Seventeen years' follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence

Long-term sexual function after mid-urethral slings for stress urinary incontinence in women

INTRODUCTION

There has been increasing concern about potential negative impact of mid-urethral slings (MUS) on sexual life. Our aim was to study sexual activity 10-20 years after MUS surgery and changes in impact of incontinence on sexual life over time and to compare subjective cure, pain, satisfaction, and incontinence between sexually active and inactive women 10-20 years after MUS.

MATERIAL AND METHODS

Historical cohort study using the Norwegian Female Incontinence Registry to identify women who underwent MUS between 2001-2006 and 2011-2012. They answered validated questionnaires about sexual activity, incontinence, pain, and satisfaction with MUS. We assessed changes in urinary incontinence during intercourse and compared symptoms and satisfaction between sexually active and inactive women. The study was registered in Clinical Trials (NCT04912830).

RESULTS

In total, 1210/1903 (64%) responded. Of women responding to questions about sexual activity, 63% (735/1166) were sexually active. 31.3% experienced negative impact of incontinence on sexual life preoperatively, decreasing to 5.9% at 10-20 years follow-up. A higher proportion of sexually inactive vs sexually active women had urinary incontinence (63.5% vs. 47.5%, aOR 1.60 [1.18-2.17]). In a subanalysis, only urgency and mixed urinary incontinence remained significant. A higher proportion of sexually inactive were dissatisfied with MUS (30.1% vs. 12.9%, aOR 2.53 [1.82-3.51]). Persistent pain after MUS was similar for sexually inactive and active women (4.0% vs. 3.2%, aOR 1.10 [0.55-2.19]). Furthermore, 3.4% of sexually inactive had persistent pain after MUS and stated pain as a reason for not being sexually active, whereas 1.7% of sexually active women had persistent pain after MUS and pain during intercourse.

CONCLUSIONS

Negative impact of incontinence on sexual life was less prevalent at 10-20 years follow-up after sling surgery compared to preoperative assessment. A higher proportion of sexually inactive had urgency and mixed urinary incontinence and were dissatisfied with MUS. Only 3%-4% of sexually active and inactive women had persistent pain after MUS and this was not associated with sexual activity. This indicates that incontinence has a greater negative impact on sexual activity than persisting pain after MUS at long-term follow-up.

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.

Long-Term Outcomes of the Altis® Single-Incision Sling: Up to 10 Years' Follow-up

INTRODUCTION AND HYPOTHESIS

Single-incision slings (SIS) have emerged as a less invasive alternative to conventional slings for stress urinary incontinence (SUI) treatment. However, long-term efficacy and safety results remain uncertain owing to a lack of studies.

MATERIAL AND METHODS

A retrospective review of 155 patients treated with Altis® for SUI between February 2012 and June 2017, held in 2022, as a continuation of a prospective study in which all patients (197) were reviewed for 2 years after surgery (1, 6, 12, and 24 months). Preoperative demographic data, comorbidities, and pressure-flow studies were also recorded. Continence status and satisfaction rates were assessed using the International Consultation on Incontinence Questionnaire-short form (ICIQ-SF) and the Patient Global Impression of Improvement (PGI-I) respectively. The assessment in the 2022 retrospective review was performed via a telephone survey.

RESULTS

Mean follow-up time after surgery was 85.3 months (82.5-88.1). In 2022, complete continence was present in 75.4% of the patients. The presence of urinary urgency conditioned the ICIQ-SF score (10.9 vs 1.7 points, p < 0.01), with the ICIQ-SF = 0 in 84.5% of the patients with no associated urgency. Satisfaction assessed by the PGI-I was high, with 84.6% of the patients showing improvement. De novo urgency was present in 37,9% of the patients by 2022. Urinary tract infections were the most frequent complication (9.7%), with only 5 documented cases of mesh erosion.

CONCLUSIONS

Altis® SIS is a safe and effective device for SUI treatment, with satisfaction rates comparable with those of the conventional slings. Persistence or development of urinary urgency influences the results.

