Factors predictive of post-TVT voiding dysfunction

Management of Complications of Prosthetic Mid-urethral Tape Surgery for Stress Urinary Incontinence in Women

OBJECTIVE

To propose guidelines for the management of complications of prosthetic mid-urethral tape surgery for stress urinary incontinence in women.

METHODS

These guidelines are based on an exhaustive literature review on retropubic and trans-obturator mid-urethral tape complications. The expert panel rated the level of evidence of each study, summarized literature for the treatment of each complication, and proposed guidelines.

RESULTS

Management of these complications is complex and the first treatment is crucial to offer the best functional result to the patient. We propose a standardized approach and guidelines for the management of complications to help physicians to early identify a surgical complication, offer adequate treatment for each complication and provide clear and appropriate information to patients. We detailed management of intraoperative complications as follows: bladder, urethral, vaginal, visceral, and vascular injury; short-term post-operative complications are the following: bleeding/hematoma, voiding dysfunction, pain, infection; and long-term post-operative complications are the following: chronic voiding dysfunction, de novo overactive bladder syndrome, chronic pain, dyspareunia, vaginal, bladder, and urethral tape erosion.

CONCLUSION

These guidelines may help physicians to improve management of prosthetic mid-urethral sling complications that may occur following stress urinary incontinence surgery.

European Urogynaecological Association Position Statement: The role of urodynamics in stress urinary incontinence evaluation and treatment decision

Stress urinary incontinence (SUI) is defined as a condition characterized by the involuntary leakage of urine during activities that increase intra-abdominal pressure which may decrease quality of life with a significant economic impact on health systems, necessitating the implementation of cost-effective management plans. Urodynamics (UDS) has been considered during the last decades as the gold standard for assessment of lower urinary tract symptoms (LUTS) due to their high reproducibility. At the same time, concerns about the systematic use of UDS before SUI surgery were raised due to a limited evidenced base to recommend their routine use. In uncomplicated female patients with SUI, UDS can offer further insights into LUTS, potentially assisting the physician in determining the appropriate therapeutic approach. However, it has not been shown that preoperative UDS can directly impact the surgical outcome for continence. Indeed, evidence supports the conclusion that pre-operative UDS in women with uncomplicated, clinically demonstrable, SUI does not improve the outcome of surgery for SUI. Nevertheless, asymptomatic detrusor overactivity (DO) identified by urodynamic testing or pre-existing voiding dysfunction are associated with an increased occurrence of postoperative overactive bladder (OAB) and voiding dysfunction, respectively. The EUGA Working Group concluded that the evidence does not support the systematic preoperative use of UDS for uncomplicated cases. However, in cases where mixed symptoms, voiding dysfunction, previous surgery, or concomitant prolapse are present, preoperative UDS are advised as they can be beneficial in anticipating postoperative outcomes. This aids in conducting comprehensive and thorough preoperative counseling. The Group recommend performing preoperative UDS considering the patient's specific clinical situation and the surgeon's judgment, with consideration given to the potential benefits, risks, and impact on treatment decisions and patient outcomes.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Risk factors for urinary retention after urogynecologic surgery: A retrospective cohort study and prediction model

AIMS

Postoperative urinary retention (POUR) is a common complication of urogynecological surgery. Our study aimed to identify demographic and perioperative risk factors to construct a prediction model for POUR in urogynecology.

METHODS

Our retrospective cohort study reviewed all patients undergoing pelvic reconstructive surgeries at our tertiary care center (Jan 1, 2013-May 1, 2019). Demographic, pre-, intra- and postoperative variables were collected from medical records. The primary outcome, POUR, was defined as (1) early POUR (E-POUR), failing initial trial of void or; (2) late POUR (L-POUR), requiring an indwelling catheter or intermittent catheterization on discharge. Risk factors were identified through univariate and multivariate logistic regression analyses. A clinical prediction model was constructed with the most significant and clinically relevant risk factors.

