the generalization of mesh terminology in clinical and research dialogues. Concluding with specific recommendations for health care providers and researchers, the paper advocates for a more nuanced understanding and communication in the field, ultimately aiming to improve patient care and safety in urogynecological practice.

Surgeon Upper Extremity Kinematics During Error and Error-Free Retropubic Trocar Passage

INTRODUCTION AND HYPOTHESIS

Surgeon kinematics play a significant role in the prevention of patient injury. We hypothesized that elbow extension and ulnar wrist deviation are associated with bladder injury during simulated midurethral sling (MUS) procedures.

METHODS

We used motion capture technology to measure surgeons' flexion/extension, abduction/adduction, and internal/external rotation angular time series for shoulder, elbow, and wrist joints. Starting and ending angles, minimum and maximum angles, and range of motion (ROM) were extracted from each time series. We created anatomical multibody models and applied linear mixed modeling to compare kinematics between trials with versus without bladder penetration and attending versus resident surgeons. A total of 32 trials would provide 90% power to detect a difference.

RESULTS

Out of 85 passes, 62 were posterior to the suprapubic bone and 20 penetrated the bladder. Trials with versus without bladder penetration were associated with more initial wrist dorsiflexion (-27.32 vs -9.03°, p = 0.01), less final elbow flexion (39.49 vs 60.81, p = 0.03), and greater ROM in both the wrist (27.48 vs 14.01, p = 0.02), and elbow (20.45 vs 12.87, p = 0.04). Wrist deviation and arm pronation were not associated with bladder penetration. Compared with attendings, residents had more ROM in elbow flexion (14.61 vs 8.35°, p < 0.01), but less ROM in wrist dorsiflexion (13.31 vs 20.33, p = 0.02) and arm pronation (4.75 vs 38.46, p < 0.01).

CONCLUSIONS

Bladder penetration during MUS is associated with wrist dorsiflexion and elbow flexion but not internal wrist deviation and arm supination. Attending surgeons exerted control with the wrist and forearm, surgical trainees with the elbow. Our findings have direct implications for MUS teaching.

More With Less: Single-Incision Sling Insertion Techniques

STUDY OBJECTIVE

To demonstrate reproducible procedures for efficient single-incision sling insertion and troubleshooting.

DESIGN

Narrated video footage with stepwise demonstration of single-incision sling insertion technique with anchor system.

SETTING

The mesh midurethral sling is a highly effective and safe procedure that is considered the gold standard for surgical treatment of stress urinary incontinence. Retropubic and transobturator approaches for midurethral slings have similar subjective cure rates with differing surgical risk profiles [1,2]. The retropubic route has a higher risk of injury to the bladder, nerves, and vascular structures, whereas the obturator approach carries a risk of groin or thigh pain [3-5]. Use of a single-incision sling decreases these risks and allows flexibility to perform the procedure without sedation or general anesthesia. Recent literature demonstrates similar subjective and objective success and safety of single-incision slings compared with both retropubic and transobturator approaches, although long-term data are forthcoming [5].

INTERVENTIONS

We demonstrate a stepwise approach for the insertion of a single-incision sling using a helical trocar. Easily reproducible procedures for setup and sling anchor management allow for efficient placement without assistance. In addition, we outline hand positioning, trocar management, and anchor deployment with troubleshooting techniques for potential placement difficulties. Finally, we review methods for sling tensioning to prevent complications such as voiding dysfunction and mesh or suture exposures.

CONCLUSION

Given that single-incision slings are more likely to be performed under local anesthesia and are less invasive with decreased recovery time, it has the potential to become the preferred approach in the future. This video demonstrates clear and detailed steps to facilitate successful placement of the single-incision mesh midurethral sling.

Robotic-assisted intravesical mesh excision following retropubic midurethral sling

INTRODUCTION AND HYPOTHESIS

Intravesical mesh is an uncommon complication following synthetic midurethral sling placement. Management options have included endoscopic techniques such as laser ablation or surgical excision. We present our technique for robotic-assisted excision of intravesical mesh following a retropubic midurethral sling.

METHODS

The patient is a 66-year-old woman with a remote history of laser ablation of intraurethral mesh after midurethral sling, and persistent symptomatic intravesical mesh with associated stone at the bladder neck and right bladder wall. Robotic excision of the intravesical mesh and stone was performed by entering the space of Retzius, carrying the dissection along the right arm of the retropubic sling, performing two cystotomies to free and remove the mesh, and finally closing the cystotomies in two layers.

