Reproducibility of a cough and jump stress test for the evaluation of urinary incontinence

Rates of subjective and objective cure, satisfaction, and pain 10-20 years after tension-free vaginal tape (TVT) surgery: A retrospective cohort study

OBJECTIVE

To evaluate rates of subjective and objective cure, treatment satisfaction, pain, and the correlation between cure and body mass index (BMI), at 10 and 20 years after tension-free vaginal tape (TVT) surgery.

DESIGN

Retrospective cohort study.

SETTING

Multicentre study including 19 units in Norway.

POPULATION

Women undergoing TVT surgery for stress urinary incontinence (SUI) during 2001-2006 (20-year cohort) and 2011-2012 (10-year cohort).

METHODS

The Norwegian Female Incontinence Registry was used to identify women eligible for the study, who answered validated questionnaires about urinary incontinence, pain and satisfaction.

MAIN OUTCOME MEASURES

Subjective cure of SUI (with stress index of <3, range 0-12), objective cure (<3 g on stress test) and persisting pain and satisfaction after TVT (scored on a five-point Likert scale).

RESULTS

In total, 1210 of 1903 (64%) patients responded. The subjective cure rate was 68% after 10 years, versus 59% after 20 years, and did not significantly differ after adjusting for age, BMI, parity and preoperative stress index (adjusted OR 1.27, 95% CI 0.82-1.94). The objective cure rate was 100% versus 93% (P < 0.001), with 89% versus 76% reporting subjective satisfaction (P < 0.001), and with 4.7% versus 2.7% reporting persisting pain (P < 0.001), after 10 versus 20 years, respectively. Women in obesity classes I and II, compared with women of normal weight, had an increased risk of not being subjectively cured (crude OR 2.02, 95% CI 1.42-2.90; OR 2.95, 95% CI 1.60-5.46, respectively).

CONCLUSIONS

Tension-free vaginal tape (TVT) provided high rates of subjective and objective cure at 10 and 20 years after surgery, with no significant difference between the two cohorts. Although 3%-5% of women experienced persisting pain, most women were satisfied with TVT surgery. Obesity was associated with a lower cure rate.

Women's experiences of assessment for urinary incontinence: a qualitative study

BACKGROUND

One in four women experience urinary incontinence. A woman's medical history, a physical examination and certain tests can guide specialists in diagnosing and offering treatment. Despite the high prevalence, little is known about women's experience of urinary incontinence assessment.

AIM

To explore the experience of a group of women undergoing an assessment for urinary incontinence.

METHODS

Individual semi-structured interviews were conducted with 10 women who had been assessed for urinary incontinence. A thematic reflective analysis method was used.

FINDINGS

The women experienced a lot of shame and worry related to their urinary incontinence and the assessment. Having a safe relationship with the urotherapist was very important, and being given information about treatment options gave hope for a better life.

CONCLUSION

Urinary incontinence and its assessment are associated with shame and anxiety. A good patient-urotherapist relationship is paramount and learning that treatments are available made women feel more optimistic about the future.

Periurethral injection with polyacrylamide after previous TVT surgery

INTRODUCTION AND HYPOTHESIS

The aim of this registry study was to assess the clinical utility of using periurethral bulking with polyacrylamide hydrogel in women with stress urinary incontinence (SUI) after previous midurethral sling surgery.

METHODS

The study period was 2007 through 2019. Using data from the Norwegian Female Incontinence Registry we included 57 women who had received Bulkamid® because of insufficient improvement or recurrent SUI after previous retropubic TVT surgery. The primary outcome was cure of SUI, and secondary outcomes were patient satisfaction, degree of leakage, change in urgency incontinence (UUI), free flow rate, postvoid residual volume, and complications. Descriptive statistics were used to characterize data and Wilcoxon signed-rank test to compare pre- and postoperative results for pairs, with level of significance at p < 0.05.

RESULTS

Pure SUI was seen in 19 (33.3%) while 38 (66.7%) had mixed incontinence. Postoperatively 72.9% had a negative stress test and 73.7% were satisfied with treatment. There was only 1 complication in 67 injections (1.5%). De novo UUI occurred in five patients, corresponding to 8.8% of the whole study group, but 26.3% among those with no preoperative UUI problems. Among the patients with preoperative UUI, 39.5% were cured of this problem and a further 36.8% were improved.