Autologous Fascial Slings for Stress Urinary Incontinence: a 17-year Follow-up of a Randomised Controlled Study

INTRODUCTION AND HYPOTHESIS

Safety concerns with the use of mesh in vaginal surgery have been ongoing. Autologous fascial slings (AFS) avoid foreign body complications. We compared the long-term (17-year) outcomes of two AFS repair methods-the standard sling and short sling (sling-on-string), and assessed durability and patient satisfaction of these for the treatment of stress urinary incontinence (SUI).

METHODS

A total of 107 patients from three urogynaecology units who had participated in a randomised controlled trial assessing standard (n = 52) and short (n = 55) slings were followed up for a median period of 17 years. Primary outcomes were Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) scores to assess the impact on the quality of life and symptom distress. Logistic quantile regression was employed to compare the two methods. Secondary outcomes included long-term complications and patient satisfaction.

RESULTS

Mean scores showed no statistically significant difference between the standard and short slings at the 17-year follow-up relating to IIQ and UDI scores, leakage or urgency (p > 0.05). Improved bladder function was observed at 17 years compared with baseline (standard sling-IIQ scores mean difference [MD] 1.22 [CI: 0.69, 1.74], UDI scores MD 0.83 [CI: 0.70, 0.97]; short sling-IIQ score MD 1.14 [CI: 0.73, 1.54], UDI scores MD 0.54 [CI: 0.40, 0.67]) with age-related deterioration over time. Re-operation rates were low and patient satisfaction rates were high (67.2%) at follow-up.

CONCLUSIONS

Autologous fascial slings are an effective and durable option for management of SUI and the short sling procedure can be recommended owing to plausible surgical advantages.

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.

Postoperative outcomes and urodynamic findings after continence mesh removal

OBJECTIVE

To analyze urodynamics findings and patient-reported outcomes after removal of a mid-urethral mesh because data regarding outcomes following mesh removal vary in different studies, and mesh removal itself may have risks.

METHODS

Women who were referred to the Female Pelvic Medicine and Reconstructive Surgery Department of University College London Hospital and underwent vaginal removal of a continence mesh between January 2014 and January 2020, were included. Patient clinical data and results of video-urodynamics investigations performed 4 months after mesh removal were collected and analyzed retrospectively.

RESULTS

In all, 204 patients were included in the study. After mesh removal, 80.5% of patients reported recurrent stress urinary incontinence (SUI), 10.1% reported prolapse symptoms, 8% reported voiding dysfunction and 2.9% reported overactive bladder (OAB) symptoms. Video-urodynamics investigations confirmed the presence of SUI (67.6%), mixed urinary incontinence (14.3%), detrusor overactivity (DO) (6.8%) and voiding dysfunction in one patient. In two women a urethral stricture was described, and 10 women were deemed to have a significant cystocele.

CONCLUSION

Recurrence of SUI was the most frequent finding after continence mesh removal, both symptomatically and objectively. Women seldom reported OAB symptoms, but urodynamics showed evidence of DO despite this. On the other hand, voiding dysfunction was often reported but less often proven on urodynamics.

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.

Three-year Follow-up of a Single Incision Sling Procedure Performed Under Local Anesthesia in an Office Setting

OBJECTIVE

To assess the 3-year success of placing a single-incision midurethral sling (SIMS) using the Dynamic Intraoperative Standing Sling Technique (DISST) in an office setting under local anesthesia.

METHODS

This is a prospective case series of 20 women who underwent in-office SIMS procedure by the DISST from July 2019 to February 2020. This is an extension of our pilot study (11) and all 20 patients were evaluated at a mean follow-up of 34.3months. Success was defined as a composite score of objective success (negative standing cough test at bladder fullness), subjective success based on the modified PGI-I score of "very much better" or "much better," and no retreatment for stress urinary incontinence. Secondary objectives were adverse events, de novo overactivity of the bladder, recurrent urinary tract infections, voiding dysfunction, pain/dyspareunia, and influence on sexual function.

