Femistina versus Canephron as a prevention of urinary tract infections after midurethral sling surgery - Non-inferiority study

OBJECTIVE

Urinary tract infection (UTI) is relatively common post-operative complication following midurethral sling placement (MUS), even in cases where intraoperative antibiotic prophylaxis was given. The primary aim of this study was to investigate the non-inferiority of Femistina as compared with Canephron in reducing symptomatic UTI in first six months following surgery.

STUDY DESIGN

A sample size of 144 patients per group was established, to provide at least 90% power to demonstrate the non-inferiority of phytodrug Femistina versus Canephron as a prevention of post-MUS urinary tract infection.

RESULTS

Women suffering from stress urinary incontinence and mixed urinary incontinence (MUI) with predominant SUI symptoms as confirmed by urodymamics (n = 320) were randomized in a 1:1 ratio to Femistina (40 mg, oral, twice daily for 20 days) or Canephron (3 × 5 ml taken orally-three times daily for 4 weeks). Both groups were homogenous for age, type of operation (only TOT outside-in) and severity of illness as indicated by ICIQ-SF questionnaire. We found that symptoms of UTI were significantly lower in patients receiving Femistina. During first 6 months after surgery UTI was confirmed in only 10 patients receiving Femistina (6,25%) when compared to 25 (15,63%) subjects receiving Canephron, p < 0.007.

CONCLUSION

Femistina is not inferior to Canephron in preventing lower urinary tract infection after midurethral sling surgery.

Twenty-Five Years of the Midurethral Sling: Lessons Learned

Midurethral slings (MUS) are widely accepted for the surgical treatment of stress urinary incontinence (SUI) in cases where conservative treatment has failed. They have been shown to be a safe and effective surgical treatment for the management of SUI. However, there have recently been growing concerns regarding the safety profile of mesh procedures, generating international debate and leading to national inquiries into the effectiveness and safety of mesh implants. A multitude of clinical, technical, manufacturer-related, and other health jurisdictional factors are involved in the outcomes of MUS. Appropriate patient selection and informed consent to all treatment options, with proper guidance from healthcare providers, are critical for empowering women to choose an appropriate treatment option based on a personalized decision.

Twisting of transobturator midurethral slings: does it matter?

INTRODUCTION AND HYPOTHESIS

We assessed rotation/twisting of transobturator midurethral slings (TOTs) and tested for associations with de novo chronic pain and voiding dysfunction.

METHODS

A retrospective pilot study including patients seen after Monarc™ TOT surgery at a single tertiary hospital in 2005-2016. Patients underwent an interview, clinical examination, uroflowmetry and 4D pelvic floor ultrasound. Volume datasets were analyzed blinded against all other data. Sling rotation/twisting was evaluated in volumes obtained at rest. The sling axis was measured relative to the vertical in the midline and in the most lateral parasagittal slice. Total sling rotation was calculated by summation of absolute angle differences between midline and lateral angles. "Corkscrew" rotation was noted when direction of rotation was opposite on the contra-lateral side.

RESULTS

The study included 215 patients. Fifty-two (24%) were excluded, leaving 163. Mean age was 57 years (28-87; SD 12), mean BMI 29.4 kg/m² (18.3-47.4, SD 6). Follow-up was at a median of 17 months (IQR 11-27). Chronic de novo pain was reported by 15 women (9%; dyspareunia by 11 and pelvic/vaginal pain by 4). On imaging, mean total sling rotation was 144° (12-335, SD 56). In the majority (n = 103, 63%) it rotated counter-clockwise from its midline position and in 30 (18%) it rotated clockwise. "Corkscrew" rotation was noted in 30 (18%). De novo chronic pain was associated with lower BMI and vaginal sling exposure but not with sling rotation. The latter was not found to be associated with voiding dysfunction either.

CONCLUSIONS

Monarc™ TOTs rotate considerably throughout their course. The degree of twisting or rotation and its direction was not found to be associated with de novo postoperative chronic pain or voiding dysfunction.

Double opposite tape incision for obstructive sling

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence affects about 34% of all adult women. The mid-urethral sling (MUS), considered the gold-standard treatment, has widespread use but also potential complications. This study aims to demonstrate a new surgical technique that releases urethral obstruction caused by MUS with urinary continence maintenance.