CONCLUSIONS

The cure rate and satisfaction rate of periurethral bulking with polyacrylamide after previous MUS are favorable and complications are rare. There seems to be a risk of overactive bladder symptoms developing in women with no such symptoms preoperatively.

Previous obstetrical history does not impact short-term mid-urethral sling outcomes

Abstract

Introduction and hypothesis

Pregnancy and delivery are known risk factors for stress and mixed urinary incontinence. The most common surgical treatment is mid-urethral sling (MUS) surgery. This study evaluated the potential impact of the obstetrical history on the short-term subjective and objective failure rates after MUS surgery.

Methods

A registry-based surgical cohort study using data from the Medical Birth Registry of Norway (MBRN) and the national Norwegian Female Incontinence Registry (NFIR). Data from 14,787 women that underwent MUS surgery from 1998 to 2016 with complete registrations in the MBRN were included. Outcomes were 6–12-month postoperative subjective and objective failure rates. The potential impact of obstetrical and constitutional factors on both outcomes was tested in a multivariate logistic regression model.

Results

Several obstetrical variables seemed to impact both outcomes in the univariate analyses. However, in the multivariate analyses, none of the obstetrical variables significantly impacted subjective failure, and only being nulliparous before MUS surgery remained a risk factor for objective failure [aOR 1.60, (95% CI 1.07–2.40), p = 0.022]. High body mass index at time of surgery, non-retropubic slings, high preoperative urgency symptom load, and surgical complications were all strong risk factors for poor outcomes in the multivariate analyses.

Conclusion

Although childbirth is considered a risk factor for developing stress urinary incontinence, childbirth does not appear to affect the result of MUS in parous women. Our results suggest that nulliparous women with SUI may have a different pathophysiology than SUI after childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04836-5.

The completeness and accuracy of the Norwegian Female Incontinence Registry

INTRODUCTION

Medical quality registries have gained popularity as tools for monitoring the quality of medical treatments and they serve as data sources for research. The Norwegian Female Incontinence Registry (NFIR) was established in 1998 to monitor and improve the quality of surgery for women with stress and mixed urinary incontinence in Norway and to collect data for research. This study aimed to assess the completeness and accuracy of the Norwegian Female Incontinence Registry, and potential differences in data accuracy over time and according to surgical volume of the reporting hospitals.

MATERIAL AND METHODS

A random selection of 300 women from a total of 20 610 operated for urinary incontinence between 1998 and 2016 reported to the Norwegian Female Incontinence Registry from 28 public hospitals were selected for validation. The database completeness was estimated for 2008-2017 by comparing surgical procedures registered both in the Norwegian Female Incontinence Registry and the Norwegian National Patient Registry. Historical data recorded in the Registry for 10 selected key variables were extracted and compared with the patients' individual medical records at the reporting hospitals as reference. The reviewers were blinded to the previously stored information. The intraclass correlation coefficient for continuous variables and Cohen's kappa for categorical variables were calculated.

RESULTS

Primary source data on 285 of the 300 women selected from Norwegian Female Incontinence Registry were successfully retrieved. The completeness of the registry has increased from 61% in 2008 to 99% in 2017. The national coverage has increased from 12 reporting departments in 1998 to all 38 public departments performing female incontinence surgery in 2017. Excellent accuracy was found for both continuous variables (intraclass correlation coefficient >0.94) and categorical variables (Cohen's kappa >0.86). No differences in data accuracy were found comparing high-volume hospitals with low-volume hospitals, or when comparing data accuracy over time.

CONCLUSIONS

The Norwegian Female Incontinence Registry is a reliable tool for quality assessment of incontinence surgery and research. The registry completeness has improved over time and now contains data on nearly all women undergoing incontinence surgery in Norway.

Is antibiotic prophylaxis necessary in mid-urethral sling surgery?