RESULTS

The composite success rate was 95% (95% CI [75.1, 99.9]) at the 36-month follow-up. The significant improvement in MESA scores was maintained over the study period. There were no cases of de novo urgency, mesh exposure, postop voiding dysfunction or recurrent urinary tract infections. There were no cases of de novo dyspareunia.

CONCLUSION

SIMS placed by the DISST technique under local anesthesia in an office setting has shown sustained efficacy over a 3-year period with no decrease in cure. Subjects remained dry and reported excellent improvement in symptoms and quality of life at the 36-month follow-up visit.

Single-incision sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence imposes a significant health and economic burden on individuals and society. Single-incision slings are a minimally-invasive treatment option for stress urinary incontinence. They involve passing a short synthetic device through the anterior vaginal wall to support the mid-urethra. The use of polypropylene mesh in urogynaecology, including mid-urethral slings, is restricted in many countries. This is a review update (previous search date 2012).

OBJECTIVES

To assess the effects of single-incision sling operations for treating urinary incontinence in women, and to summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from: CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, and two trials registers. We handsearched journals, conference proceedings, and reference lists of relevant articles to 20 September 2022.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials in women with stress (or stress-predominant mixed) urinary incontinence in which at least one, but not all, trial arms included a single-incision sling.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The primary outcome was subjective cure or improvement of urinary incontinence.

MAIN RESULTS

We included 62 studies with a total of 8051 women in this review. We did not identify any studies comparing single-incision slings to no treatment, conservative treatment, colposuspension, or laparoscopic procedures. We assessed most studies as being at low or unclear risk of bias, with five studies at high risk of bias for outcome assessment. Sixteen trials used TVT-Secur, a single-incision sling withdrawn from the market in 2013. The primary analysis in this review excludes trials using TVT-Secur. We report separate analyses for these trials, which did not substantially alter the effect estimates. We identified two cost-effectiveness analyses and one cost-minimisation analysis. Single-incision sling versus autologous fascial sling One study (70 women) compared single-incision slings to autologous fascial slings. It is uncertain if single-incision slings have any effect on risk of dyspareunia (painful sex) or mesh exposure, extrusion or erosion compared with autologous fascial slings. Subjective cure or improvement of urinary incontinence at 12 months, patient-reported pain at 24 months or longer, number of women with urinary retention, quality of life at 12 months and the number of women requiring repeat continence surgery or sling revision were not reported for this comparison. Single-incision sling versus retropubic sling Ten studies compared single-incision slings to retropubic slings. There may be little to no difference between single-incision slings and retropubic slings in subjective cure or improvement of incontinence at 12 months (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.07; 2 trials, 297 women; low-certainty evidence). It is uncertain whether single-incision slings increase the risk of mesh exposure, extrusion or erosion compared with retropubic minimally-invasive slings; the wide confidence interval is consistent with both benefit and harm (RR 1.55, 95% CI 0.24 to 9.82; 3 trials, 267 women; low-certainty evidence). It is uncertain whether single-incision slings lead to fewer women having postoperative urinary retention compared with retropubic slings; the wide confidence interval is consistent with possible benefit and harm (RR 0.47, 95% CI 0.12 to 1.84; 2 trials, 209 women; low-certainty evidence). The effect of single-incision slings on the risk of repeat continence surgery or mesh revision compared with retropubic slings is uncertain (RR 4.19, 95% CI 0.31 to 57.28; 2 trials, 182 women; very low-certainty evidence). One study reported quality of life, but not in a suitable format for analysis. Patient-reported pain at more than 24 months and the number of women with dyspareunia were not reported for this comparison. We downgraded the evidence due to concerns about risks of bias, imprecision and inconsistency. Single-incision sling versus transobturator sling Fifty-one studies compared single-incision slings to transobturator slings. The evidence ranged from high to low certainty. There is no evidence of a difference in subjective cure or improvement of incontinence at 12 months when comparing single-incision slings with transobturator slings (RR 1.00, 95% CI 0.97 to 1.03; 17 trials, 2359 women; high-certainty evidence). Single-incision slings probably have a reduced risk of patient-reported pain at 24 months post-surgery compared with transobturator slings (RR 0.12, 95% CI 0.02 to 0.68; 2 trials, 250 women; moderate-certainty evidence). The effect of single-incision slings on the risk of dyspareunia is uncertain compared with transobturator slings, as the wide confidence interval is consistent with possible benefit and possible harm (RR 0.78, 95% CI 0.41 to 1.48; 8 trials, 810 women; moderate-certainty evidence). There are a similar number of mesh exposures, extrusions or erosions with single-incision slings compared with transobturator slings (RR 0.61, 95% CI 0.39 to 0.96; 16 trials, 2378 women; high-certainty evidence). Single-incision slings probably result in similar or reduced cases of postoperative urinary retention compared with transobturator slings (RR 0.68, 95% CI 0.47 to 0.97; 23 trials, 2891 women; moderate-certainty evidence). Women with single-incision slings may have lower quality of life at 12 months compared to transobturator slings (standardised mean difference (SMD) 0.24, 95% CI 0.09 to 0.39; 8 trials, 698 women; low-certainty evidence). It is unclear whether single-incision slings lead to slightly more women requiring repeat continence surgery or mesh revision compared with transobturator slings (95% CI consistent with possible benefit and harm; RR 1.42, 95% CI 0.94 to 2.16; 13 trials, 1460 women; low-certainty evidence). We downgraded the evidence due to indirectness, imprecision and risks of bias.

