Transperineal ultrasound to assess the effect of tension-free vaginal tape position on flow rates

Do the Ultrasonographic Measures of Midurethral Sling Location Relate With Surgical Outcomes?

IMPORTANCE

The proper placement of a midurethral sling (MUS) is the key factor for a successful surgical outcome.

OBJECTIVE

This study aimed to evaluate the relationship of perineal ultrasonographic measures of the tape location with subjective and objective outcomes after MUS surgery at midterm follow-up of women.

METHODS

The tape percentile (TP; total urethral length/bladder neck tape distance×100) and urethra tape distance (UTD; the shortest distance from the longitudinal smooth muscle complex of the urethra to the midpoint of the tape) were correlated with midterm surgical success. Patient satisfaction measured with the visual analog scale (VAS) was considered as the primary outcome. The presence of stress urinary incontinence on direct questioning, the Urinary Distress Inventory 6 (UDI-6) scores, findings of the cough stress test, free uroflowmetry, postvoid residual volume, and single-cycle voiding ambulatory urodynamic monitoring (AUM) were the other outcomes.

RESULTS

Seventy-eight women were evaluated at a mean follow-up of 4.4 ±3.3 years. Women who were highly satisfied (VAS ≥ 8) had a significantly higher TP (64.7% vs 50.8%, P < 0.001) and lower UTD (3.6 vs 4.5 mm, P = 0.018). Irritative, stress, and obstructive scores at UDI-6 increased as the tape was located closer to the bladder neck (P < 0.001, P < 0.001 and P = 0.044, respectively), and stress symptoms decreased with a tape closer to the urethra (P < 0.001). Women with detrusor overactivity at AUM were found to have a lower TP (P < 0.001).

CONCLUSION

The perineal ultrasonographic evaluation of tape location with UTD and TP seems to be well correlated with the women's midterm MUS surgical outcomes.

Comparison of retropubic tension-free vaginal tape inserted on two different height positions

INTRODUCTION AND HYPOTHESIS

Surgical treatment using the mid-urethral tape has become a gold standard in the treatment of stress urinary incontinence in women. Many urogynecologists use ultrasound during the postoperative follow-up. The aim of this study was to investigate whether the position of the tape in the mid- or distal-urethra could influence the subjective assessment after surgery in 1-month control based on questionnaires of genitourinary symptoms, UDI6-SF and VAS scale.

METHODS

A group of 76 patients using a synthetic tension-free retropubic vaginal tape after anti-incontinence surgery was retrospectively included in this study. In a postoperative follow-up, the synthetic tape detection was performed using introital ultrasound, and its position was determined as a quotient T/U (T = distance between the external urethral orifice and the lower edge of the tape, U = urethral length). The patients were divided into two groups of 38 patients: one group with the position of the tape in the distal urethra (T/U ≤ 0.24) and the other group with the tape localised in the mid-urethra (T/U = 0.25-0.37). The correlation between the height of the tape position and the subjective assessment was evaluated in both groups of patients in the 1-month control.

RESULTS

No association was found between the height of the tape position in a group of patients after anti-incontinence surgery with a T/U value not exceeding 0.375 and the subjective assessment or the value of Vres.

CONCLUSIONS

The height of the tape position, with the T/U not exceeding 0.375, has no impact on the subjective assessment of the surgical anti-incontinence treatment in 1-month control.

The Use of Imaging for Synthetic Midurethral Slings

Ultrasound and magnetic resonance imaging can be used to image midurethral slings, which have may have complications such as pain. There is considerable misunderstanding regarding the utility of the different modalities. This article aims to review the current literature to identify the benefits and limitations of each imaging modality and identify the place that each should have for patients with midurethral sling complications. A literature search was performed, and all relevant articles were identified and reviewed. Different imaging modalities are complementary, but more research is required in this area.

The role of TVT position in relation to the pubic symphysis in eliminating the symptoms of stress urinary incontinence and urethral funneling

The introduction of suburethral sling was a breakthrough in the treatment of stress urinary incontinence in women. The method is highly effective. However, the mechanism of action of a sling and the reasons for surgical failures are not fully understood. Aim: The aim of the study was to assess the impact of sling-pubic symphysis distance on eliminating the symptoms of stress urinary incontinence and urethral funneling. Materials and methods: The analysis included 106 patients who reported 3 to 6 months after sling placement for a follow-up visit encompassing clinical examination and standard ultrasonography. We evaluated the position of sling in relation to the pubic symphysis, urethral length, as well as urethral funneling length and width. Results: Cure criteria were met by 91 patients. Elimination of urethral funneling was achieved in 76.9% (n = 70) of cured patients. Urethral funneling was still present, yet shorter by a mean of 10.2 mm (p = 0.02) than before surgery in the remaining cured patients. There was a 32.5% reduction in the mean relative length of urethral funneling (p = 0.002). No significant differences were found in the pre- and postoperative funneling width. The tape-pubic symphysis distance was lower in cured women: 23.2 mm vs. 26.1 mm in failed women (p = 0.04). Similar observations were made for cured patients with persistent urethral funneling vs. failed patients (22.47 mm vs. 26.0 mm, p = 0.027). There were no differences between cured patients without urethral funneling and cured patients with persistent postoperative funneling (23.5 mm; 22.5 mm; p = 0.417). Conclusions: Tape position in relation to the pubic symphysis is important for the elimination of stress urinary incontinence. Sling location closer to the pubic symphysis reduces the length of urethral funneling, but has no effects on its width in cured patients with persistent postoperative funneling.

