Risk factors for failure of repeat midurethral sling surgery for recurrent or persistent stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

To study the outcomes following repeat midurethral sling (MUS) surgery in patients with persistent or recurrent stress urinary incontinence after failure of primary MUS surgery and risk factors for surgical failure.

METHODS

The medical records of 24 patients who underwent repeat MUS surgery at a single tertiary center from January 2004 to February 2014 were reviewed. The types of MUS used for the repeat surgey were transobturator, retropubic and single incision slings. Objective cure was defined as no demonstrable involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction observed during filling cystometry, and subjective cure was defined as a negative response to Urogenital Distress Inventory six (UDI-6) question 3 during follow-up between 6 months and 1 year postoperatively. The change in the inclination angle between the urethra and pubic axis was measured with introital ultrasonography and the cotton swab test performed.

RESULTS

The objective and subjective cure rates were 79.2 % and 75 %, respectively. There were no differences in demographics between the patients with failure of surgery and those with successful surgery. Significant independent risk factors for failure of repeat MUS surgery were a change in cotton swab angle at rest and straining of <30° (OR 4.6, 95 % CI 2.5 - 7.9°), a change in inclination angle of <30° (OR 4.6, 95 % CI 2.5 - 7.9°), intrinsic sphincter deficiency (OR 3.4, 95 % CI 1.8 - 6.1) and a mean urethral closure pressure of <60 cm H2O (OR 2.9, 95 % CI 1.5 - 4.5). In one patient the bladder was perforated.

CONCLUSIONS

Repeat MUS surgery is safe and has a good short-term success rate, both objectively and subjectively, with independent risk factors for failure related to bladder neck hypomobility and poor urethral function.

Results of sling surgery in a non-selected population

OBJECTIVE

To evaluate sling surgery in terms of effectiveness and quality of life, and describe the effects of confounding variables on outcomes.

METHODS

A retrospective cohort study using multiple validated questionnaires was conducted in a specialized pelvic floor center in the Netherlands. Women were enrolled after undergoing sling surgery between January 1, 2010, and January 31, 2012. In addition to the preoperative questionnaire, participants completed a questionnaire a minimum of 6weeks after surgery to assess outcomes.

RESULTS

Of 255 eligible participants, 228 (89.4%) returned the postoperative questionnaire after a mean follow-up of 14.9months (range 2-32). At the time of follow-up, 158 (69.3%) patients considered themselves cured, and an improvement was observed in 155 (68.9%) patients; 70 (31.1%) patients rated their postoperative situation as little improved, unchanged, or deteriorated. Compared with patients who had no history of previous related surgery, patients with prior sling surgery benefited significantly less from surgery, whereas those with concomitant vaginal surgery showed similar scores in all outcome parameters. A high body mass index was found to have a negative effect on the results of surgery.

CONCLUSION

midurethral sling surgery is both efficient and effective in curing stress urinary incontinence. However, patient characteristics and confounding variables can influence the outcome of surgery and should therefore always be discussed with the patient.

A Giant Female Urethral Stone: An Unusual Complication after MidUrethral Sling Operation

Primary giant urethral stones are extremely rare in females, and they usually appear in the case of congenital diverticula, not as complications of surgery. Herein, we report a 54-year-old woman with a giant female urethral stone developed after tension-free obturator tape procedure. To our knowledge, this is the first late complication reported in the literature after midurethral sling procedure.

Effectiveness of botulinum toxin injection in the treatment of de novo OAB symptoms following midurethral sling surgery

Introduction and hypothesis

Intravesical onabotulinumtoxinA (Botox®) is effective for idiopathic overactive bladder (OAB) symptoms. Our primary objective was to compare the efficacy of onabotulinumtoxinA for women with de novo OAB after midurethral sling (MUS) surgery and women with idiopathic OAB.

Methods

Women enrolled in this prospective study had idiopathic (n = 53) or de novo (n = 49) OAB symptoms after MUS, with at least one episode of urgency urine incontinence per day. OnabotulinumtoxinA (100 U) was administered in 20 intradetrusor injections. Postvoid residual volumes were checked at 2, 4 and 12 weeks. Participants completed a 3-day bladder diary and the King’s Health Questionnaire (KHQ) before and 12 weeks after treatment.

Results

After 12 weeks, 22 patients (41.5 %) in the idiopathic OAB and 19 patients (38.8 %) in the de novo OAB groups were completely dry. OnabotulinumtoxinA injections had a significant benefit within both groups (p <0.001) to decrease both the daily numbers of voids (−2.39 and −2.0) and incontinence episodes (−1.38 and −1.44), with no significant difference between groups. We observed an increase of mean voided volume of >90 ml in both groups. Urinary retention was observed in four patients.

