Do different vaginal tapes need different suburethral incisions? The one-half rule

Current Treatment of Stress Urinary Incontinence by Bulking Agents and Laser Therapy-An Update

Stress urinary incontinence (SUI) affects around 20% of women. In addition to the established suburethral sling insertion, two less invasive approaches are of interest today: urethral bulking agents and vaginal laser therapy. This review discusses articles through December 2023 identified by a PubMed literature search using the keywords "incontinence" and "bulking" or "laser". Although the two approaches are less effective than sling insertions, there are specific conditions in which one or the other technique is more advantageous. Injecting bulking agents into the urethra only takes some minutes and works without general anesthesia. The method is particularly suited for elderly, frail, or obese patients with multiple comorbidities, but is also applicable for all patients and in combination with other therapies. Generally, the safety profile is good but differs between bulking materials. Two laser types-the Erbium:YAG laser with SMOOTH-mode and the fractional ablative CO2 laser-deliver heat into the tissue to induce tissue tightening and regeneration. Intravaginal laser therapy improves mild to moderate SUI, while studies describe how intraurethral laser therapy is also beneficial for severe SUI. Young women between childbirths, as well as postmenopausal women, may benefit from laser therapy. The method is safe, can be performed on an outpatient basis, and does not require any artificial material.

Use of intraoperative ultrasound to improve tension-free vaginal tape-obturator placement: A pilot study

OBJECTIVE

To evaluate the use of intraoperative ultrasound (IUS) to achieve a postoperative optimal placement of the tension-free vaginal tape-obturator (TVT-O).

METHODS

A cohort study was performed among women who underwent TVT-O placement. In 25 women, ultrasound was used for the placement, and based on current evidence, the optimal intraoperative and postoperative ultrasound pattern was selected. They were compared with 25 women where IUS was not used.

RESULTS

IUS increased operative time (by 7.5 min), and in 36% (9/25) of cases it was necessary to perform some corrections based on the ultrasound findings. After 1 month, in patients of the IUS group, the tapes were more frequently placed at a distance of 3-5 mm (P = 0.01), and it was more common for it to be placed between 40% and 70% relative to the urethral length (P = 0.011). Of tapes placed with IUS, 76% (met the optimal postoperative ultrasound pattern, as opposed to only 48% placed without IUS (P = 0.041). No differences were found in the complications or the functional results at 1 month post-surgery.

CONCLUSION

The use of IUS for the placement of TVT-O allows us to position them optimally and avoid erroneous placements, although IUS increases the operative time without improving the functional results and the rate of complications.

Stress urinary incontinence is caused predominantly by urethral support failure

Whales are mammals that can dive to depths of > 1000 m without the high water pressure pushing open their mouth or anus. The same is true for the female urethra. The meatus externus and internus are seals that cannot be pushed open by high water pressures. Recent evidence suggests that the female meatus internus is pushed open when the bladder pressure exceeds the urethral pressure. For a relaxed detrusor, this opening is not possible for at least three reasons: the law of elastic collision, Pascal’s law of hydrostatics and the Hagen-Poiseuille law. The three laws do not support that urethral function failure is the predominant cause of stress urinary incontinence (SUI); however, they do support that urethral support failure is. Influential urogynecologists claim the opposite. TVT surgery, according to the integral theory of SUI (IT), has high failure rates because it does not principally prevent the urethra from hanging on a less mobile bladder neck. In the case of a long urethra, the tape is set too distally, and in hypomobile SUI, the use of a tension-free suburethral tape is unwarranted/ineffective, because the proximal urethra is not elevated above its resting position. A successful operation corrects urethral support failure and not urethral function failure.

Sonographic sling position and cure rate 10-years after TVT- O procedure

AIM

To examine the position of the TVT-O sling 10 years postoperatively and its association with outcome.

METHODS

A total of 124 patients who received a TVT-O sling at two centers in 2004 and 2007 were invited for follow-up. The position of the sling on perineal ultrasound was described relative to the bladder neck and the lower margin of the pubic symphysis at rest and on Valsalva. Objective cure was defined as a negative cough stress test at 300 ml. Subjective cure was evaluated with the Kings´ Health Questionnaire (KHQ), Incontinence Outcome Questionnaire (IOQ), Female Sexual Function Index Questionnaire (FSFI) and the Patient Global Impression of Improvement score (PGII).

RESULTS

78 of 124 patients (57%) were available for follow-up 10 years after surgery. I Eleven (14%) had undergone reoperation and were excluded. Tapes were visualized in the remaining 67 (54%) women. The subjective and objective cure rates in this sub-cohort were 67% (45/67) and 77% (52/67), respectively. In these 67 women the mean distances from the bladder neck to the proximal edge of the tape (BNTD) during Valsalva maneuver were significantly higher in cured women compared to the not-cured women (11.2 vs. 9.4mm). The distance between tape and urethra (TUD) was significantly lower in cured vs. not cured patients (2.6 vs. 4.1mm). All women with a TUD of >5mm (n = 5) were incontinent. Tape position was not associated with overactive bladder symptoms.