Introduction and hypothesis

Antibiotic prophylaxis is commonly used when implanting a mid-urethral sling (MUS) for female stress urinary incontinence. Use of antibiotics may lead to adverse events and the development of antibiotic resistance. This study compared a variety of outcomes after MUS surgery with and without antibiotic prophylaxis using data from the national Norwegian Female Incontinence Registry.

Methods

Preoperative and 6–12 months postoperative subjective and objective data from 28,687 patients who received MUS surgery from 1998 through 2017 were extracted from the registry. Categorical outcomes were compared between women with or without antibiotic prophylaxis using chi-square test for independence. Primary outcome was incidence of postoperative surgical site infection (SSI). Secondary outcomes were incidence of tape exposure, de novo or persistent urgency urinary incontinence, postoperative pain > 3 months, subjective and objective cure rates, and patient satisfaction.

Results

Antibiotic prophylaxis was used in 9131 and not used in 19,556 patients. SSIs and prolonged postoperative pain occurred significantly more often without antibiotic prophylaxis. Subjective and objective cure rates were significantly higher and tape exposures significantly lower in women not receiving prophylactic antibiotics. There were no significant differences in other outcomes.

Conclusions

Antibiotic prophylaxis resulted in fewer women developing postoperative infections or prolonged postoperative pain after MUS surgery, but did not offer protection against tape exposure. The differences in cure rates were small and probably without clinical relevance. If a small increase in surgical site infections is accepted, the routine use of antibiotic prophylaxis can probably be omitted.

No. 397 - Conservative Care of Urinary Incontinence in Women

OBJECTIVE

To outline the evidence for conservative care, including both assessment and management options, for urinary incontinence in women.

INTENDED USERS

Relevant primary care providers and medical specialists including but not limited to physicians, nurses, midwives, and pelvic health physiotherapists.

TARGET POPULATION

Women (>18 years of age) with urinary incontinence.

OPTIONS

Assessment options include gathering of a detailed history, physical examination, laboratory analysis, urodynamic evaluation, and cystoscopy. Conservative management options include lifestyle management, pelvic floor muscle training, behavioural management, and mechanical devices.

OUTCOMES

To provide an evaluation-based summary of current available evidence concerning efficacy of conservative care (assessment and management) strategies for urinary incontinence in women.

EVIDENCE

The Cochrane Library and Medline (2013-2018) were searched to find articles related to conservative care of urinary incontinence in women (>18 years). Articles were appraised, and the collective evidence was graded.

VALIDATION METHODS

The evidence obtained was reviewed and evaluated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Urogynecology Committee under the leadership of the principal authors. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework.

BENEFITS, HARMS, AND COSTS

Evidence for the efficacy of conservative care (assessment and management) options for women with urinary incontinence is strong. Furthermore, these options carry minimal or no harm and confer an established cost benefit.

GUIDELINE UPDATE

This SOGC Clinical Practice Guideline will be automatically reviewed 5 years after publication.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Surgeon's experience and clinical outcome after retropubic tension-free vaginal tape-A case series

INTRODUCTION

The retropubic tension-free vaginal tape procedure has been the preferred method for primary surgical treatment of stress and stress-dominant mixed urinary incontinence in women for more than 20 years. In this study, we assessed associations between surgeon's experience with the primary tension-free vaginal tape procedure and both perioperative complications and recurrence rates.

MATERIAL AND METHODS

Using a consecutive case-series design, we assessed 596 patients treated with primary retropubic tension-free vaginal tape surgery performed by 18 surgeons from 1998 through 2012, with follow up through 2015 (maximum follow-up time: 10 years per patient). Data on perioperative complications and recurrence of stress urinary incontinence from medical records was transferred to a case report form. Surgeon's experience with the tension-free vaginal tape procedure was defined as number of such procedures performed as lead surgeon (1-19 ["beginners"], 20-49 and ≥50 procedures). All analyses were done with a 5% level of statistical significance. We applied the Chi-square test in the assessment of perioperative complications. The regression analyses of recurrence rate by number of tension-free vaginal tape procedures performed were restricted to the three surgeons who performed ≥50 procedures.