RESULTS

In 501 women, 182 (36.3%) had E-POUR and 61 of these women (12.2% of the entire cohort) had L-POUR. Multivariate logistic regression revealed preoperative postvoid residual (PVR) over 200 ml (odds ratio [OR]: 3.17; p = 0.026), voiding dysfunction symptoms extracted from validated questionnaires (OR: 3.00; p = 0.030), and number of concomitant procedures (OR: 1.30 per procedure; p = 0.021) as significant predictors of E-POUR; preoperative PVR more than 200 ml (OR: 4.07; p = 0.011) and antiincontinence procedure with (OR: 3.34; p = 0.023) and without (OR: 2.64; p = 0.019) concomitant prolapse repair as significant predictors of L-POUR. A prediction model (area under the curve: 0.70) was developed for E-POUR.

CONCLUSIONS

Elevated preoperative PVR is the most significant risk factor for POUR. Alongside other risk factors, our prediction model for POUR can be used for patient counseling and surgical planning in urogynecologic surgery.

The influence of diabetes on postoperative complications following colorectal surgery

Background

Diabetes mellitus has been commonly associated with poor surgical outcomes. The aim of this meta-analysis was to assess the impact of diabetes on postoperative complications following colorectal surgery.

Methods

Medline, Embase and China National Knowledge Infrastructure electronic databases were reviewed from inception until May 9th 2020. Meta-analysis of proportions and comparative meta-analysis were conducted. Studies that involved patients with diabetes mellitus having colorectal surgery, with the inclusion of patients without a history of diabetes as a control, were selected. The outcomes measured were postoperative complications.

Results

Fifty-five studies with a total of 666,886 patients comprising 93,173 patients with diabetes and 573,713 patients without diabetes were included. Anastomotic leak (OR 2.407; 95% CI 1.837–3.155; p < 0.001), surgical site infections (OR 1.979; 95% CI 1.636–2.394; p < 0.001), urinary complications (OR 1.687; 95% CI 1.210–2.353; p = 0.002), and hospital readmissions (OR 1.406; 95% CI 1.349–1.466; p < 0.001) were found to be significantly higher amongst patients with diabetes following colorectal surgery. The incidence of septicemia, intra-abdominal infections, mechanical failure of wound healing comprising wound dehiscence and disruption, pulmonary complications, reoperation, and 30-day mortality were not significantly increased.

Conclusions

This meta-analysis and systematic review found a higher incidence of postoperative complications including anastomotic leaks and a higher re-admission rate. Risk profiling for diabetes prior to surgery and perioperative optimization for patients with diabetes is critical to improve surgical outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10151-020-02373-9) contains supplementary material, which is available to authorized users.

Anesthetics' role in postoperative urinary retention after pelvic organ prolapse surgery with concomitant midurethral slings: a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

Spinal anesthesia can be a potential risk factor for postoperative urinary retention (POUR). Our objective was to compare POUR rates for outpatient vaginal pelvic floor surgeries when using spinal versus general anesthesia. Our hypothesis was that spinal anesthesia would have higher POUR rates compared with general anesthesia.

METHODS

This was a randomized clinical trial on subjects undergoing outpatient pelvic organ prolapse (POP) surgery with a concomitant midurethral sling (MUS). Subjects were discharged home the same day as surgery. Subjects were excluded if they had a preoperative post-void residual > 150 ml, they were < 40 years of age, surgery was < 1 h, or they had contraindications to spinal or general anesthesia. A standardized voiding trial was performed. The primary aim was to compare POUR rates between anesthesia groups. A power analysis estimated 28 subjects were required per group to detect a 37% difference with 80% power and an alpha of 0.05.

RESULTS

The trial was registered at ClinicalTrials.gov on July 15, 2015. Sixty-one subjects were enrolled between June 22, 2015, and December 31, 2017. Three were excluded, leaving 29 in each group. Groups were similar in demographics. For the primary outcome, there was a 14.3% difference in POUR rates between spinal and general anesthesia, which did not reach statistical significance based on our power calculation (p = 0.2516).

CONCLUSIONS

Based on this study, there is not an increased rate of POUR with the use of spinal anesthesia for POP surgery with MUS. However, since there was a trend toward higher rates of POUR in the spinal group, it is possible that a larger powered study design would be able to detect a statistically significant difference between the groups. Based on these findings, if surgical patients would benefit from spinal anesthesia, the risk of urinary retention should not be considered a reason to not utilize this form of anesthesia.