METHODS

This video presents a 43-year-old patient with acute urinary retention after a suburethral sling procedure treated with a double opposite tape incision through a "U"-shaped inverted incision at the anterior vaginal wall.

RESULTS

The patient resumed her usual activities 1 week later with urinary continence. After 6 weeks, she was allowed to resume physical activities and sexual intercourse. At 3-month follow-up, she is still satisfied without urine leakage recurrence.

CONCLUSIONS

The double opposite tape incision is feasible and effective for urethral loosening after the MUS procedure. Concerned that this is a unique case, further studies are required to compare this technique to other surgical treatment options.

Comparison of Morphological and Histological Characteristics of Human and Sheep: Sheep as a Potential Model for Testing Midurethral Slings in vivo

INTRODUCTION

The sheep was evaluated as a potential model for preclinical evaluation of urethral slings in vivo based on: (1) anatomical measurements of the sheep vagina and (2) histological tissue integration and host response to polypropylene (PP) slings.

METHODS

Eight female, multiparous sheep were utilized. Three of 8 animals underwent surgery mimicking human tension-free vaginal tape protocols for midurethral slings and were euthanized at 6 months. The following measurements were obtained: vaginal length, maximum vaginal width with retraction, symphysis pubis length, and distance from the pubic bone to incision. Explanted sling samples from sheep and human were stained with hematoxylin and eosin for host reaction assessment.

RESULTS

Geometric measurements were similar between humans and sheep. Sheep vaginal anatomy allowed sling placement similar to procedures in human surgeries, and all sheep recovered without problems. Comparative histology between the sheep and human indicated similar host reaction and collagen deposition around implants, confirming suitability of the sheep model for biomaterial response assessment.

CONCLUSION

Sheep vaginal length is comparable to humans. Tissue integration and host response to PP slings showed chronic inflammation with rich collagen deposition around the material in both sheep and human specimens, highlighting the sheep as a potential animal model for preclinical testing of midurethral slings.

Predictors of postoperative complications from stress urinary incontinence procedures: a NSQIP database study

INTRODUCTION AND HYPOTHESIS

There are few studies examining patient risk factors for postoperative complications following midurethral sling (MUS) placement for stress urinary incontinence (SUI). The objective of this study was to describe 30-day postoperative complications after MUS using the National Surgical Quality Improvement Program database. Secondary objectives included rates of readmission and patient factors associated with postoperative complications and readmissions following MUS.

METHODS

We identified 16,491 women who underwent MUS for SUI between 2014 and 2018. American Society of Anesthesia (ASA) classification, medical comorbidities, readmission, reoperation, and 30-day postoperative complications were extracted. Outcomes included the 30-day postoperative complications, readmission, and reoperations. Descriptive statistics, univariate analyses, and multivariate logistic regression were used.

RESULTS

The majority of patients were white (66.9%) and had an ASA classification II (60.9%). Postoperative complications occurred in 4.2% of patients; 1.5% required readmission and 1.0% required reoperation. The most common complication was urinary tract infection (3.4%). Using multivariate logistic regression, older age, i.e., ≥80 years of age, was associated with increased odds of complication (aOR 1.77, 95%CI 1.14-2.72) and readmission (aOR 3.84, 95%CI 1.76-8.66). ASA class III and IV were associated with increased odds of complications (aOR 1.55, 95%CI 1.13-2.14, and aOR 3.06, 95% CI 1.48-5.86 respectively) and readmissions. Women of Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander descent ("other") were associated with increased postoperative complications (aOR 1.51, 95%CI 1.07-2.07).

CONCLUSION

Postoperative complications following MUS are rare. Factors associated with complications following MUS for SUI include age, ASA class, and women of "other" race.

Surgical outcomes of tension-free vaginal tape (TVT)- abbrevo® and TVT-obturator® for the treatment of stress urinary incontinence: a retrospective study

OBJECTIVE

We compared the efficacy and postoperative complications of tension-free vaginal tape (TVT)-abbrevo® (TVT-A) and TVT-obturator® (TVT-O) surgeries for the treatment of stress urinary incontinence (SUI).