CONCLUSIONS

Tape position near the bladder neck and large distance to the urethra is associated with incontinence 10 years after TVT-O.

Demographic features of female urethra length

AIMS

To determine cohort urethral length, identify epidemiological factors influencing the parameter and to establish the percentage of cases with clinically relevant outsized urethras.

METHODS

Prospective cohort study conducted in two tertiary clinical centers between 2013 and 2017. Nine hundred and twenty seven consecutive adult, Caucasian females attending outpatients' clinics were included. The urethral length has been measured in pelvic floor ultrasound examination. The exclusion criteria were inadequate bladder filling (<200 mL; >400 mL), previous history of pelvic floor surgery, and no consent.

RESULTS

Urethral length varied from 19 to 45 mm. The distribution of the examined parameter was normal. Obese patients had significantly longer urethras as compared to non-obese subjects. Number of vaginal deliveries was connected with shorter urethral length. The limitations of the study are: analysis only of Caucasian patients and subjects without previous pelvic floor surgeries.

CONCLUSIONS

Differences in urethral length in the female population were demonstrated. Thirty percent of patients have atypical urethras that may be a risk factor for sling surgery failure. We therefore postulate introduction of urethral measurement before the procedure.

Does the suburethral sling change its location?

OBJECTIVES

To ascertain whether a phenomenon of sling migration exists after suburethral sling placement, whether this might be responsible for suboptimal sling location and persistent incontinence, and whether a link exists between sling dislocation or migration and risk factors, such as obesity or age.

METHODS

The present prospective cohort study was carried out in a group of 244 patients who underwent retropubic sling implantation. Sling location was determined by means of pelvic floor ultrasound, and calculated relative to the individual patient's urethral length measured before the procedure. The sling location was visualized on 1 day, and 1 and 6 months post-surgery. Overweight/obese and elderly patients were analyzed separately to assess the possible influence of those factors on sling location.

RESULTS

The mean urethral length in the studied cohort was 28.76 ± 3.67 mm. The mean tape position 1 day post-surgery was 66.18 ± 8.43% of the urethral length, and it did not change 1 and 6 months post-surgery in the whole group. Similar results were obtained in elderly and overweight/obese patients.

CONCLUSIONS

Suboptimal sling location appears to result from incorrect surgical technique, and should be diagnosed and treated early after the primary surgery. Sling location does not change after mid-term follow up.

Current Treatment Concepts for Stress Urinary Incontinence

Initially, stress urinary incontinence should be treated by conservative measures, such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise and/or the use of pessaries. Incontinence surgeries are only recommended in case of unsuccessful conservative therapy. Today, tension-free suburethral sling insertions represent the gold standard of incontinence surgery yielding very good outcomes (cure rates of 80–90 %). Pelvic-floor sonography provides important information on decision of surgical methods and the management of complications. Furthermore, intra- or paraurethral injection of bulking agents is a promising, minimally invasive surgical alternative. This article discusses treatment concepts, pre-, intra- and post-operative examinations, decision on surgical methods, operational details for surgical success, and the prevention and management of complications.

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Zusammenfassung. Zusammenfassung: Eine Belastungsinkontinenz sollte immer zuerst konservativ behandelt werden. Schon eine Gewichtsreduktion, Hormonpräparate, Physiotherapie, Beckenbodentraining und/oder die Anwendung von Pessaren können zum Erfolg führen. Nach Ausschöpfen dieser Therapien werden heute Inkontinenzoperationen mit meist sehr guten Heilungschancen (ca. 80–90 %) angeboten. Der operative Goldstandard ist die suburethrale Schlingeneinlage. Die Pelvic-Floor-Sonografie liefert dazu sehr wichtige Hinweise zur Wahl der Operationstechnik und zur Behebung von Komplikationen. Ferner bildet die intra- oder paraurethrale Injektion von Bulking Agents eine vielversprechende, wenig invasive operative Alternative. In diesem Artikel werden Behandlungskonzepte, prä-, intra- und postoperative Untersuchungen, Wahl der Operationsmethode, operationstechnische Details für den Operationserfolg sowie Vorbeugung und Behandlung von Komplikationen diskutiert.

Repeatability and reproducibility of measurements of the suburethral tape location obtained in pelvic floor ultrasound performed with a transvaginal probe

Introduction

Implants used to treat patients with urogynecological conditions are well visible in US examination. The position of the suburethral tape (sling) is determined in relation to the urethra or the pubic symphysis.

Aim of the study

The study was aimed at assessing the accuracy of measurements determining suburethral tape location obtained in pelvic US examination performed with a transvaginal probe.