CLINICAL TRIAL REGISTRATION

Does spinal anesthesia for prolapse surgery with concomitant sling lead to an increase in urinary retention compared to general anesthesia? https://clinicaltrials.gov/ct2/show/NCT02547155?term=laura+martin&rank=3 (NCT02547155).

Clinical outcomes on tension-releasing suture appendage on single-incision sling devices for postoperative voiding dysfunction involving undue tape tension

INTRODUCTION AND HYPOTHESIS

To determine the clinical outcomes of adding a tension-releasing suture (TRS) appendage for manipulation of over-tensioned single-incision slings (SIS) as a means to relieve postoperative voiding dysfunction.

METHODS

A retrospective observational study conducted from January 2010 to July 2017. The records of patients with urodynamic stress incontinence (USI) without needing concurrent procedures who underwent anti-incontinence surgery using MiniArc, Solyx, and Ajust with voiding dysfunction were collated and analyzed. The primary outcome measure was the recovery of normal post-void residual urine (PVR) after TRS manipulation. The secondary outcome measures were the pain intensity noted during manipulation (quantified by visual analog scale) and the continence rate [assessed by (1) objective cure: 1-h pad test weight < 2 g and absence of USI; (2) subjective cure index score ≤ 1 on question 3 of the UDI-6: "Urine leakage related to physical activity, coughing, or sneezing?"].

RESULTS

There were 73 patients with high post-void residual (PVR) urine. The 42 (9.5%) patients with over-tensioned slings were managed with TRS manipulation while the 31 patients (7%) with high PVR and no sling over-tension were managed with intermittent catheterization. All patients in both groups regained normal PVR. The TRS-manipulated group demonstrated an objective cure rate of 92.9% (39/42) and subjective cure rate of 91% (38/42). Pain experienced during TRS manipulation was significantly higher with the Ajust system (p = 0.018). Three patients had persistence of USI, two with MiniArc and one with Solyx.

CONCLUSIONS

The TRS manipulation is a well-tolerated procedure that can effectively relieve voiding dysfunction for over-tensioned SIS without affecting continence cure rates.

One normal void and residual following MUS surgery is all that is necessary in most patients

INTRODUCTION AND HYPOTHESIS

There is considerable variation worldwide on how the assessment of voiding function is performed following midurethral sling (MUS) surgery. There is potentially a financial cost, and reduction in efficiency when patient discharge is delayed. Using our current practice of two normal void and residual (V&R) readings before discharge, the aim of this retrospective study was to evaluate the likelihood of an abnormal second V&R test if the first V&R test was normal in order to determine if a policy of discharge after only one satisfactory V&R test is reasonable.

METHODS

Data from 400 patients who had had MUS surgery with or without other procedures were collected. Our unit protocol included two consecutive voids of greater than 200 ml with residuals less than 150 ml before discharge. The patients were divided into the following groups: MUS only, MUS plus anterior colporrhaphy (AR) plus any other procedures (MUS/AR), and MUS with any non-AR procedures (MUS+).

RESULTS

Complete datasets were available for 335 patients. Once inadequate tests (low volume voids <200 ml) had been excluded (28% overall), the likelihood of an abnormal second V&R test if the first test was normal was 7.1% overall, but 3.6% for MUS, 11.5% for MUS/AR and 8.6% for MUS+.

CONCLUSION

The findings in the MUS-only group indicate that it is probably safe to discharge patients after one satisfactory V&R test, as long as safety measures such as 'open access' are available so that patients have unhindered readmission if problems arise.

Evaluation and Classification of Stress Urinary Incontinence: Current Concepts and Future Directions

CONTEXT

Stress urinary incontinence (SUI) is a common and bothersome problem that frequently requires operative management. Over the past two decades, novel techniques have been introduced into clinical practice. With the greater variety of surgical options now available, there is an increasing focus on selecting the appropriate procedure for the individual patient based on the likely underlying pathophysiologic mechanism.

OBJECTIVE

To review the methods used in the evaluation of SUI and the proposed classification systems.

EVIDENCE ACQUISITION

A search of the PubMed database for the relevant search terms was conducted, and selected articles were retrieved and reviewed.