METHODS

We retrospectively analyzed the medical records of 143 female patients with SUI who underwent TVT-A or TVT-O surgery between January 2010 and December 2019 at the Asan Medical Center in Seoul. We evaluated intra- and postoperative complications such as bladder injury, groin pain, urinary retention, and mesh exposure. We also checked the success rate at 6 months after surgery.

RESULTS

There were no complications, including fever, hematuria, hematoma of the vulva, or bladder injury, immediately after surgery in either group. Postoperative complications 2 weeks post-surgery were groin pain (11.3%), urinary retention (4.9%), and mesh exposure (0.7%). Groin pain was not significantly different between the two groups at 2 weeks, 3 months, and 6 months after surgery (TVT-O vs. TVT-A after 2 weeks: 12.5% vs. 10.3%, P=0.791; 3 months: 0.0% vs. 1.4%, P=0.999; and 6 months: 0.0% vs. 0.0%, P=0.999). Over 90% of the patients reported cure or improved symptoms in both groups. In the univariate logistic analysis, the type of TVT (TVT-O or TVT-A) was not associated with the success rate (odds ratio, 3.21; 95% confidence interval, 0.59-17.40; P=0.175).

CONCLUSION

TVT-A surgery is comparable with TVT-O in terms of high success rate and low frequency of complications, including bladder injury and groin pain.

Evaluation of the long-term effect and complication rate of single-incision slings for female stress urinary incontinence

OBJECTIVE

To evaluate the long-term outcomes of single-incision midurethral slings (SIMS) in real-life practice.

STUDY DESIGN

This retrospective, single-arm, patient cohort study was performed in a large Dutch teaching hospital, including 397 consecutive women who underwent a SIMS-procedure between 2009 and 2018. Data were obtained through questionnaires and patient record study. Subjective improvement was the primary outcome, defined as a Patient Global Impression of Improvement (PGI-I) of '(very) much better'. Secondary outcomes were subjective cure rate (defined as a negative Urogenital Distress Inventory - item 4 'Do you experience involuntary urine leakage related to physical activity, coughing or sneezing?'), complication rate and sling failure (defined as the need for additional research or treatment for persisting stress urinary incontinence (SUI)). All data was analysed with a statistical significance level of 5%.

RESULTS

The mean follow-up time was 54 months. All patients received SIMS (Ajust® or Altis®). Of all respondents, 75% reported a (very) much improved burden of disease. The subjective cure rate was 61%. In 93 patients a total of 120 complications were registered. In 10% of patients a sling failure was observed, 76% of these failures appeared in the first two years post-surgery.

CONCLUSION

This study showed that, in real life practice, SIMS are both effective and safe over a long period of time.

Efficacy and Safety of Surgical Treatments for Neurogenic Stress Urinary Incontinence in Adults: A Systematic Review

CONTEXT

Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI).

OBJECTIVE

To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management.

EVIDENCE ACQUISITION

A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

EVIDENCE SYNTHESIS

A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively.

CONCLUSIONS

The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques.

PATIENT SUMMARY

Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence.

Vaginally Assisted Laparoscopic Urethrolysis and Mesh Excision after Tension-free Vaginal Tape

STUDY OBJECTIVE

To present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape.

DESIGN

Demonstration video.

SETTING

Despite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1]. Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3]. Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation (Fig. 1). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra (Fig. 2).

INTERVENTIONS

(1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] (Fig. 3).

CONCLUSION

Laparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.

Impact of preoperative pelvic floor muscle training (pretraining) on urinary storage and emptying symptoms in women undergoing sling surgery

INTRODUCTION AND HYPOTHESIS

Although pelvic floor muscle training (PFMT) is an option for female mixed incontinence (MUI), the role of PFMT prior to midurethral sling (MUS) surgery is not well defined. We hypothesize that preoperative PFMT (pretraining) positively impacts urinary storage and voiding symptoms prior to retropubic MUS.

METHODS

We carried out an institutional review board-approved, retrospective chart review of women with stress-predominant MUI undergoing a retropubic MUS. Seventy-two women elected for initial PFMT before MUS (group 1). These were age-matched with 72 women who underwent MUS only (group 2). The primary outcome was the change in urinary voiding and storage symptoms (Emptying [E] and Inhibition [I; UUI] subsets of the SEAPI classification). Additional outcomes were stress urinary incontinence (SUI) resolution and change in quality of life (QoL) indices.