RESULTS

The patient was discharged on postoperative day 1. A cystogram prior to catheter removal showed no extravasation and a competent bladder neck. She reported no new stress incontinence and had improvement in overactive bladder symptoms.

CONCLUSIONS

Robotic excision of intravesical mesh after synthetic midurethral sling was safely performed in this patient who had multiple areas of intravesical mesh. Management aspects reported here may be helpful for complex presentations of intravesical mesh.

Evaluation of Outcomes Between the Top-down Versus the Bottom-up Approach for Retropubic Midurethral Sling

INTRODUCTION AND HYPOTHESIS

Retropubic midurethral sling (MUS) placement is the gold standard for the treatment of stress urinary incontinence in the USA. The procedure can be approached from either a top-down or a bottom-up direction, but there is a paucity of contemporary data regarding outcomes between these approaches. The aim of this study was to provide updated clinical outcomes data.

METHODS

This was a retrospective cohort study of women undergoing the retropubic MUS procedure alone or at the time of pelvic organ prolapse repair between 2010 and 2020 at a single academic medical center. The electronic medical record was used to extract demographic data, operative approach, and perioperative complications. The primary outcome was a composite incidence of any perioperative complication.

RESULTS

Of the 309 patients analyzed, 140 (45.3%) underwent top-down and 169 (54.7%) underwent bottom-up retropubic MUS placement. Patients undergoing top-down MUS placement were more likely to be older (mean age 58 vs 54, p=0.02), have a history of diabetes mellitus (20% vs 8.9%, p=0.004), and have had a prior hysterectomy (27% vs 16%, p=0.02). They were less likely to have a concurrent anterior (p<0.001) or posterior repair (p<0.001). Patients undergoing the top-down procedure were less likely to experience sling exposure (p=0.02); complications in the two groups were otherwise similar.

CONCLUSIONS

The top-down approach to retropubic MUS placement was associated with lower rates of mesh erosion in this population of patients. Neither approach is associated with an increased overall risk of complications or de novo overactive bladder symptoms.

Impact of Preoperative Urinary Tract Infection Screening in Asymptomatic Women Undergoing Midurethral Sling

INTRODUCTION

There is limited information regarding the utility of preoperative urine culture (Ucx) screening to decrease postoperative UTI rates following midurethral sling (MUS).

HYPOTHESIS

The primary objective of this study was to determine if the rate of postoperative UTI within the first 6 weeks after surgery is lower in women undergoing MUS when preoperative Ucx is obtained compared to when it is not. Secondary objectives were to determine clinical factors associated with postoperative UTI risk.

METHODS

This is a retrospective cohort study of women who did not have symptoms of or a diagnosis of cystitis at the time of their preoperative evaluation and are undergoing MUS. Patients were grouped into those who had preoperative Ucx screening within 6 weeks preceding surgery and those who did not. UTI rates 6 weeks following surgery were compared between groups. Additionally, factors impacting the risk of developing a UTI within 6 weeks of surgery were assessed.

RESULTS

Among 661 patients, 13.2% had a UTI within the first 6 weeks. There was no significant difference in UTI rates between those who did and did not have preoperative Ucx, respectively (14.9% vs 10.2%, p = 0.09). On multivariable analysis, current smoker status (OR 3.02, 95% CI 1.10-8.26), history of recurrent UTI (OR 3.00, 95% CI 1.14-7.86), and requiring postoperative SIC (OR 8.75, 95% CI 1.83-41.74) were independently associated with a UTI within 6 weeks of MUS.

CONCLUSION

Obtaining preoperative Ucx in asymptomatic women prior to MUS does not appear to be associated with lower postoperative UTIs rates within 6 weeks of surgery.

Racial and ethnic disparity in national practice patterns for stress urinary incontinence surgery

INTRODUCTION AND HYPOTHESIS

There is a paucity of information assessing whether race/ethnicity is associated with differences in surgical treatment of stress urinary incontinence (SUI). The primary objective was to assess for racial/ethnic disparities in SUI surgeries. Secondary objectives were to assess for surgical complication differences and trends over time.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we conducted a retrospective cohort analysis of patients undergoing SUI surgery from 2010 to 2019. Chi-squared or Fisher's exact test and ANOVA were used for categorical and continuous variables respectively. Breslow day score and multinomial and multiple logistic regression models were used.