AUTHORS' CONCLUSIONS

Single-incision sling operations have been extensively researched in randomised controlled trials. They may be as effective as retropubic slings and are as effective as transobturator slings for subjective cure or improvement of stress urinary incontinence at 12 months. It is uncertain if single-incision slings lead to better or worse rates of subjective cure or improvement compared with autologous fascial slings. There are still uncertainties regarding adverse events and longer-term outcomes. Therefore, longer-term data are needed to clarify the safety and long-term effectiveness of single-incision slings compared to other mid-urethral slings.

A 10- to 20-year follow-up after tension-free vaginal tape for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Midurethral slings (MUS) have become the gold standard in the treatment of stress urinary incontinence (SUI). Some information is already available on the outcome of tension-free vaginal tape (TVT) after 10 years or more. Our objective was to assess the current outcome (efficacy, adverse events) of women who had been successfully operated upon for SUI by means of a TVT procedure 10 to 20 years ago.

METHODS

We performed a retrospective cohort study including 291 women (mean age 69.4 years) who underwent a successful TVT procedure (retropubic bottom-to-top route) in a teaching hospital between January 2001 and December 2010. The main outcome measure was the incidence of SUI at 10-20 years' follow-up. Others were incidence of re-operation, tape exposure and de novo overactive bladder symptoms. We carried out a univariate logistic regression analysis to examine the relationship between outcomes and a set of clinical variables.

RESULTS

After a median of 15 years, TVT remains highly effective: 272 women (94%) experienced either no leakage under any circumstance (214=74%) or leakage less than weekly (58=20%). Mesh exposure (8=2.7%; 1.8 events per 1,000 patient-years) and repeat surgery for SUI (11=3.8%; 2.5 events per 1,000 patient-years) were low. Three women (1%) needed to perform intermittent self-catheterisation. Bothersome overactive bladder symptoms (45=15%) were common and associated with polypharmacy, cardiovascular medication and obesity.

CONCLUSION

The efficacy of TVT is demonstrated up to 20 years. The presence of bothersome OAB symptoms in the population may be an indicator of multimorbidity.

Predictors of Surgical Failure of Open Burch Colposuspension Versus Retropubic Midurethral Sling for Stress Urinary Incontinence

OBJECTIVE

To identify and compare long-term predictors for 'surgical failures' in matched groups of Midurethral sling (MUS) and Burch colposuspension (BC).