RESULTS

Mean age and follow-up were 49 ± 12 years and 33 ± 12 months respectively. After MUS, SUI resolved in 79.2% and 69.4% in groups 1 and 2 respectively (p > 0.05). In group 1, 18% and 20.8% had improvement/resolution in the E and I subsets prior to MUS. Postoperatively, similar rates of improvement/resolution in the E (25% for both) and I (68% vs 63.9%) subsets were observed in groups 1 and 2 respectively. Postoperative QoL indices were statistically improved in both groups, with no significant difference between groups.

CONCLUSIONS

Pretraining with PFMT before MUS was associated with preoperative improvement in emptying symptoms and UUI. Although not statistically significant, pretraining was associated with a higher chance of SUI resolution in the long term. If pretraining is beneficial before MUS, the effect appears to be small.

Telemedicine follow-up is safe and efficacious for synthetic midurethral slings: a randomized, multi-institutional control trial

Introduction and hypothesis

The objective was to assess whether telemedicine-based follow-up is equivalent to office-based follow-up in the early postoperative period after routine synthetic midurethral sling placement.

Methods

This is a prospective, international, multi-institutional, randomized controlled trial. Patients undergoing synthetic midurethral sling placement were randomized to 3-week postoperative telemedicine versus office-based follow-up. The primary outcome was the rate of unplanned events. Secondary outcomes included patient satisfaction, crossover from telemedicine to office-based follow-up, and compliance with 3- to 5-month office follow-up.

Results

We included 238 patients (telemedicine: 121 vs office: 117). No differences in demographics or medical comorbidities were noted between the study groups (p = 0.09–1.0). No differences were noted in unplanned events: hospital admission, emergency department visit, or unplanned office visit or call (14% vs 12.9%, p = 0.85) or complications (9.9% vs 8.6%, p = 0.82). Both groups were equally “very satisfied” with their surgical outcomes (71.1% vs 69%, p = 0.2). Telemedicine patients were more compliant with 3- to 5-month office follow-up (90.1% vs 79.3%, p = 0.04).

Conclusions

After synthetic midurethral sling placement, telemedicine follow-up is a safe patient communication option in the early postoperative period. Telemedicine patients reported no difference in satisfaction compared with office-based follow-up but had greater compliance with 3- to 5-month follow-up.

The impact of midurethral sling surgery on the development of urinary tract infections

PURPOSE/OBJECTIVE

To measure the impact of the placement of a midurethral sling (MUS) on development of urinary tract infections (UTI) in women with stress urinary incontinence.

METHODS

This is an analysis of a large managed care organization MUS database from 2005 to 2016. The database was queried to identify UTI and diagnosis of recurrent UTI. The primary outcome was the UTI rate after MUS. Secondary outcomes included the recurrent UTI rate and rates of UTI over time.

RESULTS

Over the study period, 13,404 MUS were performed. In the 12 postoperative months, 23% of patients developed a UTI, while 4% developed a de novo recurrent UTI diagnosis. UTIs were most frequently diagnosed in the 1st month, with the 7th postoperative day the most common. Predictors of UTI development included increased age (OR 3.69 [95% CI 2.58-5.26]), being diabetic (OR 1.43 [95% CI 1.28-1.60]), and having urinary retention requiring prolonged catheterization (OR 2.45 [95% CI 2.11-2.85]). UTIs were less likely to be diagnosed in those with transobturator MUS (OR 0.85 [95% CI 0.78-0.94]). Patients who developed a UTI were more likely to have a reoperation (p = 0.0147), including a reoperation for mesh revision/removal (p = 0.0287), and recurrent SUI (p = 0.0394). Patients who developed a UTI were more likely to develop postoperative de novo urgency urinary incontinence (UUI) (p < 0.0001).

CONCLUSION

Patients are at risk of UTI and rUTI after MUS. Risk of developing UTIs decreases with time. Predictors of developing UTI can help surgeons in the care of patients after MUS.

Evaluation of efficacy and safety of single-incision sling versus transobturator sling in women with stress incontinence and intrinsic sphincter deficiency

INTRODUCTION AND HYPOTHESIS

Urethral intrinsic sphincter deficiency (ISD) is associated with severe urine leakage and a higher risk of sling failure. The aim of this study is to evaluate the efficacy and safety of single-incision slings (SISs) versus transobturator slings (TOSs) in such patients.