RESULTS

A total of 53,333 patients were analyzed. Using White race/ethnicity and sling surgery as references, Hispanic patients underwent more laparoscopic surgeries (OR1.17 [CI 1.03, 1.33]) and anterior vesico-urethropexy/urethropexies (OR 1.97 [CI 1.66, 2.34]); Black patients underwent more anterior vesico-urethropexy/urethropexies (OR 1.49 [CI 1.07, 2.07]), abdomino-vaginal vesical neck suspensions (OR 2.19 [CI 1.05-4.55]), and inflatable urethral slings (OR 4.28 [CI 1.23-14.90]). White patients had lower rates of inpatient stay (p < 0.0001) and blood transfusion (p < 0.0001) compared with patients who were Black, indigenous, people of color (BIPOC). Over time, Hispanic and Black patients were more likely to undergo anterior vesico-urethropexy/urethropexies than White patients (RR 2.03:1 [CI 1.72-2.40]) and (RR 1.59 CI [1.15-2.20]) respectively. Adjusting for possible confounders, Hispanic and Black patients had a greater chance of having a nonsling surgery, 37% (p < 0.0001) and 44% (p = 0.0001) greater chances respectively.

CONCLUSION

We observed racial/ethnic differences in SUI surgeries. Although causality cannot be proven here, our results confirm previous findings suggesting inequities in care.

Does local vaginal estrogen after tension-free transobturator vaginal tape reduce overactive bladder symptoms in postmenopausal women? A prospective randomized, controlled study

Objective

We aimed to evaluate the efficacy of topical estrogen after transvaginal tension-free vaginal tape-obturator (TVT-O) in the treatment of de novo overactive bladder symptoms that appear after surgery.

Methods

This is a prospective randomized controlled study performed in the Urology and Gynecology Departments, Kasr Al Ainy Hospital, Cairo University, Cairo, Egypt. Two hundred and ten postmenopausal females presenting during the period between January 2017 and November 2020 with stress urinary incontinence were included in the study. Patients were divided into two groups, 105 patients in Group A (treatment group) and 105 patients in Group B (control group). Patients in Group A underwent transvaginal TVT-O followed by local vaginal estrogen treatment for 6 months, while patients in Group B underwent transvaginal TVT-O only. The study included any postmenopausal female with urodynamic stress urinary incontinence. All patients had to fulfill a 3-day bladder diary, overactive bladder symptoms score, urine analysis, urodynamic study, and post-voiding residual urine measurement by abdominal ultrasound preoperatively and at 3-month and 6-month follow-ups.

Results

At 6-month follow-up, daytime frequency was reduced to 8% in Group A (increased to 21% in Group B) with a statistically significant difference between both groups (p=0.009). At 6-month follow-up, nocturia was 8% in Group A (11% in Group B) with no statistically significant difference between both groups (p=0.469). There was a statistically significant difference between both groups as regards to urinary urgency at 6-month follow-up (p=0.024). There was a statistically significant difference in postoperative wound healing events as regards to cure, hyperemia, gapping, and wound infection 1 week after intervention between both groups (p=0.008). No local or systemic side-effects were reported from local estrogen use.

Conclusion

Local vaginal estrogen treatment given to postmenopausal patients after midurethral sling procedures can reduce the symptoms of daytime frequency and urinary urgency. Long-term follow-up is needed.

Cognitive models for mentally visualizing a sharp instrument in a blind procedure

Purpose

Our objective was to understand the cognitive strategies used by surgeons to mentally visualize navigation of a surgical instrument through blind space.

Methods

We conducted semi-structured interviews with 15 expert and novice surgeons following simulated retropubic trocar passage on 3D-printed models of pelvises segmented from preop MRIs. Midurethral sling surgery involves blind passage of a trocar among the urethra, bladder, iliac vessels, and bowel while relying primarily on haptic feedback from the suprapubic bone (SPB) for guidance. Our conceptual foundation was based on Lahav's study on blind people's mental mapping of spaces using haptic cues. Participants detailed how they mentally pictured the trocar's location relative to vital anatomy. We coded all responses and used constant comparative analysis to generate themes, confirmed with member checking.