Conclusions

We observed similar improvement in OAB symptoms after intravesical onabotulinumtoxinA injections within both groups. The rates of retention and requirement for catheterization even for women with a prior MUS were acceptable. These observational data provide evidence that onabotulinumtoxinA can effectively treat patients with OAB following stress urinary incontinence surgery.

Incontinence surgery in obese women: comparative analysis of short- and long-term outcomes with a transobturator sling

INTRODUCTION AND HYPOTHESIS

Midurethral slings (MUS) are still discussed in complex incontinence situations, such as obesity, lacking sustained efficacy validation in this particular sub-population. We hypothesized that the outcomes of a transobturator MUS, such as TVT-O, do not differ according to body mass index (BMI) over a 4-year period.

METHODS

We conducted a retrospective analysis of 281 women who underwent TVT-O at our institution, between 2004 and 2012. Patients were stratified into obese (BMI ≥ 30 kg/m(2)) or non-obese (BMI < 30 kg/m(2)). We compared preoperative and postoperative parameters, including objective cure (negative stress test), complications, and quality of life scores. Data were collected at 0, 6, 12, 24, and 48 months. We used Fisher's exact test for categorical variables and Student's t test or the Mann-Whitney U test for continuous variables.

RESULTS

Baseline characteristics of the obese (n = 122) and non-obese groups (n = 159) were similar. We found no significant differences between groups in terms of objective cure rates at all follow-up evaluations, with 95.8 % and 95 % at 48 months in the non-obese and obese groups respectively. There were no significant differences in the cumulative complication rates of both groups. Quality of life assessment also showed no significant differences between groups at all follow-up visits. At 48 months our follow-up rate was 59 % (n = 96) and 60.4 % (n = 72) in the non-obese and obese group respectively (p = 0.9).

CONCLUSIONS

The TVT-O procedure is effective and safe in the long term for stress incontinence treatment, regardless of BMI.

[Outpatient suburethral sling in women: Review of the literature]

INTRODUCTION

The aim of this study was to assess efficacy, complication and feasibility of outpatient suburethral slings for stress urinary incontinence in women.

MATERIAL AND METHODS

A systematic review of the literature was done from the Pubmed data-base by searching following keywords: suburethral sling, midurethral sling, TVT, TOT, outpatient surgery, day surgery.

RESULTS

Seventy-eight percent to 88% of patients were continent postoperatively, and 6.8 to 12% of patients were significantly improved. No major complication occurred and minor complications were observed in 7.2 to 19.8% of patients. Eighty to 86.6% of patients experienced no complication. Seventy percent to 100% of patients were discharged on post operative day 0. The satisfaction rate was 89.4 to 95%.

CONCLUSION

Outpatient suburethral sling for stress urinary incontinence is suitable, effective, with a low complication rate, and with a high rate of satisfaction.

Postoperative groin pain and success rates following transobturator midurethral sling placement: TVT ABBREVO® system versus TVT™ obturator system

INTRODUCTION AND HYPOTHESIS

Placement of a transobturator midurethral sling (MUS) is the standard surgical treatment for stress urinary incontinence. Most recent MUS procedures have been poorly evaluated. We compared the results using a "new" device expected to reduce postoperative pain, the TVT ABBREVO® system (TVT-Abb), with those using the TVT™ obturator system (TVT-O).

METHODS

This was a retrospective study comparing the use of the TVT-Abb (in 50 patients) and the TVT-O (in 50 patients). The main outcomes were the amount of postoperative pain, the success rate (no reported urinary leakage and negative cough test) with both MUS procedures, and the prevalence of complications.

RESULTS

The mean follow-up time was 12 months. The preoperative characteristics of the two groups were comparable. There was less postoperative pain (VAS, 0 to 100) in the TVT-Abb group than in the TVT-O group (12.2 vs. 24.4, p < 0.01). However, at 6 weeks after surgery there was no significant difference between the two groups (p = 0.32). The incidence of de novo bladder outlet obstruction symptoms was similar in the TVT-Abb group and the TVT-O group (8 % vs. 12 %, p = 0.74). The prevalences of perioperative and postoperative complications (bladder/urethral injury, haemorrhage) in the two groups were equal. The success rates were similar at 12 months after surgery (88 % vs. 78 %, p = 0.29).