EVIDENCE SYNTHESIS

Standardised terminology for the description of SUI has been produced by the International Continence Society describing the problem in terms of symptoms, clinical signs, and urodynamic observations. The two major pathophysiologic theories that have emerged over the past 50 yr, urethral hypermobility and intrinsic sphincteric deficiency, have influenced the development and adoption of surgical techniques. It is now recognised that these two entities are not dichotomous but often coexist. The primary aim of the evaluation of the patient presenting with SUI is to confirm the diagnosis and assess symptom severity before instituting conservative treatments. Secondary evaluation consists of more sophisticated techniques that assess anatomy of the bladder neck and urethra under rest and stress (eg, videourodynamics, ultrasound) or direct or indirect physiologic measures of the integrity of the sphincter mechanism.

CONCLUSIONS

Classification of patients with SUI into distinct groups based on probable pathophysiologic mechanism could help guide the choice of surgical procedure, but current systems are likely too simplistic, and methods of assessment lack standardisation in techniques and sensitivity.

PATIENT SUMMARY

Urinary leakage on exertion, termed stress incontinence, is a common problem that affects many women. There is a need to develop better ways of categorising the underlying causes of leakage to ensure that patients receive the optimal treatments.

Tension-free polypropylene mesh-related surgical repair for pelvic organ prolapse has a good anatomic success rate but a high risk of complications

BACKGROUND

Food and Drug Administration announcements have highlighted the standard rate of mesh-related complications. We aimed to report the short-term results and complications of tension-free polypropylene mesh (PROSIMA™) surgical repair of pelvic organ prolapse (POP) using the standard category (C), timing (T), and site (S) classification system.

METHODS

A prospective cohort study of 48 patients who underwent PROSIMA™ mesh kit-related surgical repairs were followed for two years at Peking Union Medical College Hospital. Recurrence was defined as symptomatic POP quantification (POP-Q) Stage II or higher (leading edge ≥ -1 cm). The Patient Global Impression of Change Questionnaire, the Chinese version of the Pelvic Floor Impact Questionnaire short-form-7 and POP/Urinary Incontinence Sexual Questionnaire short-form-12 were used to evaluate the self-perception and sexual function of each patient. Mesh-related complications conformed to the International Urogynecological Association/International Continence Society joint terminology. The paired-sample t-test, one-way analysis of variance, Fisher's exact test, Kaplan-Meier survival analysis and log-rank test were used to analyze data.

RESULTS

All patients were followed up for ≥12 months; 30 (62.5%) patients completed the 24 months study. We observed a 93.8% (45/48) positive anatomical outcome rate at 12 months and 90.0% (27/30) at 24 months. Recurrence most frequently involved the anterior compartment (P < 0.05). Pelvic symptoms improved significantly from baseline (P < 0.05), although the patients' impressions of change and sexual function were not satisfying. Vaginal complication was the main complication observed (35.4%, 17/48). The survival analysis did not identify any relationship between vaginal complication and anatomical recurrent prolapse (POP-Q ≥ Stage II) (P = 0.653).

CONCLUSIONS

Tension-free polypropylene mesh (PROSIMA™ )-related surgical repair of POP has better short-term anatomical outcomes at the apical and posterior compartments, but a low patient satisfaction rate. The mesh complications were not the definitive cause of recurrence.

Clinical risk factors and urodynamic predictors prior to surgical treatment for stress urinary incontinence: a narrative review

INTRODUCTION AND HYPOTHESIS

Knowledge about clinical risk factors and the value of urodynamic testing is important to optimize treatment strategy and secure true informed consent.

METHODS

We reviewed the relevant literature to clarify the evidence regarding clinical risk factors and the predictive value of urodynamic testing in patients with urinary incontinence, where surgery is considered. Because of the paucity of evidence based on randomized controlled trials, we conducted a narrative review of the published literature.

RESULTS

Clinical risk factors in terms of mixed urinary incontinence, previous incontinence surgery, body mass index (BMI) ≥ 35, age ≥ 75, and presence of diabetes mellitus were significantly related to decreased outcome of incontinence surgery. Furthermore, noninvasive and invasive urodynamic parameters indicating detrusor overactivity, voiding difficulties, low urethral pressure, and bladder-neck immobility were related to poorer outcome of surgery.