Results

Expert and novice participants utilized multiple cognitive strategies combined with haptic feedback to accomplish safe trocar passage. Some used a step-by-step route strategy, visualizing sequential 2D axial images of anatomy adjacent to the SPB. Others used a map strategy, forming global 3D pictures. Although these mental pictures vanished when they were "lost," a safe zone could be reestablished by touching the SPB. Experts were more likely to relate their body position to the trocar path and rely on minor variations in resistance. Novices were more inclined toward backtracking of the trocar.

Conclusions

Our findings may be extended to any blind surgical procedure. Teaching visualization strategies and incorporating tactile feedback can be used intraoperatively to help learners navigate their instrument safely around vital organs.

The effect of 12-month postoperative weight change on outcomes following midurethral sling for stress urinary incontinence: a secondary analysis of the ESTEEM and TOMUS randomized trials

INTRODUCTION AND HYPOTHESIS

Prior studies demonstrate mixed results on the impact of obesity on the success of midurethral slings (MUS), with little known about how postoperative weight change affects outcomes. We aimed to examine the effect of postoperative weight change on outcomes 12 months after MUS for stress urinary incontinence (SUI).

METHODS

This secondary analysis utilized data from two multicenter randomized trials of women undergoing MUS placement. Subjects were categorized into cohorts based on change in body weight at 12 months postoperatively: weight gain (≥5% increase); weight loss (≥5% decrease), and weight stable (<5% change). The primary outcome was SUI cure (no SUI episodes in a 3-day bladder diary). Patients with mixed urinary incontinence (MUI) were analyzed for changes in daily average urge incontinence (UUI) episodes in a 3-day diary. Penalized logistic regression assessed the impact of demographic and perioperative variables on the primary outcome.

RESULTS

Of the 918 women included, 635 (70%) were weight stable, 144 (15%) had weight gain, and 139 (15%) had weight loss. Patients in the weight loss cohort had a higher smoking rate and a higher baseline body mass index (SD 0.29, 2.7 respectively). All cohorts experienced high SUI cure rates ranging from 77 to 81%, with no significant difference in SUI cure between cohorts (p = 0.607). Of 372 subjects with MUI, the weight loss cohort had significantly greater improvement in UUI episodes.

CONCLUSIONS

Weight change at 12 months postoperatively did not significantly alter efficacy of MUS for treatment of SUI. Patients with MUI who lost ≥5% body weight had significantly greater improvement in UUI episodes.

Urethral Bulkamid® injection after failed midurethral sling: a step-by-step video

INTRODUCTION AND HYPOTHESIS

Bulking agents are a minimally invasive treatment option for women with stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (MUI). Recurrent SUI is a major challenge for most clinicians because there is little evidence in the literature on the best option after midurethral sling (MUS) failure.

METHODS

Bulkamid® (Contura International A/S), a urethral bulking agent, is a homogenous gel without particles, consisting of a polyacrylamide hydrogel that is nonbiodegradable.

RESULTS

In this video case report, we demonstrate the Bulkamid® injection procedure. This procedure can be carried out as an office-based procedure under local anesthesia, with no down time and only minor possible complications.

CONCLUSIONS

We consider it a valid option for patients with recurrent or persistent SUI after failed MUS surgery.

Impact on urinary incontinence after management of complications related to a retropubic midurethral sling

INTRODUCTION AND HYPOTHESIS

The most common complications to midurethral sling (MUS) operations for stress urinary incontinence are postoperative urinary retention (POUR), vaginal MUS exposure, and urgency. They are well described but consensus regarding their management is missing. An evaluation of the treatment of POUR, exposure and urgency after the MUS procedure in our department was implemented. Incontinence status after treatment of complications was evaluated.

METHODS

A review of the medical records of women undergoing MUS procedures from 1 January 2017 to 31 December 2021 (n = 329).

RESULTS

A total of 279 women (85%) had no complications. Fifty women had one or more complications. Twenty-three women (7%) experienced POUR. Final treatment in 9 women was clean intermittent self-catheterization (CISC). All remained continent. Nine women had the MUS mobilized. This was successful in 8 women who remained continent. Six women had their MUS incised (one after unsuccessful mobilization). Four became incontinent again and 2 remained continent. Eight women had vaginal MUS exposure. Seven attempted recovering of the MUS. This was successful in 3 patients. The remaining had a partial MUS removal. Only 33% remained continent after removal. Ten patients developed de novo urge, but only 2 needed medication.