CONCLUSIONS

The success rates with TVT-Abb and TVT-O were equal at 12 months after surgery, but there was less immediate postoperative pain with TVT-Abb.

Twelve-month outcomes following midurethral sling procedures for stress incontinence: impact of obesity

OBJECTIVE

To evaluate impact of body mass index (BMI) ≥30 on objective and subjective cure rates 12 months after midurethral sling surgery.

DESIGN

Secondary analysis.

SETTING

Three hospitals in Calgary, Canada, 2005-07.

POPULATION

A total of 182 women enrolled in a randomised control trial of tension-free vaginal tape versus transobturator tape.

METHODS

Women were classified as obese or nonobese from height and weight on day of surgery. Women underwent postoperative standardised pad tests, self-reporting of urinary incontinence, and quality of life scores. Categorical data compared with chi-square or Fisher's exact, continuous data compared with Mann-Whitney U test.

MAIN OUTCOME MEASURES

Primary outcome was objective cure, defined as <1 g urine loss on postoperative 1-hour pad test. Secondary outcomes were subjective cure of incontinence (no stress incontinence in previous 7 days), presence of urinary urgency in previous 7 days, Urogenital Distress Inventory (UDI-6) scores, Incontinence Impact Questionnaire (IIQ-7) scores, and surgical complication rates.

RESULTS

Objective cure differed, with 85.6% of nonobese women leaking <1 g on 1-hour pad test, versus 67.8% of obese women (P = 0.006, risk difference [RD] 17.8%, 95% confidence interval [95% CI] 4.2-31.4%). Subjective cure was 85.8% for nonobese women versus 70.7% for obese women (P = 0.016, RD 15.1%, 95% CI 1.9-28.4%). For both groups, improvement was seen for postoperative UDI-6 (median -33.3 [-44.4 to -22.2] and -27.2 [-44.4 to -16.7]) and IIQ-7 scores (median -26.2 [-45.2 to -14.3] and -23.8 [-42.9 to -14.3]). No differences existed in rates of operative complications between the two groups.

CONCLUSION

Twelve months after midurethral sling surgery, obese women experience lower rates of cure than those who are nonobese.

The changes of voiding pattern after midurethral sling between pure stress urinary incontinence and stress urinary incontinence with overactive bladder group

Purpose

The purpose of this study is to compare changes in voiding pattern after midurethral sling surgery (MUS) between the stress urinary incontinence (SUI) group and the overactive bladder (OAB)+SUI group.

Materials and Methods

From January 2008 to February 2011, a retrospective survey was conducted of 225 female patients who had been diagnosed with SUI and undergone MUS. The subjects were divided into the SUI group and the OAB+SUI group. Changes in the overactive bladder symptom score (OABSS) and American Urological Association-Symptom Index (AUA-SI) before and three months after the MUS were compared.

Results

Of the 225 patients, 165 patients (73.3%) were classified as SUI group, and 60 patients (26.7%) were classified as OAB+SUI group. The mean age of the subjects was 54.7 years (range, 31-80 years), and the mean age of patients was 53.9 years (range, 34-80 years), and 56.8 years (range, 31-78 years) in the SUI group and OAB+SUI group. In SUI group, voiding symptom and storage symptom among the AUA-SI were significantly increased (p<0.05). OABSS were slight increased, but was statistically insignificant (p=0.847). In OAB+SUI group, voiding symptom score and OABSS showed a significant increase (p<0.05), but storage symptom score showed an insignificant increase (p=0.790).

Conclusions

OAB may occur in approximately 18% of SUI patients who undergo MUS surgery, and voiding dysfunctions with deteriorated voiding symptom and storage symptom may also occur. The deteriorated OAB was shown in 45% of SUI patients with OAB after the surgery.

Management of complications after tension-free midurethral slings

Since their introduction in 1996, tension-free midurethral slings (MUS) have been proven to have long-term efficacy and safety. They are considered the gold standard treatment of female stress urinary incontinence, especially in cases that are associated with urethral hypermobility. However, they are not free of complications and, although rare, some of these complications can be challenging for both patients and physicians. Some complications occur intraoperatively, whereas others appear in the early or late postoperative period. There is less controversy in the diagnosis and treatment of complications such as vaginal extrusion or urinary system erosion, whereas de novo voiding problems are at best not completely understood. Voiding dysfunction after MUS placement may vary in a wide range from urinary frequency or urgency to retention and is usually attributed to the obstructive or irritative effect of the sling. However, present urodynamic criteria for the diagnosis of female infravesical obstruction are not satisfactory, and the best management policy for de novo voiding dysfunction remains controversial. In the majority of cases, the diagnosis of obstruction leading to a urethral release surgery depends on a combination of several clinical findings. The timing of urethral release surgery varies depending on the preferences of the surgeon, and the outcome of this surgery is not always predictable. The purpose of this review was to assess the diagnosis and management of the immediate, short-term, and long-term complications of MUS in light of the current literature in an attempt to determine the best management policy.