METHODS

Patients who had stress incontinence and ISD who underwent SIS or TOS procedures from 2010 to 2017 were retrospectively reviewed. The objective and subjective cure rates and surgical adverse events were compared between different slings. Objective cure was defined as no stress urine leakage with a comfortably full bladder. Subjective cure was determined by the patient's satisfaction. Incontinence-related symptom distress and quality of life were evaluated using the short forms of the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7).

RESULTS

Among 111 patients, 37 underwent SIS and 72 underwent TOS with a median follow-up of 21 (range: 12-72) months and 24 (range: 14-84) months (p = 0.265). For both groups, the UDI-6, IIQ-7, and 1-h pad test all significantly improved after surgery (all p < 0.001). The objective and subjective cure rates were comparable after SIS and TOS procedures (objective: 76% vs. 76%, p = 0.837; subjective: 78% vs. 83%, p = 0.212). There were no significant differences in adverse events, except SISs had a shorter surgery time (16.4 ± 9.3 vs. 27.3 ± 12.4 min, p = 0.020) and lower postoperative visual analog scale pain score (1.3 ± 1.1 vs. 3.9 ± 1.4, p < 0.001).

CONCLUSION

SISs and TOSs had similar surgical results in women with stress incontinence and ISD after at least 1 year of follow-up. However, SISs had a shorter operation time and lower postoperative pain than TOSs.

Inability to walk and persistent thigh pain after transobturator tape procedure for stress urinary incontinence: surgical management

INTRODUCTION AND HYPOTHESIS

Groin pain after transobturator tape is often a self-limiting situation, but can occasionally persist and be associated with serious neurological sequelae. The video is aimed at presenting the surgical management of persistent groin pain and inability to walk after transobturator sling placement and subsequent partial removal.

METHODS

The featured patient is a 31-year-old woman unable to walk after transobturator sling implantation 2 years before. She reported left thigh pain immediately after surgery that was not responsive to postoperative medication. Six months later, suburethral portion excision was performed but no pain relief was obtained. She was unable to walk, and needed a wheelchair. Electromyography showed axonal injury of the left obturator nerve. After providing proper informed consent, the patient was admitted for combined transvaginal and transcutaneous transobturator tape arm removal.

RESULTS

The featured procedure was completed in 120 min and blood loss was <100 ml. No surgical complications were observed. The patient is currently doing left leg rehabilitation, has regained the ability to walk with the aid of a crutch, and the need for chronic pain control medication is greatly reduced.

CONCLUSION

This represents a valid surgical approach for the late management of this mesh-related complication.

Urinary retention is rare after colpocleisis and concomitant midurethral sling: a 10-year experience

OBJECTIVES

The optimal method of managing stress urinary incontinence (SUI) in women undergoing colpocleisis remains unclear, especially in a setting of urinary retention. We aim to compare postoperative retention after colpocleisis with or without concomitant midurethral sling (MUS).

METHODS

A retrospective chart review of all women who underwent colpocleisis with or without MUS from October 2007 to October 2017 was performed. Women with preoperative and 2-week postoperative post-void residual volume (PVR) measurements were included. Urinary retention was defined as PVR of ≥100 ml. Analysis included t tests/Wilcoxon rank, Chi-squared/Fisher's exact, and multivariate linear regression models.

RESULTS

A total of 231 women with a mean age of 77.7 years (± 6.0 years SD) met the inclusion criteria. One hundred and thirty-eight women underwent colpocleisis alone, whereas 93 women had colpocleisis with MUS. Preoperative retention rates were high (44.9% vs 34.4%, for colpocleisis alone versus with MUS, p = 0.114). Postoperative retention rates were lower and similar between the groups (10.1% vs 11.8%, for colpocleisis alone vs with MUS, p = 0.69). Linear regression models showed the adjusted odds ratio for postoperative urinary retention in patients with concomitant MUS was 1.68 (95% confidence interval: 0.64-4.41) compared with patients with colpocleisis alone and this did not reach statistical significance (p = 0.292). Fortunately, after colpocleisis, women had high rates of resolution of retention, regardless of MUS (80.3% vs 90.6% for colpocleisis alone vs with MUS; p = 0.20). Few women required reoperation for retention (3.1%).