CONCLUSIONS

Mobilization of the MUS must be considered the optimal treatment for POUR when CISC fails. It is the most effective intervention with the best effect on POUR and the lowest risk of incontinence. Concerning vaginal exposure, a trial of recovering should be attempted as the risk of incontinence when undergoing a partial removal of the MUS is considerable.

Bibliometric analysis of studies on stress urinary incontinence surgery

Background

Stress urinary incontinence (SUI) is characterized by the involuntary leakage of urine during activities that increase abdominal pressure. In recent years, a considerable number of studies on SUI surgery have been published. However, there has been a lack of systematic quantification and comprehensive summarization of these studies. Bibliometrics is a discipline that utilizes measurement methods to quantify scientific literature. Thus, this study utilized publications from the Web of Science (WOS) as a data source and conducted a comprehensive analysis and visualization of studies related to SUI surgery in recent years using bibliometric techniques.

Methods

We conducted a search and retrieved information on 988 studies related to SUI surgery in the WOS Core Collection. The data covered ten years from September 7, 2013, to September 7, 2023. We employed VOSviewer software, CiteSpace software, and Bibliometrix for analysis and visualization.

Results

Over the ten years, the number of publications exhibited a fluctuating trend, initially decreasing and then increasing. The United States emerged as the leading contributor in terms of both publication volume and quality. The University of Alabama Birmingham ranked as the institution with the highest number of publications, while the International Urogynecology Journal featured the most publications among journals.

Conclusions

This paper presents a bibliometric analysis of publications related to SUI surgery from 2013 to 2023. The aim is to offer researchers a concise overview of the field and inspire future research directions.

The clinical efficacy and safety of outside-in transobturator sling with additional paraurethral fixation - The prospective longitudinal study

Stress urinary incontinence (SUI) is a common condition that affect 30-40% of women in their lifetime. Midurethral slings (MUS) either suprapubic or transobturator can be safely used in the surgical treatment of SUI. The aim of this study was to collect clinical long-term data regarding safety and performance of transobturator sling with an additional tape fixation in women with urinary incontinence. This prospective longitudinal study was conducted on a group of 2086 female patients diagnosed with stress urinary incontinence. Follow up visits where scheduled 6 weeks, 6 and 12 months after surgery followed by annual checking when possible. Patients underwent transobturator sling procedure from 01.01.2011 to 31.12.2021. All patients had a monofilament tape inserted at the mid-urethra using outside-in technique (TOT) with 2 absorbable sutures parallel to the urethra. Success of surgery was defined as lack of any leakage during cough stress test whereas the subjective cure rate was determined by Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-SF). 87% of patients who were operated at least 10 years before assessment reported ICIQ -SF < 6. Main postoperative complications were storage symptoms - de novo urgency and voiding difficulties. TOT is safe and highly effective surgical treatment for (SUI) in a long-term observation.

Surgeon estimation of retropubic trocar position in blind 3D space

INTRODUCTION AND HYPOTHESIS

Retropubic midurethral sling surgery involves the blind passage of trocars near vital organs. We quantified the proximity of surgeons' mental representation of trocar position relative to actual position using a pelvis simulation platform. We hypothesized that novice surgeons, compared with experts, would estimate the trocar's location to be further from the actual location.

METHODS

Novice and expert surgeons performed bilateral retropubic trocar passes of a Gynecare TVT trocar (#810041B-#810,051) on the simulation platform. We measured the trocar tip's position using a motion capture system, and recorded vocalizations when they perceived contacting the bone and crossing three landmark-oriented planes. We calculated differences (∆Bone, ∆Turn, ∆Top, ∆Pop) between vocalization times and when the trocar crossed the corresponding plane. We performed Mann-Whitney and Chi-squared tests to investigate differences between novices and experts and Levene's test to assess equality of variances for subject-level variation.