CONCLUSIONS

This study summarized the available evidence regarding preoperative clinical risk factors and urodynamic parameters indicating decreased or adverse outcome of surgery, and this report also provides clinical recommendations.

Prevention and management of postoperative urinary retention after urogynecologic surgery

Postoperative urinary retention (POUR) is a frequent consequence of gynecologic surgery, especially with surgical correction of urinary incontinence and pelvic organ prolapse. Estimates of retention rates after pelvic surgery range from 2.5%–43%. While there is no standard definition for POUR, it is characterized by impaired bladder emptying, with an elevation in the volume of retained urine. The key to management of POUR is early identification. All patients undergoing pelvic surgery, especially for the correction of incontinence or prolapse, should have an assessment of voiding function prior to discharge. There are several ways to assess voiding function – the gold standard is by measuring a postvoid residual. Management of POUR is fairly straightforward. The goal is to decompress the bladder to avoid long-term damage to bladder integrity and function. The decision regarding when to discontinue catheter-assisted bladder drainage in the postoperative period can be assessed in an ongoing fashion by measurement of postvoid residual. The rate of prolonged POUR beyond 4 weeks is low, and therefore most retention can be expected to resolve spontaneously within 4–6 weeks. When POUR does not resolve spontaneously, more active management may be required. Techniques include urethral dilation, sling stretching, sling incision, partial sling resection, and urethrolysis. While some risk of POUR is inevitable, there are risk factors that are modifiable. Patients that are at higher risk – either due to the procedures being performed or their clinical risk factors – should be counseled regarding the risks and management options for POUR prior to their surgery. Although POUR is a serious condition that can have serious consequences if left untreated, it is easily diagnosed and typically self-resolves. Clinician awareness of the condition and vigilance in its diagnosis are the key factors to successful care for patients undergoing surgical repair.

Effect of preoperative flow rate on postoperative retention and voiding difficulty after transobturator tape operation

Purpose

Controversy exists over the preoperative risk factors for postoperative urinary retention after the midurethral sling procedure for stress urinary incontinence (SUI). We intended to analyze the effect of preoperative flow rate on postoperative urinary retention after the transobturator tape (TOT) operation.

Materials and Methods

A total of 322 patients who underwent TOT from June 2006 to May 2012 were included in this retrospective study. All patients were preoperatively investigated for urinary symptoms and underwent preoperative urodynamic studies including urine flow rate. Postoperative urinary retention, voiding difficulty, and uroflowmetry were checked. Urinary retention was defined as the need for additional catheterization longer than 1 day. Patients were divided by preoperative peak flow rate (Qmax) of 15 mL/s (low Qmax group and normal Qmax group).

Results

There were 3 cases of postoperative urinary retention (0.9%) and 52 cases of voiding difficulty (16.1%). The low Qmax group included 40 patients (12.4%) and the normal Qmax group included 282 patients (87.5%). Between the two groups, there were no significant differences in age, previous pelvic surgery history, or past medical history. The low Qmax group had higher scores for voided volume and detrusor pressure at Qmax. However, there was no significant difference in postoperative voiding difficulty between the two groups. Furthermore, three patients who experienced postoperative retention showed high flow rates preoperatively.

Conclusions

Our results suggest that voiding difficulty in the group with low preoperative flow was tolerable and the treatment success rate was comparable to that in patients in the normal flow group. According to our analysis, patients with a low flow rate preoperatively can be safely treated with TOT for SUI.