METHODS

A secondary analysis of patients with urodynamic stress incontinence who were treated either by open BC or retropubic MUS. The study had a cohort of 1344 women with a ratio of 1:3 (BC: MUS). We defined surgical success or failure by combining Patient Reported Outcome Measures and the need for repeat surgery. Risk factors for failure identified by multivariate analysis.

RESULTS

Of the 1344 women included, 336 had BC, and 1008 had MUS. Patients were followed-up for 13.1 and 10.1 years, and the rate of failure was 22% and 20%, for BC and MUS, respectively (P = 0.35). Significant predictors for MUS failure were Body mass index (BMI) > 30, preoperative anticholinergic medication use, smoking, diabetes, and previous surgery for incontinence (Hazard ratio 3.6, 2.6, 2.5, 1.8, 2.3, respectively). BMI > 25, preoperative use of anticholinergic medication, age > 60, previous surgery for incontinence, and loss of follow-up>5 years (Hazard ratio: 3.2, 2.8, 2.6, 2.5, 2.1, respectively), were significant predictors of BC failure.

CONCLUSION

This study shows similar predictors for surgical failure for BC and MUS, with high BMI, mixed urinary incontinence, and previous continence procedures being the most important.

Surgical Treatments for Women with Stress Urinary Incontinence: A Systematic Review

Stress urinary incontinence affects a large proportion of women in their lifetime. The objective of this review was to describe and compare the latest surgical trends in urinary incontinence and focus on the literature advantages, disadvantages, complications and efficacy of surgical procedures regarding this pathology. Using network meta-analysis, we have identified the most frequently used procedures (Burch surgery, midurethral sling and pubovaginal sling), and we have described and characterized them in terms of effectiveness and safety. Midurethral procedures remain the gold standard for surgical treatment of stress urinary incontinence, although the potential of serious complications following this procedure should be taken into consideration always. There is a clear need for a much more unified evaluation of possible complications and postoperative evolution. This process will help practitioners to adapt and individualize their strategy for each patient.

Tape-Releasing Suture with "Long Loop" on Mid-Urethral Sling: A Novel Procedure for Management of Iatrogenic Urethral Obstruction

BACKGROUND

To report our experiences of a tape-releasing suture with "long-loop" in women with iatrogenic urethral obstruction following the mid-urethral sling procedure.

METHODS

A total of 149 women underwent a tape-releasing suture with "Long Loop" during the operation. Post-void residual volume was evaluated after Foley removal. Lower urinary tract symptoms and urodynamic studies were assessed before and six months postoperatively.

RESULTS

Nine women out of 149 who underwent mid-urethral sling surgery were found to have iatrogenic urethral obstruction post-operatively based on their urinary symptoms and ultrasound findings. There was no apparent difference between tested groups in mid-urethral sling products and concomitant procedures. 77.8% had successful releases after the first Long-loop manipulation procedure, and 22.2% required two or more releases. However, the SUI cure rate is similar in groups receiving the Long-loop manipulation or not (88.9% and 87.1%, respectively).

CONCLUSIONS

We are convinced of the practicability and efficacy of the tape-releasing suture "Long-loop." We adopted subjective and objective means to evaluate both groups before and after a six-month follow-up. The Long-loop manipulation procedure can successfully resolve the iatrogenic urethral obstruction without compromising the effectiveness of mid-urethral sling for the treatment of SUI.

Retropubic slings are more efficient than transobturator at 10-year follow-up: a Swedish register-based study

INTRODUCTION AND HYPOTHESIS

Long-term performance of mid-urethral slings (MUS) and potential differences between the retropubic and the transobturator technique for insertion are scarcely studied. This study aims to evaluate the efficacy and safety 10 years after surgery and compare the two main surgical techniques used.

METHODS

Women who underwent surgery with a MUS between 2006 and 2010 were identified using the Swedish National Quality Register of Gynecological Surgery and were invited 10 years after the operation to answer questionnaires regarding urinary incontinence and its impact on quality-of-life parameters (UDI-6, IIQ-7) and impression of improvement, as well as questions regarding possible sling-related complications and reoperation.