CONCLUSIONS

Placement of an MUS at the time of colpocleisis is a safe and effective therapy. This appears to be unaffected by preoperative urinary retention status.

Autologous Fascial Slings for Surgical Management of Stress Urinary Incontinence: A Come Back

Stress urinary incontinence (SUI) is a common type of urinary incontinence adversely affecting the quality of life of women. For mild SUI, life style changes, pelvic floor exercises and medical treatment with duloxetine may help. Most patients of moderate to severe SUI usually require surgical treatment. Various surgical treatment options include Kelly's plication, Burch colposuspension, bulking agents and sling surgeries. Although, suburethral fascial slings including the autologous rectus fascia slings were in vogue before 1990, they were overtaken by minimally invasive, faster and easier artificial midurethral slings (tension free vaginal tape and transobturator tape). However, observation of serious long-term and life changing complications of synthetic midurethral slings like mesh erosion, chronic pelvic pain and dyspareunia led to their adverse publicity and medico legal implications for the operating surgeons. This led US FDA (Food and Drug Administration) to issue a warning against their use. Currently, their use has significantly decreased in many countries, and they are no longer available in some countries. This has led to renaissance of use of natural autologous fascial sling, especially rectus fascia for surgical management of SUI. Although performing rectus fascia sling surgery is technically more challenging, takes longer, has more short-term morbidity like voiding dysfunction, their long-term success is high with very little risk of serious complications like mesh erosion, chronic pelvic pain and dyspareunia. However, multicentric trials and longer follow ups are needed before it's routine recommendation This review discusses the role of autologous fascial sling (especially rectus fascia) for the surgical management of SUI in the current time and the need of ongoing training of this procedure to gynecology residents and urogynecology fellows.

The impact of the 2011 US Food and Drug Administration transvaginal mesh communication on utilization of synthetic mid-urethral sling procedures

INTRODUCTION AND HYPOTHESIS

We sought to examine the change in utilization of the midurethral sling (MUS) for the treatment of stress urinary incontinence (SUI) after the 2011 US FDA communication regarding transvaginal mesh.

METHODS

This is a retrospective cohort study evaluating surgical utilization of MUS at a managed care organization of 4.5 million patients from 2008 to 2016. The primary outcome was the change in utilization of synthetic mesh MUS before and after the July 2011 FDA communication. Secondary outcomes were the changes in surgeon level MUS utilization.

RESULTS

MUS procedures decreased from 131 to 116 per 100,000 adult women with a decrease of 11.5% from 2010 to 2012. Year over year utilization of MUS was rapidly increasing (p < 0.01) prior the FDA communication from 116 (in 2008) to 131 (in 2010) per 100,000 women and then significantly declined (p < 0.01) after its release from 135 (in 2011) to 75 (in 2016) per 100,000 women (13% increase vs 44% decrease). The number of surgeons performing MUS increased (p < 0.01) from 172/year to 186/year from 2008 to 2010 (Table 1). This decreased (p < 0.01) from 183/year to 121/year from 2011 to 2016.

CONCLUSIONS

MUS for SUI drastically declined after the FDA communication. Despite the 2011 FDA communication concerning only transvaginal mesh for pelvic organ prolapse, there was a significant decrease in MUS with synthetic mesh utilization. Our findings support the importance of continued long-term outcome data regarding the safety and efficacy of MUS and highlight the impact of the FDA warning on MUS utilization.

Management of Vaginal Mesh Exposures Following Female Pelvic Reconstructive Surgery

PURPOSE OF REVIEW

To discuss considerations and current evidence for the diagnosis and management of vaginal mesh exposures following female mesh-augmented anti-incontinence and pelvic organ prolapse surgery.

RECENT FINDINGS

Since the introduction of mesh into female pelvic surgery, various applications have been reported, each with their own unique risk profile. The most commonly encountered mesh-related complication is vaginal mesh exposure. Current evidence on the management of vaginal mesh exposure is largely limited to observational studies and case series, though this is continuing to expand. We present a synthesis of the available data, as well as clinical and surgical approaches to managing this complication. It is important for surgeons to be familiar with the management of vaginal mesh exposures. Depending on the patient's presentation and goals, there is a role for conservative measures, mesh revision, or mesh excision. Further study is warranted to standardize mesh resection techniques and explore non-surgical treatments.