Voiding dysfunction following suburethral tape

Voiding dysfunction (VD) is relatively common following suburethral tape insertion. Our study aimed to identify perioperative variables that predict VD. Women who underwent suburethral tapes (TVT(TM) and TVT-O(TM)), either as sole procedure or with a concomitant prolapse repair, were studied retrospectively. The primary outcome was women requiring catheterisation and/or re-catheterisation in the postoperative period. A total of 319 women underwent suburethral tapes within the study period: 256 case notes (80.2%) were available for review and 40/256 women (15.6%) developed postoperative VD. No preoperative urinary symptoms were associated with postoperative VD. Univariate analysis demonstrated three variables associated with VD: average flow rate (Q-ave) ≤5th centile (odds ratio (OR) 2.3, 95% CI 1.2-6.5, p = 0.016), a combination of Q-ave and maximum flow rate (Q-max) ≤5th centile (OR 2.8, 95% CI 1.1-6.9, p = 0.030) and concomitant prolapse procedure (OR 3.6, 95% CI 1.5-8.9, p = 0.005). Following multivariate logistic regression Q-ave ≤5th centile and concomitant prolapse procedure showed the strongest association with VD.

Transobturator tapes are preferable over transvaginal tapes for the management of female stress urinary incontinence: Against

Midurethral placement of tension-free vaginal tapes with a transvaginal route for stress urinary incontinence achieves higher and better long-term success rates than the transobturator route. Bladder perforations are reported more in transvaginal tape (TVT) but incidences of vaginal erosions, extrusion, and groin pain are exceedingly more in TOT groups. There is no clear evidence that transobturator tape (TOT) is associated with less post-operative voiding problems than TVT. Major complications such as bowel injuries and significant vascular injuries with TVT are rare. TVT has been found to be superior to TOT and preferable in technically demanding conditions such as prior anti-incontinence operation failures, obese women, and very elevated and scarred lateral cul-de sac. TVT is always preferred in severe grades of stress urinary incontinence and with patients of intrinsic sphincter deficiency (ISD) with little or no urethral mobility.

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

OBJECTIVE

To determine whether the position of the tension-free vaginal tape (TVT) has an effect on postoperative flow rates and voiding function in women successfully cured of urodynamic stress incontinence.

METHODS

Postoperatively 72 women who had undergone TVT surgery had a transperineal ultrasound examination to assess the position of the TVT on the urethra. The tape was categorized as proximal, mid or distal urethral. The effect on voiding was assessed using the maximum flow rate (MFR) centiles corrected for voided volume and detrusor pressure at maximum flow.

RESULTS

Forty-six women had distal tapes and 26 mid-urethral tapes. A tape lying on the mid urethra was associated with a fall in MFR centile (P = 0.04) while a tape lying on the distal urethra did not cause a fall in the MFR centile (P = 0.52). There was no significant change in the detrusor pressure at maximum flow between mid and distally placed tapes.

CONCLUSIONS

Distally placed tapes cause less alteration in flow rates than do mid-urethrally placed tapes. This may be beneficial in certain patient groups.

Tape functionality: position, change in shape, and outcome after TVT procedure--mid-term results

INTRODUCTION AND HYPOTHESIS

This study evaluates the relevance of the tape position and change in shape (tape functionality) under in vivo conditions for mid-term outcome.

METHODS

Changes in the sonographic tension-free vaginal tape (TVT) position relative to the percentage urethral length and the tape-urethra distance were determined after 6 and 48 months in 41 women with stress urinary incontinence.

RESULTS

At 48 months, 76% (31/41) of women were cured, 17% (7/41) were improved, and 7% (3/41) were failures. Disturbed bladder voiding was present in 12% (5/41), de novo urge incontinence in 7% (3/41). The median TVT position was at 63% of urethral length. Median tape-urethra distance was 2.7 mm, ranging from 2.9 mm in continent patients without complications to 1.1 mm in those with obstructive complications. Patients with postoperative urine loss had a median distance of 3.9 mm. The tape was stretched at rest and C-shaped during straining in 15 of 41 women (37%) at 48 months (all continent). Patients with this tape functionality at 6 months were also cured at 48 months in 86% of cases (19/22), and only 14% (3/22) showed recurrent incontinence.

CONCLUSIONS

Mid-term data suggest an optimal outcome if the tape is positioned at least 2 mm from the urethra at the junction of the middle and distal thirds. Patients with optimal tape functionality at 6 months are likely to show mid-term therapeutic success.