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.

[Imaging for urinary incontinence]

BACKGROUND

Ultrasonography and functional cine magnetic resonance imaging (MRI) are noninvasive and x-ray free tools, which are currently widely used in clinical diagnostics and scientific research of male and female urinary incontinence. The increasing use and improving techniques of modern imaging tools are closely linked to rapid development of minimally invasive surgery in patients with urinary incontinence and insights gained in continence mechanisms.

METHODS

Whereas ultrasonography is a cost-efficient and readily available diagnostic tool for a routine use, the more expensive functional MRI, as a tool with more precise visualization of functional interactions and spatial representation of anatomical structures of the pelvic floor, is suitable for complex diagnostic purposes and scientific research. Both tools are already well established for evaluations of the female pelvic floor. For evaluation of the male pelvic floor, and in particular postprostatectomy incontinence, perineal ultrasonography and functional cine MRI are becoming increasingly evident.

CONCLUSION

Further development of both imaging tools will contribute to new insights into the continence mechanism and improve the techniques of radical prostatectomy and minimally invasive surgery of male and female urinary incontinence in the future.

Complications following Tension-Free Vaginal Tapes: Accurate Diagnosis and Complications Management

The sling procedures are the gold standard for SUI treatment. They are highly effective but not free from complications. The most common adverse effect for the surgery with the implant insertion is: overactive bladder occurring de novo after the surgery, voiding dysfunctions, urine retention, and unsatisfactory treatment outcome. The most important question that arises after 20 years of sling procedures is how to manage the complications and what can be offered to complicated patients. The above review summarises the ultrasound findings in complicated cases and shows the scheme of management of the clinical problems concerning the tape location in suburethral region.

Midurethral sling incision: indications and outcomes

INTRODUCTION AND HYPOTHESIS

Controversy continues over the effectiveness of sling incision, which is the most common operative approach to treating complications following suburethral sling insertion. This retrospective analysis assessed the indications for sling incision and patient outcomes regarding resolution of complications and stress urinary incontinence.

METHODS

A review was conducted of the medical records of women who underwent sling incision between 2003 and 2010. Data such as surgical indications, ultrasound findings and medical outcomes were extracted from 198 records, and descriptive and inferential statistical methods of analysis were used.

RESULTS

In the 198 patients eligible for study inclusion, the primary reasons for sling incision were overactive bladder (68 %), voiding dysfunction (61 %), and recurrent urinary tract infections (53 %). Additional complications included dyspareunia (18 %), chronic pelvic pain (17 %), and sling exposure (15 %). Sling incision led to immediate postoperative cure of voiding dysfunction in 97 % of patients. Cure rates for overactive bladder and dyspareunia were 60 % and 94 % respectively. Chronic pelvic pain was resolved in 82 % of cases and all cases of sling exposure were cured. Eighty-five (61 %) of the 140 patients who were continent before sling incision developed recurrent stress urinary incontinence (SUI) postoperatively.

CONCLUSIONS

These findings indicate that sling incision can be highly successful in improving voiding dysfunction and dyspareunia, and moderately successful in curing overactive bladder and chronic pain. However, SUI may recur in more than 60 % of the patients undergoing sling incision. Consequently, patients being considered for a sling incision procedure should be informed about this possible complication.

Can we place tension-free vaginal tape where it should be? The one-third rule

OBJECTIVES

The tension-free vaginal tape (TVT) insertion technique generally does not take into account individual urethral length. In this study we investigated whether preoperative sonographic measurement of individual urethral length allows for reliable TVT positioning under the midurethra, which is a critical segment for the continence mechanism.

METHODS

Urethral length was measured by preoperative introital ultrasonography in 102 consecutive female patients with stress urinary incontinence. TVT procedures were performed as recommended by the manufacturer. The suburethral incisions were initiated at one-third of the sonographically measured urethral length. TVT position and tape-urethra distance were followed up 6 months postoperatively.

RESULTS

At 6-month examination of the 102 study participants, 93.1% were cured and 6.9% showed improved continence. TVTs were found in the target range of 50-70% of the urethral length in 88.2% of the cohort. Women with the TVT in the 50-70% urethral length range and a 3-5-mm tape-longitudinal smooth muscle distance had a greater likelihood of being cured without complications (P < 0.001).

CONCLUSIONS

Preoperative sonographic measurement of urethral length, combined with the one-third rule, may aid in reliable midurethral TVT positioning.