RESULTS

A total of 34 trials, including 22 expert and 12 novice trials, were performed by six participants. ∆Bone was significantly smaller among novice surgeons (1.27 vs 2.81 s, p=0.013). There were no significant differences in the remaining three deltas or in vocalizing early versus late. Levene's test revealed no significant differences in within-subject variability for any of the four deltas. Novices passed the trocar anterior to the pubic bone on three passes.

CONCLUSIONS

Novices were similar to expert surgeons in their estimation of the trocar's location and may have relied more heavily on anticipatory mechanisms to compensate for lack of experience. Teaching surgeons should make sure the novice surgeon trocar pass starts posterior to the bone.

Pain resolution and functional outcomes of total mesh excision: a case series

INTRODUCTION AND HYPOTHESIS

The objective was to assess the impact of total excision of polypropylene midurethral slings (MUS) on patient pain levels and to report on functional outcomes including recurrent/de novo stress urinary incontinence (SUI), sexual function, and quality of life measures.

METHODS

This is a retrospective analysis of patients who underwent total MUS excision from March 2017 to December 2019. The primary outcome was the impact on pain assessed by a Numeric Rating Scale (NRS). Questionnaires analyzed were: Pain Catastrophizing Scale, Pelvic Floor Distress Inventory Short Form-20, Female Sexual Function Index, and McGill Pain Index questionnaires.

RESULTS

Thirty-two women underwent total mesh excision within the inclusion period; with follow-up data available for 31 out of 32; 14 (43.8%) had previously undergone one or more partial vaginal mesh excision procedures. Types of MUS removed were: 14 (43.8%) transobturator midurethral slings, 12 (37.5%) retropubic midurethral slings, 4 (12.5%) mini-slings, and 2 (6.3%) mesh slings placed by laparotomy. Pain was the main reason for referral in 31 patients (96.9%). Mean pain NRS reduced from 6.1 pre-operatively to 3.3 post-operatively, with paired comparison showing a significant difference (p<0.01). Qualitatively, complete symptoms resolution was observed in 10 out of 31 (32.3%), another 9 out of 31 (29.0%) patients experienced clinically significant improvement, 2 out of 31 (6.5%) did not experience improvement in pain, and 10 out of 31 (32.3%) reported new/worsening pain. Post-operative complications occurred in 9 (29.0%) patients; all were Clavien-Dindo grade II. Nineteen (61.3%) reported de novo/recurrent SUI post-operatively.

CONCLUSION

Total MUS mesh excision yields high complication and SUI recurrence rates, counter-balanced by a 61.3% pain resolution/improvement rate. These data are pertinent for patient counseling.

Does trocar puncture of the bladder during midurethral sling impact postoperative urinary storage and voiding symptoms?

INTRODUCTION AND HYPOTHESIS

The incidence of trocar bladder puncture during midurethral sling (MUS) surgery varies widely. We aim to further characterize risk factors for bladder puncture and examine its long-term impact on storage and emptying.

METHODS

This is an Institutional Review Board-approved, retrospective chart review of women who underwent MUS surgery at our institution from 2004 to 2018 with ≥12 months of follow-up. Unless prolonged catheterization was necessary, a voiding trial was performed prior to discharge, or the next morning in outpatients, regardless of puncture. Preoperative and postoperative details were obtained from office charts and operative records.

RESULTS

Of 1,500 women, 1,063 (71%) had retropubic (RP) and 437 (29%) had transobturator MUS surgery. Mean follow-up was 34 months. Thirty-five women (2.3%) sustained a bladder puncture. RP approach and lower BMI were significantly associated with puncture. No statistical association was found between bladder puncture and age, previous pelvic surgery, or concomitant surgery. Mean day of discharge and day of successful voiding trial were not statistically different between the puncture and nonpuncture groups. There was no statistically significant difference in de novo storage and emptying symptoms between the two groups. Fifteen women in the puncture group had cystoscopy during follow-up and none had bladder exposure. Level of the resident performing trocar passage was not associated with bladder puncture.

CONCLUSIONS

Lower BMI and RP approach are associated with bladder puncture during MUS surgery. Bladder puncture is not associated with additional perioperative complications, long-term urinary storage/voiding sequelae, or delayed bladder sling exposure. Standardized training minimizes bladder punctures in trainees of all levels.