Female voiding dysfunction: prevalence and common associations

The understanding of voiding dysfunction has been greatly assisted by the current introduction of clear definitions for its diagnosis and for the abnormalities of urine flow rates and postvoid residuals that are its basis. Its prevalence in women with symptoms of pelvic floor dysfunction is up to 40%. Most of the recent research has centered on the associations of voiding dysfunction with age, pelvic organ prolapse, and prior continence surgery. The effects of parity, medications, and pelvic tumors have also been explored.

Predicting short-term urinary retention after vaginal prolapse surgery

AIMS

Identification of risk factors for urinary retention after vaginal prolapse surgery.

METHODS

The medical records of 345 women undergoing surgical correction for symptomatic pelvic organ prolapse were analyzed. Independent risk factors for the development of post-operative urinary retention were identified by performing univariate and multivariate logistic regression analysis. Variables included in the analysis were age, parity, body mass index, previous prolapse surgery, previous hysterectomy, menopausal status, degree of prolapse, type of anesthesia, type and technique of surgery, operation time, intra-operative blood loss, preoperative urinary stress-incontinence, and other co-morbidities. Main outcome measure was the occurrence of urinary retention defined as a residual volume after voiding higher than 200 ml as measured by bladder scan.

RESULTS

High grade cystocele (OR 2.5, CI 1.3-4.7), performing levator plication (OR 4.3, CI 2.0-9.3), performing Kelly plication (OR 5.1, CI 1.7-15.5) and amount of intra-operative blood loss (OR 1.4 per 100 ml, CI 1.1-1.8) were identified as independent risk factors for the occurrence of urinary retention after vaginal prolapse surgery.

CONCLUSIONS

Urinary retention after vaginal prolapse surgery occurs more frequently in women with larger cystoceles, severe intra-operative blood loss and the application of levator plication and Kelly plication.

The benefit of early mobilisation of tension-free vaginal tape in the treatment of post-operative voiding dysfunction

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess the outcome of early mobilisation of tension-free vaginal tape (TVT) in cases of post-operative voiding dysfunction.

METHODS

Thirty-three consecutive cases of early mobilisation of TVT to treat post-operative voiding dysfunction were analysed retrospectively. In each case, the TVT was mobilised and loosened without dividing it, under general anaesthesia, within 2 weeks after the original procedure.

RESULTS

Voiding function subsequently returned to normal in 29 out of 33 women with no recurrence of original stress incontinence. The four remaining women had the tape divided.

CONCLUSIONS

The study shows that early mobilisation of the TVT allows rapid resolution of post-operative voiding dysfunction without compromising the outcome of the original continence procedure.

[Can candidates for reimplantation of suburethral sling after sling removal due to chronic obstruction be identified intraoperatively?]

OBJECTIVE

To intraoperatively identify candidates for immediate reimplantation of a suburethral sling after sling removal due to chronic obstruction.

MATERIAL AND METHOD

Clinical study of 22 women, operated by suburethral sling for stress urinary incontinence between 2000 and 2007, who subsequently developed lower urinary tract obstructive symptoms. The suburethral sling was removed in all patients under local anaesthesia and fentanyl/midazolam sedation. Immediate replacement of the suburethral sling was performed in patients with cough incontinence demonstrated intraoperatively after sling removal. The measure of handicap urinary (MHU) questionnaire, UDI-6/IIQ-7 score and uroflowmetry with determination of the post-voiding residual volume were performed before and three months after the operation.

RESULT

Twelve patients (group 1) underwent removal and reimplantation of a new sling and 10 patients (group 2) underwent simple sling removal. The two groups were comparable. In each group, a significant difference was observed between preoperative and postoperative post-voiding residual volume, peak flow rate and MHU score and a non-significant difference was observed for the UDI-6/IIQ-7 score in group 2, in contrast to group 1. The urinary continence rate was 100% in both groups. The success rate, defined urodynamically, was 75% in group 1 and 80% in group 2. The success rate, defined by resolution of the initial urinary symptoms and improvement of the questionnaire score, was 75% in group 1 and 90% in group 2.

CONCLUSION

Candidates for immediate replacement of suburethral sling after sling removal due to obstructive symptoms can be identified intraoperatively. The cough test under local anaesthesia and fentanyl/midazolam sedation allows selection of these patients. Immediate sling replacement is accompanied by good results on continence without inducing a new obstruction.