RESULTS

The subjective cure rate reported by 2421 participating women was 63.3%. Improvement was reported by 79.2% of the participants. Women in the retropubic group reported higher cure rates, lower urgency urinary incontinence rates and lower UDI-6 scores. No difference was shown between the two methods regarding complications, reoperation due to complications or IIQ-7 scores. Persisting sling-related symptoms were reported by 17.7% of the participants, most commonly urinary retention. Mesh exposure was reported by 2.0%, reoperation because of the tape by 5.6% and repeated operation for incontinence by 6.9%, significantly more in the transobturator group (9.1% vs. 5.6%). Preoperative urinary retention was a strong predictor for impaired efficacy and safety at 10 years.

CONCLUSIONS

Mid-urethral slings demonstrate good results for the treatment of stress urinary incontinence and tolerable complication profiles in a 10-year perspective. The retropubic approach displays higher efficacy than the transobturator, with no difference regarding safety.

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.

Urinary Incontinence and Pelvic Organ Prolapse in Women

BACKGROUND

Pelvic floor disorders are common, especially in pregnancy and after delivery, in the postmenopausal period, and old age, and they can significantly impact on the patient's quality of life.

METHODS

This narrative review is based on publications retrieved by a selective search of the literature, with special consideration to original articles and AWMF guidelines.

RESULTS

Pelvic floor physiotherapy (evidence level [EL] 1), the use of pessaries (EL2), and local estrogen therapy can help alleviate stress/urge urinary incontinence and other symptoms of urogenital prolapse. Physiotherapy can reduce urinary incontinence by 62% during pregnancy and by 29% 3-6 months post partum. Anticholinergic and β-sympathomimetic drugs are indicated for the treatment of an overactive bladder with or without urinary urge incontinence (EL1). For patients with stress urinary incontinence, selective serotonin-noradrenaline reuptake inhibitors can be prescribed (EL1). The tension-free tape is the current standard of surgical treatment (EL1); in an observational follow-up study, 87.2% of patients were satisfied with the outcome 17 years after surgery. Fascial reconstruction techniques are indicated for the treatment of primary pelvic organ prolapse, and mesh-based surgical procedures for recurrences and severe prolapse (EL1).

CONCLUSION

Urogynecological symptoms should be specifically asked about by physicians of all relevant specialties; if present, they should be treated conservatively at first. Structured surgical techniques with and without mesh are available for the treatment of urinary incontinence and pelvic organ prolapse. Preventive measures against pelvic floor dysfunction should be offered during pregnancy and post partum.

Conceptualizing stress urinary incontinence surgery beyond midurethral slings: Very early results from simplified ligament repair without tapes

AIMS AND METHODS

To find a simpler cure for stress urinary incontinence (SUI) without tapes. Proposed is a paraurethral operation with incisions in both sulci to plicate pubourethral ligaments (PUL) with thick polyester sutures.

RESULTS

VIDEO and ultrasound experiments showed the main cause of SUI was weak PULs extending on effort, allowing the posterior pelvic muscles to open out posterior urethral wall, so urine was lost on effort. Midurethral sling (MUS) tapes prevent PUL extension and SUI. The research question: "Would PUL plication by 0.5 or 0.25 mm polyester tapes create sufficient new collagen to cure SUI in the longer term?" Instron-testing of collagen from a rejected polyester aortic graft indicated sufficient potential collagen strength. Five surgeons unrelated to the authors who tested the new operation, reported negative cough tests on 30/31 women before patient discharge; these data were encouraging, but not conclusive.

CONCLUSIONS

PUL ligament repair by large polyester sutures, like the MUS, appears to prevent PUL elongation and cure SUI in the very short term, thereby validating the predictions of the Integral Theory as regards the role of ligaments in continence. If successful long term, this operation could avoid many problems associated with MUS operations. 1. Simplicity: less surgical skill is required; the local anesthetic methodology makes the operation widely scalable especially in poor countries with few health facilities. 2. Built-in safety: there is no tape to compress urethra, no applicators to damage bladder, nerves, blood vessels, bowel. 3. Cost: a polyester suture.