Liberal vs. restricted opioid prescribing following midurethral sling dataset

Postoperative opioid prescribing has historically lacked information critical to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications. This data evaluates pain control, satisfaction with pain control, and opioid utilization among patients undergoing isolated mid-urethral sling (MUS) randomized to one of two different opioid prescribing regimens. This study was registered on clinicaltrials.gov (NCT04277975). Women undergoing isolated MUS by a Female Pelvic Medicine and Reconstructive Surgery physician at a Penn State Health hospital from June 1, 2020 to November 22, 2021 were offered enrollment into this prospective, randomized, open-label, non-inferiority clinical trial. Participants gave informed consent and were enrolled by a member of the study team. Allocation was concealed to patient and study personnel until randomization on the day of surgery. Preoperatively, all participants completed baseline demographic and pain surveys including CSI-9, PCS, and Likert pain score (scale 0-10). Participants were randomized to either receive a standard prescription of ten 5 mg tablets oxycodone provided preoperatively (standard) or opioid prescription provided only upon patient request postoperatively (restricted). Randomization was performed by the study team surgeon using the REDCap randomization module on the day of surgery. Following MUS, subjects completed a daily diary for 1 week, i.e., postoperative day (POD) 0 through 7. Within the dairy, subjects provided the following information: average daily pain score, opioid use and amount of opioid utilized, other forms of pain management, satisfaction with pain control, perception of the amount of opioid prescribed, and need for pain management hospital/clinic visits. The online Prescription Drug Monitoring Program (PDMP) was queried for all patients to determine if prescriptions for opioids were filled during the postoperative period. The primary outcome was average postoperative day 1 pain score and an a priori determined margin of non-inferiority was set at 2 points. Secondary outcomes included whether subject filled an opioid prescription (indicated by the online PDMP), opioid use (yes/no), satisfaction with pain control (on a scale of 1= "much worse" to 5= "much better" than expected), and how subjects felt about the amount of opioid prescribed (on a scale of 1="prescribed far more" to 3="prescribed the right amount" to 5="prescribed far less" opioid than needed). 82 participants underwent isolated MUS placement and met inclusion criteria; 40 were randomized to the standard arm and 42 to the restricted group. Within this manuscript, we detail the data obtained from this randomized clinical trial and the methods utilized.

Sling plication for persistent stress urinary incontinence after midurethral sling

INTRODUCTION AND HYPOTHESIS

Persistent or recurrent stress urinary incontinence after midurethral sling placement is not uncommon. Treatment options include placement of a second midurethral sling, autologous fascial sling, retropubic urethropexy, or urethral bulking. Shortening of the sling by plication has also been suggested as an alternative option which may reduce operative time, cost, risk of trocar injury, and mesh burden. In this video, we aimed to demonstrate our technique and experience on sling plication.

METHODS

The key steps of the procedure are as follows: (1) suburethral incision and sharp dissection to identify the sling; (2) mobilization of the suburethral portion of the sling; (3) plication with two interrupted, horizontal sutures placed 1 cm laterally on each side; (4) application of upward pressure while tying the sutures and tensioning the sling. In our experience, we have found this technique to be most successful for retropubic slings, especially when performed within 2-12 weeks of the initial surgery.

CONCLUSIONS

Sling plication is an effective and minimally invasive option to treat persistent stress urinary incontinence after failed midurethral sling procedures. It avoids additional mesh burden or more invasive retropubic surgery and should be offered as a treatment option for appropriately counseled patients.

Surgical teaching of the retropubic midurethral sling: a virtual reality training system

INTRODUCTION AND HYPOTHESIS

The objective is to develop a low-risk, cost-effective method to teach procedures that require learning by feel and high-volume pattern recognition, starting with the midurethral sling.

METHODS

This video describes the creation of a virtual reality model utilizing de-identified patient data, artificial intelligence algorithms and haptics; and demonstrates the use of the training system for trocar passage of the retropubic midurethral sling procedure.

RESULTS

This innovative system overcomes the lack of visualization and "blind" nature of sling surgery. Novel artificial intelligence provides high accuracy of anatomical landmarks and a realistic 3D environment. The trainee benefits from haptic and visual alerts for real-time feedback on the trocar insertion pathway and scoring to develop competency.