Material and methods

The analysis covered the results of sonographic measurements obtained according to a standardized technique in women referred for urogynecological diagnostics. Data from a total of 68 patients were used to analyse the repeatability and reproducibility of results obtained on the same day.

Results

The intraclass correlation coefficient for the repeatability and reproducibility of the sonographic measurements of suburethral tape location obtained with a transvaginal probe ranged from 0.6665 to 0.9911. The analysis of the measurements confirmed their consistency to be excellent or good.

Conclusions

Excellent and good repeatability and reproducibility of the measurements of the suburethral tape location obtained in a pelvic ultrasound performed with a transvaginal probe confirm the test’s validity and usefulness for clinical and academic purposes.

Role of intrinsic sphincter deficiency with and without urethral hypomobility on the outcome of tape insertion

AIMS

Intrinsic sphincter deficiency (ISD) is a known risk factor for therapy failure after tension-free vaginal tape (TVT) insertion. The purpose of this study was to investigate if the severity of ISD alone or other factors such as urethral mobility and tape localization influence outcomes.

METHODS

One hundred and nine women with urodynamically determined ISD, a TVT insertion, and a 6-month follow-up visit were included. Urethral length, mobility, and tape localization were evaluated by pelvic floor sonography. Patients were classified into three urethral mobility groups (hypomobile, normomobile, hypermobile). Surgical outcome was assessed by a combination of objective and subjective criteria.

RESULTS

Therapeutic success rate after TVT insertion was 81.6%. The severity of ISD did not associate with therapy failure. But urethral mobility (P < 0.0001), relative tape position (P = 0.0003), and tape-urethra distance (P < 0.0001) differed between cured and not cured patient groups. Patients with a relative tape position toward 1/2 of urethral length had a higher cure rate. Significantly different cure rates (P = 0.0003) were found for hypomobile (67%), normomobile (76%), and hypermobile (100%) urethras. For ISD patients with a hypomobile urethra, highest cure rates were obtained for tape-urethra distances between 2.5 and 3.5 mm.

CONCLUSIONS

The reduced cure rate for ISD patients was due to the subgroup with a hypomobile urethra. A prospective study is needed to confirm that slightly shorter tape-urethra distances and a relative tape position more toward the mid-urethra will lead to better outcomes for this patient group.

Ultrasound imaging in urogynecology - state of the art 2016

The role of ultrasound imaging in urogynecology is not clearly defined. Despite significant developments in visualization techniques and interpretation of images, pelvic ultrasound is still more a tool for research than for clinical practice. Structures of the lower genitourinary tract and pelvic floor can be visualized from different approaches: transperineal, introital, transvaginal, abdominal or endoanal. According to contemporary guidelines and recommendations, the role of ultrasound in urogynecology is limited to the measurement of post-void residue. However, in many instances, including planning and audit of surgical procedures, management of recurrences or complications, ultrasound may be proposed as the initial examination of choice. Ultrasound may be used for assessment of bladder neck mobility before anti-incontinence procedures. On rare occasions it is helpful in recognition of pathologies mimicking vaginal prolapse such as vaginal cyst, urethral diverticula or rectal intussusception. In patients subjected to suburethral slings, causes of surgery failure or postsurgical voiding dysfunctions can be revealed by imaging. Many reports link the location of a tape close to the bladder neck to unfavorable outcomes of sling surgery. Some postoperative complications, such as urinary retention, mesh malposition, hematoma, or urinary tract injury, can be diagnosed by ultrasound. On the other hand, the clinical value of some applications of ultrasound in urogynecology, for example measurement of the bladder wall thickness as a marker of detrusor overactivity, has not been proved.

Tomographic Ultrasound Imaging to Control the Placement of Tension-Free Transobturator Tape in Female Urinary Stress Incontinence

Purpose. The objective was to evaluate, by means of tomographic ultrasound imaging (TUI), the reliability of a novel approach for determining the position of the implanted tension-free transobturator tape (TOT). Furthermore, we analyzed the association between the position of the tape at rest and the subjective cure in stress incontinent women. Methods. This retrospective pilot study consists of 32 stress incontinent women, who underwent TOT procedure and routine sonographic control at day 1 postoperatively and at follow-up visit. TUI was applied on the resulting 4D volumes, thereby delivering 9 axial slices with a 4 mm interslice distance starting at the meatus urethrae internus in caudal direction. The reliability of the approach was tested by two examiners. Postoperative and follow-up ultrasound parameters of uncured and cured patients were analyzed. Results. Measurements of the position of the TOT demonstrated high intraclass correlation coefficients. We found minor differences between sonographic parameters at day 1 postoperatively and at follow-up after a median period of 321 days. In cured patients, the position of the tape was measured in a more caudal position than in uncured patients. Conclusions. TUI can be a reliable method for determining the position of the tape. Further studies are needed to evaluate whether the postoperatively determined position can be used as an indicator of future subjective cure.