Understanding the mechanics of closure is key to optimal midurethral sling technique

The animal experiments and prototype midurethral sling operations demonstrated that the sling provided new collagen to reinforce weak pubourethral ligaments (PUL). The now strengthened PULs were able to restore the contractile power of the 3 oppositely-acting directional closure forces. By contraction, these three forces exponentially altered the intraurethral resistance to flow when they closed the urethra to sustain continence. Relaxation of the forward force allowed the two posterior forces to uninhibitedly open the posterior urethral wall just prior to detrusor contraction, to facilitate evacuation of urine. The aim of this work is to examine the mechanics of the component anatomical structures which contribute to these functions, to analyse how subtle details impact on the actual surgical technique of the midurethral sling operations to optimize success, contribute to complications and how to prevent and fix them.

Incontinence outcomes after "second primary" compared to repeat midurethral sling for recurrent and persistent stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The current study aims to assess the continence rate of a "second primary" midurethral sling (MUS) in women with recurrent/persistent stress urinary incontinence (SUI) after sling excision compared to a historical cohort who underwent a repeat MUS.

METHODS

A retrospective cohort study of women who underwent excision of a primary MUS and placement of a "second primary" MUS from 2009 to 2016 compared to a historical cohort who underwent a repeat MUS from 2006 to 2009. The primary outcome was continence rate, defined as "not at all" or "somewhat" to Urogenital Distress Inventory (UDI-6) SUI subscale questions. Secondary outcomes included assessment of symptom severity (UDI-6), symptom-specific quality of life, Incontinence Impact Questionnaire (IIQ-7), Medical and Epidemiologic Aspects of Aging (MESA), and Patient Global Impression of Improvement (PGI-I).

RESULTS

Survey responses were available for 23/64 (36%) in the "second primary" MUS group versus 88/135 (65%) in the historical cohort. Mean follow-up in months, second primary: 41.8 ± 26.1 versus repeat: 36.2 ± 14.1, p = 0.16 and age (years): 56.4 ± 10.7 versus 59.8 ± 10.8, p = 0.19. Continence rates were 48% in "second primary" versus 56% in the repeat group (p = 0.50). Both groups had significant improvement in questionnaire scores postoperatively with no intergroup differences. Multivariable analysis demonstrated that odds of success did not differ between groups (adjusted odds ratio: 0.73, 95% confidence interval: 0.27-1.99).

CONCLUSIONS

In women with recurrent/persistent SUI, repeat and "second primary" MUS procedures demonstrate similar success outcomes and improvement in UI symptom distress and QOL. Continued research is needed for this increasingly important clinical question.

Impact of severe obesity on long-term success and complications of the retropubic midurethral sling

INTRODUCTION AND HYPOTHESIS

With conflicting evidence in the literature, we hypothesised that the long-term subjective outcomes of the retropubic midurethral sling (MUS) are the same in the severely obese and non-obese populations.

METHODS

A retrospective matched cohort study was performed on women with a BMI ≥ 35 and < 30 who had a retropubic MUS placed between 2010 and 2015 using telephone questionnaires. The primary outcome was the success rate of surgery defined by the Urogenital Distress Inventory Short Form (UDI-6) stress subscale. Statistical analysis was performed to test for associations between primary and secondary outcomes across the two groups.

RESULTS

Seventy-eight severely obese (SOG) and 74 non-obese (NOG) were recruited. At a median time from surgery of 3.8 years the success rate was 47.4% in the SOG compared to 64.9% in the NOG (p = 0.03). There was a 22% reduction in the odds of success with every 5 unit increase in BMI (p = 0.03). There were higher rates of mixed urinary incontinence preoperatively (60.3% vs. 37.8%, p = 0.006) and persistent urinary urge incontinence postoperatively (48.7% vs. 32.4% p = 0.04) in the severely obese. Lower PGI-I scores were obtained in the severely obese group indicating less improvement in symptoms from surgery. There was no difference in complication rates between the groups.