CONCLUSION

This is one of the first noncadaveric, nonstatic models available in the field. It allows for multiple low-risk exercises and provides more surgeons with training outside the operating room, at their own institution, and avoids the need for patient subjects. Training can be disseminated at a significantly lower cost and greater convenience than remote cadaver laboratories or intraoperative observation and has a higher fidelity than available static models, particularly after multiple passes. This has implications not only for retropubic midurethral slings but also for urogynecological and "blind" surgery as a whole.

A time-frame comparison study of surgical volume shifts on female primary stress urinary incontinence surgery

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the surgical volume shifts for primary female stress urinary incontinence (SUI) over a 20-year period (1999-2018) in Taiwan.

METHODS

This was a retrospective cohort study based on Taiwan's National Health Insurance Research Database. We divided the time-frame into four periods: first period (1999-2003), second period (2004-2008), third period (2009-2013), and fourth period (2014-2018). The variables included major surgical types for SUI (retropubic urethropexy, pubovaginal sling, midurethral sling, etc.), surgeon gender, specialty, surgical volume (high ≥30, median 5-29, low <5), and hospital accreditation level. Reoperation rates within 1 year were analyzed as an outcome measurement.

RESULTS

A total of 51,018 patients were identified. Major surgical types increased significantly during the first three periods and slightly decreased during the fourth period. The proportion of surgical volume shifted from high- to medium-, and low-volume, but it reversed during the fourth period. The proportion of SUI surgeries decreased in medical centers, whereas it increased in regional and local hospitals. The proportion of SUI surgeries by female surgeons increased. Similar phenomena occurred in MUS. As for surgeon specialty, major surgical types were performed by gynecologists and urologists equally, whereas MUS were performed more by gynecologists than by urologists. Unexpectedly, 1-year reoperation rates were higher in high-volume surgeons.

CONCLUSIONS

The surgical trend of SUI surgeries shifted from high- to medium-, and low-volume surgeons, medical centers to regional and local hospitals during the study periods. This implied surgical skills and performance spreading, which may have a great influence on patient and healthcare provider choice of treatment.

Suburethral Synthetic Adjustment-controlled Tape Compared with Conventional Treatment for Female Stress Urinary Incontinence: A Randomized Controlled Trial

BACKGROUND

Urinary incontinence (UI) is a urological problem in women. Currently, suburethral slings are the standard of surgical treatment for stress UI in the female population.

OBJECTIVE

To prove the feasibility of an operating technique using suburethral adjustment-controlled tape (SACT) placement.

DESIGN, SETTING, AND PARTICIPANTS

A single-center comparative randomized controlled trial included patients randomized according to the CONSORT checklist from April to October 2018 and from November 2018 to April 2019. The inclusion criteria were women from 21 to 81 yr, stress and mixed UI forms, and positive cough test. The exclusion criteria were pregnancy, lactation, neurogenic bladder dysfunction, recurrent forms of UI, radiation therapy and pelvic surgery in anamnesis, genital prolapse (Pelvic Organ Prolapse Quantification system >2), urinary infection, and obstructive urination.

INTERVENTION

The first group (50 patients) was using synthetic SACT and the second group (75 patients) a transobturator tape (TOT) midurethral sling (MUS).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Subjective efficacy of 96% was established in group 1 and 86% in group 2, with a median follow-up of 12 mo. According to gynecological examination results, the objective surgical treatment efficiency was 96% in group 1 and 90.7% in group 2. This statistically significant indicator was evaluated in each group. However, when comparing both groups, no statistical difference was revealed. According to urodynamic studies, 1 mo after surgery in group 1, terminal and phase detrusor overactivity signs were 18% (n = 9) and 12% (n = 6), respectively. In group 2, these were 14.7% (n = 11) and 12% (n = 9), respectively.

RESULTS AND LIMITATIONS

The block approach was used to randomize patients into groups. A total of 125 patients (50 in the main group and 75 in the control group) were analyzed.

CONCLUSIONS

Our results prove the efficacy and safety of SACT in treating UI in women. The subjective and objective effectiveness results of treating patients in the study group show the possibility of using SACT in the same row with TOT MUS.

PATIENT SUMMARY

Our purpose was to standardize the surgery stage for urinary incontinence, and evaluate the effectiveness and safety of suburethral adjustment-controlled tape placement. We analyzed women with urinary incontinence and used two different surgical methods. Our results prove the efficacy and safety of suburethral adjustment-controlled tape in treating urinary incontinence in women.