RESULTS

We found a significantly higher rate of bladder perforations (P = .03) and a higher rate of urinary retentions among patients whose tension-free vaginal tape procedures were performed by "beginners" (P = .06). We observed a significant reduction in recurrence rates with increasing number of tension-free vaginal tape procedures for one surgeon (P = .03).

CONCLUSIONS

Surgeon's experience with the tension-free vaginal tape procedure is associated with the risk of bladder perforation and urinary retention, and may be associated with the long-term effectiveness of the procedure.

Comparison of retropubic midurethral slings in the treatment of female stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Over 50 different types of midurethral slings have been marketed. They have generally been considered comparable in performance. Many studies have compared retropubic with obturator slings, but few have compared different makes of retropubic slings with each other. We have compared the performance of retropubic slings using data from the Norwegian Female Incontinence Registry.

METHODS

From June 2015 through 2017, 2843 women underwent a retropubic sling procedure, with 6-12-month follow-up data available for 2612 (92%). Results for six different types of slings used in this time period are presented: TVT Exact, TVT Classic, Advantage, Advantage Fit, TVT A.M.I. and RetroArc. The TVT Exact was the most prevalent sling, and the outcomes were compared with this sling as reference using chi-square and Dunnet's tests with significance at 0.05.

RESULTS

There were only small differences among the four slings, TVT Exact, TVT Classic, Advantage and Advantage Fit, with subjective cure rates from 77.7 to 81.9% and objective cure rates from 90.8 to 96.6%. The TVT A.M.I. sling had a high cure rate but significantly fewer satisfied patients and less improvement in urgency bother. The Retro Arc's results were clearly inferior. There was little difference in terms of obstruction or de novo urgency incontinence among the six slings. Most complication rates were not statistically different.

CONCLUSIONS

At 6-12-month follow-up there was no significant difference in clinical results between the TVT Exact, TVT Classic, Advantage and Advantage Fit slings, while RetroArc and to some extent TVT A.M.I. slings underperformed.

The retropubic tension-free vaginal tape procedure-Efficacy, risk factors for recurrence and long-term safety

INTRODUCTION

The retropubic tension-free vaginal tape has been the preferred method for primary surgical treatment of stress urinary incontinence and stress-dominated mixed urinary incontinence in women for more than 20 years. This study presents long-term safety and efficacy data and assesses risk factors for long-term recurrence.

MATERIAL AND METHODS

In a case-series design we assessed a historical cohort of primary surgeries performed with the tension-free vaginal tape procedure in 596 women from 1998 to 2012 with follow up through 2015. Information from the medical records was transferred to a case report form comprising data on early and late complications and recurrence of urinary incontinence defined as bothersome stress urinary incontinence symptoms. All analyses were performed with SPSS using Pearson chi-square, survival and Cox regression analyses.

RESULTS

After a 10-year follow up, mixed urinary incontinent women (hazard ratio 2.1, 95% confidence interval [CI] 1.4-3.0) had a significantly increased risk of recurrence of stress urinary incontinence symptoms compared with women with pure stress urinary incontinence as the indication for surgery. Overall cumulative cure rates after 1, 5 and 10 years were 92% (95% CI; 90%-94%), 79% (95% CI; 75%-83%) and 69% (95% CI; 63%-75%), respectively. Recurrent surgery (0.3%) and serious tape complications needing major surgical treatment (0.3%) were rare. Six patients (1.0%) had the tape cut due to urinary retention, and nine patients (1.5%) reported urinary retention more than 3 months after surgery.

CONCLUSIONS

The tension-free vaginal tape procedure has a high long-term durability. Mixed urinary incontinence as an indication for surgery predicted long-term recurrence. Long-term complications were rare.

Mid-urethral slings in young, middle-aged, and older women

AIMS

To compare subjective and objective outcomes of mid-urethral sling (MUS) surgery in women in different age decades and the utilization rates for MUS in Norwegian women.

METHODS

Data from the national Norwegian Female Incontinence Registry on 21 832 women with stress or mixed urinary incontinence who underwent MUS surgery from 1998 to 2016 were used. Primary outcomes were treatment satisfaction and absence of objective stress leakage at 6-12 months follow-up and "MUS utilization rate." Secondary outcomes were increase in urgency incontinence symptoms and surgical complications.