Translabial ultrasound evaluation after tension-free transobturator tape technique: Outcomes based on the tape's position

OBJECTIVE

The purpose of this study was to evaluate the feasibility and accuracy of postoperative translabial ultrasound to assess the position of the tape implanted with the tension-free transobturator tape technique.

METHODS

We enrolled women with clinically and urodynamically proven type I or II stress urinary incontinence who were referred for transobturator tape treatment.

RESULTS

A total of 50 women underwent a transobturator tape procedure and were included in the analysis. We divided the patients into two study groups (group A and group B), characterized by normal and obstructed flow at least 30 days after the surgical procedure visit, respectively. We performed a translabial ultrasound evaluation to assess the suburethral localization of the sling. On the longitudinal scan, the distance between the bladder neck and the suburethral sling was >10 mm in all patients in group A (16.7 ± 1.6). On the contrary, the values in group B were ≤10 mm (5.3 ± 4.8).

CONCLUSION

Our findings highlight the role of a skilled sonographic operator performing translabial ultrasound as a first-line method for evaluating postoperative transobturator tape procedure and sling positioning. Moreover, translabial ultrasound could be helpful to determine a "cutoff" of the bladder neck to sling distance, as this is related to the onset of the obstruction.

Using clinical estimate or catheter measurement of urethral mid-point result in similar retropubic mid-urethral sling position: a randomized trial

INTRODUCTION AND HYPOTHESIS

The objective was to determine whether standardized, intraoperative urethral measurement improves retropubic mid-urethral sling (RPMUS) positioning and if the intraoperative position remains stable at 2 weeks postoperatively.

METHODS

Participants undergoing a RPMUS were randomized to mid-urethral placement as per usual surgical care (no Foley catheter measurement, no-FCM) vs urethral mid-point Foley catheter measurement (FCM). The primary outcomes were RPMUS location as determined by 2D and 3D ultrasound 2 weeks postoperatively (as percentage from urethral meatus - relative to the urethral length) and intraoperatively following the RPMUS placement.

RESULTS

Forty-four women enrolled, underwent RPMUS, and provided baseline data and intraoperative ultrasound measurements; of these, 36 (82%) had interpretable intraoperative and postoperative ultrasound measurements. Demographic data were similar in the two groups. The mean RPMUS mid-point was 57 % and 55 % in measured and controls (p = 0.685); this same measurement was relatively unchanged at 2 weeks postoperatively at 57% and 54% respectively (p = 0.538). Very much and much improvement was reported on the PGI-I by 84% and 85% of participants in the FCM and no-FCM groups respectively.

CONCLUSIONS

Intraoperative RPMUS position at 2 weeks after surgery is similar to the intraoperative position. Compared with usual surgical care, intraoperative measurement of urethral mid-point with a Foley catheter did not affect RPMUS sling position.

Bladder filling test, cystoscopy, or both for checking bladder perforation in tension-free-vaginal tape operations