CONCLUSION

Long-term subjective outcomes from the retropubic MUS are lower in severely obese women than in non-obese women with no difference in complication rates. High satisfaction and recommendation rates were found in both groups.

Female Pelvic Medicine and Reconstructive Surgery challenges on behalf of the Collaborative Research in Pelvic Surgery Consortium: managing complicated cases : Series 5: management of recurrent stress urinary incontinence after midurethral sling exposure

This case presents the work-up and management of a patient requesting surgical intervention for recurrent stress urinary incontinence after previous excision of a portion of her midurethral sling because of mesh exposure. Four international experts provide their approach to this complex case. There is little consensus regarding further surgery in a patient who has required mesh excision. Treatment by fascial sling was commonly considered and the literature review outlines the pros and cons of autologous fascia versus donor fascia for this specific case.

Voided volume for postoperative voiding assessment following prolapse and urinary incontinence surgery

INTRODUCTION AND HYPOTHESIS

The objective was to compare the safety and accuracy of voided volume with the standard retrograde fill approach for voiding assessment after pelvic floor surgery.

METHODS

This cohort represents all women in our repository who underwent postoperative voiding assessment following procedures for pelvic floor disorders between September 2011 and June 2014. One surgeon utilized a spontaneous voiding (SV) protocol and allowed any patient who voided 150 ml or more at one time to pass the trial. The other surgeon used a retrograde fill (RF) protocol. This involved instilling the bladder with 300 ml of water or until maximum capacity immediately after the outpatient procedures and on the first postoperative day for hospitalized patients. For this protocol, a voided volume of 200 ml was considered sufficient to pass the trial.

RESULTS

In this cohort, 431 women had a voiding trial with SV, and 318 with RF. The groups were similar with respect to baseline characteristics but more women in the RF group had a sling-only procedure. The failure rates of the RF (22.8%) and SV (20.0%) groups were similar (p = 0.46). Among women who passed the voiding trial, similar percentages of women returned with urinary retention and needed catheter insertion after the RF (1.6%) and SV (0.9%) methods (p = 0.65).

CONCLUSION

Spontaneous voiding trial based on a minimum voided volume of 150 ml is a safe and reliable alternative to the retrograde fill method after female pelvic floor procedures.

[Predictive factors of immediate post-operative acute urinary retention or voiding dysfunction following mid-urethral sling surgery: A literature review]

OBJECTIVE

Immediate postoperative urinary retention (UR) and voiding dysfunction (VD) are some factors limiting outpatient procedure for mid-urethral sling (MUS) surgery in women presenting with stress urinary incontinence. The objective of the current review was to report the main predictive factors associated with immediate postoperative UR/VD following MUS surgery in women.

METHODS

A systematic review was performed using Medline database, according to PRISMA methodology, using following keywords midurethral sling; tension-free vaginal tape; TVT; transobturator tape; TOT; predicting factor; voiding dysfunction; urinary retention; postvoid residual; postoperative residue of urine.

RESULTS

Thirteen studies were included. Main clinical predictive factors associated with immediate postoperative urinary retention (UR) and voiding dysfunction (VD) were: previous pelvic surgery (hysterectomy, incontinence or pelvic organ prolapse surgery) [OR: from 3.7 ((CI95%: 1.14-12.33); P=0.029)] to 8.93 [(CI95%:1.17-61.1); P=0.035)], previous UR [OR: 415 (CI95%: 20-8619); P<0.001], age over 65 y/o [OR: 3,72 (CI95%:1.40-9.9); P<0.01], and general anesthesia [OR: 4.5 (CI95%:1.1-18.9); P=0.02]. Urodynamic predictive factors were underactive bladder at cystometry [OR: from 2.52 ([CI95%: 1.03-6.13]; P=0.042) to 5.6 ([IC95%: 1.6-19.2]; P=0.02] and preoperative maximum flow rate (Qmax) (the prevalence of UR was ranging from 12 to 35% when Qmax was under 15ml/s, versus 0% when Qmax was over 30ml/s).

CONCLUSION

Predictive factors associated with immediate postoperative UR/VD following MUS surgery in women were age over 65 y/o, previous pelvic surgery or previous UR, underactive bladder and preoperative Qmax under 15ml/s.