Utilizing preoperative 20-minute pad testing with vaginal gauze packing for indicating concomitant midurethral sling during cystocele repair

OBJECTIVE

To investigate the feasibility of using preoperative 20-minute pad testing with vaginal gauze packing for cystocele reduction to indicate a concomitant midurethral sling during cystocele repair.

STUDY DESIGN

Retrospective review of the records of consecutive women with pelvic organ prolapse quantification≥stage II symptomatic cystocele who visited the urogynecologic outpatient clinics and underwent cystocele repair between July 2005 and December 2010. Only patients who underwent preoperative urodynamic studies and 20-minute pad testing with vaginal gauze packing for cystocele reduction were enrolled.

RESULTS

Twenty-one patients did not demonstrate any stress urinary incontinence. For evident stress urinary incontinence (>1g pad weight before reduction), the criterion of ≥8g pad weight before reduction was chosen for concomitant midurethral sling. For patients with occult stress urinary incontinence (≤1g pad weight before reduction), the criterion of ≥8g pad weight after reduction was chosen as an indication for concomitant midurethral sling. Among 22 patients with evident stress urinary incontinence (<8g) without concomitant midurethral sling, only one patient (4.5%) received a midurethral sling during the follow-up period (median follow-up interval: 30.5 months). Among 21 patients with occult stress incontinence but <8g after reduction without concomitant midurethral sling, only one patient (4.8%) received midurethral sling during the follow-up period (median follow-up interval: 38 months).

CONCLUSIONS

A preoperative 20-minute pad test with vaginal gauze packing for cystocele reduction is a feasible and practical method to decide for a concomitant midurethral sling.

Single-incision mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: an updated systematic review and meta-analysis of effectiveness and complications

CONTEXT

An updated systematic review and meta-analysis of randomised controlled trials (RCTs) comparing single-incision mini-slings (SIMS) versus standard midurethral slings (SMUS) in the surgical management of female stress urinary incontinence (SUI).

OBJECTIVE

To evaluate the clinical efficacy, safety, and cost effectiveness of SIMS compared with SMUS in the treatment of female SUI.

EVIDENCE ACQUISITION

A literature search was performed for all RCTs and quasi-RCTs comparing SIMS with either transobturator tension-free vaginal tape (TO-TVT) or retropubic tension-free vaginal tape (RP-TVT). The literature search had no language restrictions and was last updated on May 2, 2013. The primary outcomes were patient-reported and objective cure rates at 12 to 36 mo follow-up. Secondary outcomes included operative data; peri- and postoperative complications, and repeat continence surgery. Data were analysed using RevMan software. Meta-analyses of TVT-Secur versus SMUS are presented separately as the former was recently withdrawn from clinical practice.

EVIDENCE SYNTHESIS

A total of 26 RCTs (n=3308 women) were included. After excluding RCTs evaluating TVT-Secur, there was no evidence of significant differences between SIMS and SMUS in patient-reported cure rates (risk ratio [RR]: 0.94; 95% confidence interval [CI], 0.88-1.00) and objective cure rates (RR: 0.98; 95% CI, 0.94-1.01) at a mean follow-up of 18.6 mo. These results pertained on comparing SIMS versus TO-TVT and RP-TVT separately. SIMS had significantly lower postoperative pain scores (weighted means difference [WMD]: -2.94; 95% CI, -4.16 to -1.73) and earlier return to normal activities and to work (WMD: -5.08; 95% CI, -9.59 to -0.56 and WMD: -7.20; 95% CI, -12.43 to -1.98, respectively). SIMS had a nonsignificant trend towards higher rates of repeat continence surgery (RR: 2.00; 95% CI, 0.93-4.31).

CONCLUSIONS

This meta-analysis shows that, excluding TVT-Secur, there was no evidence of significant differences in patient-reported and objective cure between currently used SIMS and SMUS at midterm follow-up while associated with more favourable recovery time. Results should be interpreted with caution due to the heterogeneity of the trials included.