RESULTS

Women in the sixth decade and older had more objective postoperative stress urinary leakage, and women in the seventh decade and older were less satisfied. Urgency incontinence symptoms (persistent and de novo) after MUS increased with age. Intermittent catheterization occurred significantly more often in the seventh decade and bladder perforation in the seventh and eighth decades. Women younger than the fifth decade had fewer complications, except the need for tape transection in the fourth decade. The "MUS utilization rate" increased in all age groups during the study period, but declined slightly in the oldest age group after 2010.

CONCLUSION

All age groups had a high percentage of "very satisfied" and no objective stress leakage at 6-12 months follow-up, but declining slightly with age after the sixth decade. Urgency incontinence symptom bother increased with age, but the overall complication rates were low. Our study strengthens the argument that management of stress urinary incontinence with MUS seems suitable regardless of age.

Urethral pressure reflectometry in women with pelvic organ prolapse: a study of reproducibility

INTRODUCTION AND HYPOTHESIS

The mechanism of continence in women with pelvic organ prolapse (POP) before and after surgery remains unknown. Urethral pressure reflectometry (UPR) separates women with stress urinary incontinence (SUI) from continent women by measuring urethral opening pressure at an abdominal pressure of 50 cmH₂O (P _{O-Abd 50}). UPR can help identify women with POP at risk of postoperative de novo SUI. The aim of this study was to investigate the reproducibility of UPR in women with POP.

METHODS

Women with anterior or posterior vaginal wall prolapse were recruited for this prospective, observational study from our outpatient clinic. The women were examined with UPR on two occasions. Measurements were done at rest, and during squeezing and straining. Statistical analyses were performed using SAS 9.4. A Bland-Altman analysis with limits of agreement and coefficients of variation was used to determine the level of agreement between measurements. Paired t tests were used to estimate the difference; a two-tailed P value of <0.05 was considered significant.

RESULTS

We recruited 19 women with anterior vaginal wall prolapse and 11 women with posterior vaginal wall prolapse. There were no significant differences in the opening pressures at rest or during squeezing or in the values of P _{O-Abd 50}. P _{O-Abd 50} showed limits of agreement of 15.3 cmH₂O and a coefficient of variation of 9.9 %.

CONCLUSIONS

UPR was found to be a highly reproducible method in women with POP. UPR may be used in future studies to help reveal urodynamic features predictive of postoperative de novo SUI in women with POP.

Risk factors for long-term failure of the retropubic tension-free vaginal tape procedure

AIMS

To investigate potential risk factors for long-term (10-year) subjective and objective failure of the retropubic tension-free vaginal tape procedure (TVT).

METHODS

Secondary risk analysis was performed using data from a recently published multi-center study that were merged with additional preoperative and operative data individually stored in the Norwegian Female Incontinence Registry (NFIR). Subjective data from 483 women and objective data from 327 women were obtained 10 years after retropubic TVT surgery. A validated questionnaire was used for subjective outcome data and a stress test for objective outcome data. Uni- and multivariate logistic regression analyses were performed using preoperative and operative variables extracted from the NFIR. The outcomes were 10-year subjective failure defined as women stating not cured, and objective failure was defined as ≥1 g urinary leakage during stress testing.

RESULTS

Age ≥56 years at the time of TVT surgery was associated with both long-term subjective failure (adjusted OR: 2.15, CI: 1.40-3.30) and long-term objective failure (adjusted OR: 2.81, CI: 1.30-6.09). Mixed incontinence was associated with subjective, but not objective failure if the urgency incontinence component was severe (adjusted OR: 2.33, CI: 1.27-4.28). Surgical complications occurring at or immediately following surgery were associated with both outcomes in the univariate analyses, but were only an independent risk factor for subjective failure in the multivariate analysis (adjusted OR: 3.02, CI: 1.53-5.95).

CONCLUSIONS

Age ≥56 years, a severe preoperative urgency incontinence component and surgical complications seem to represent independent risk factors for long-term (10-year) failure.