Background/Aim: Tension-free-vaginal tape (TVT) has been widely used for treatment of stress urinary incontinence as a mid-urethral sling operation. Cystoscopy is routinely performed during tension-free-vaginal tape operations to check for bladder perforation or injury. This study aims to check the applicability and accuracy of the bladder filling test for predicting bladder perforation in tension-free-vaginal tape operations. Methods: Between 2015 and 2020, 285 women who had TVT operations were subject to evaluation. Out of 285 cases, 23 cases were suspected subjectively by the operating surgeons to have visible or occult bladder perforation during the TVT procedure. A routine cystoscopy was performed at the end of all operations. Additionally, before the routine cystoscopy, in cases suspected of a visible or occult bladder perforation, the bladder was filled with 500 ml saline or diluted methylene blue dye through a urinary catheter (bladder filling test) to check for occult bladder perforation that might not be visualized by cystoscopy. Any fluid leakage through the paraurethral dissected canals or from the abdominal incisions was observed for the possibility of bladder perforation. The accuracy of the bladder filling test was compared to cystoscopy to diagnose bladder perforation in suspected cases. In addition, all cases were followed up for three months to record any cases with late or occult bladder perforations missed in the diagnosis using cystoscopy or the bladder filling test perioperatively. Results: Out of 23 cases suspected subjectively by the operating surgeons to have visible or occult bladder perforation, 11 had visible bladder perforations (3.9%) confirmed by both cystoscopy and the bladder filling test. After the filling test, leakage at the abdominal incision site and/or para-urethral dissected canal was observed in all cases with bladder perforation. No leakage was observed in the remaining patients (n = 12) suspected of, but not diagnosed with bladder perforation by cystoscopy. The bladder filling test did confirm the same diagnosis revealed by cystoscopy in all suspected cases. Conclusion: The bladder filling test was found to be very sensitive in predicting bladder perforation at tension-free-vaginal tape operations compared to cystoscopy. This test can decrease the need for routine cystoscopy at tension-free-vaginal tape insertion, and cystoscopy can be limited to cases with leakage in the bladder filling test.

The efficacy and complications of retropubic tension‐free vaginal tapes after twenty years: a prospective observational study

OBJECTIVE

Long-term data regarding risks associated with tension-free vaginal tapes (TVT) are sparse, and where available are limited to small numbers. We analyse patient-reported outcomes of TVT after 16-24 years.

DESIGN

Prospective observational study.

SETTING

Single-centre study in a tertiary referral urogynaecology unit.

POPULATION

A cohort of 350 women who had a TVT inserted between 1999 and 2004, in which 96% had urodynamically proven stress incontinence.

METHODS

Postal questionnaire survey using the International Consultation on Incontinence Questionnaire, a visual analogue scale and a yes/no question as to whether they would have the procedure again.

MAIN OUTCOME MEASURES

The primary outcome was cure of stress urinary incontinence, which was assessed using the ICIQ-FLUTS questionnaire. Secondary outcomes included overactive bladder symptoms, pain, sexual dysfunction, and patient satisfaction with the procedure.

RESULTS

A total of 183/350 (52%) responses were received. The median age of women at follow up was 67 years (range 53-93 years) and the median follow up was 20 years (17-24 years). Stress urinary incontinence was denied by 39.3% of women. Urgency was reported by 42.1%. Bladder pain was reported either 'never' or 'occasionally' by 92.3% of women. The median satisfaction rate was 98/100 and 92.4% said they would have the TVT procedure again.

CONCLUSIONS

Tension-free vaginal tape has high levels of satisfaction and cure up to 24 years after placement. Pain was uncommon and its impact on quality of life was low. Symptoms of urgency were prevalent but may be related to age. TVT is an effective treatment for SUI more than 20 years after initial placement.

The subjective and objective very long-term outcomes of TVT in the COVID era: A 20-year follow-up

Introduction and hypothesis

Few studies in literature have assessed the long-term durability and mesh-related complications of mid-urethral slings (MUSs). The aim of this study is to assess the efficacy and safety of retro-pubic tension-free vaginal tape (TVT) 20 years after implantation for the treatment of female stress urinary incontinence (SUI).

Methods

A prospective observational study was conducted in two urogynaecologic units in two countries. All the patients involved were consecutive women with urodynamically proven pure SUI treated by TVT. The patients underwent preoperative clinical and urodynamic evaluations. Subjective outcomes, objective outcomes and adverse events were recorded during the follow-up period.

Results

Fifty-two patients underwent a TVT surgical procedure. Twenty years after surgery, 32 out of 36 patients (88.8%) declared themselves cured (p = 0.98). Similarly, 33 out of these 36 patients (91.7%) were objectively cured (p = 0.98). No significant deterioration of subjective and objective cure rates was observed over time (p for trend 0.50 and 0.48). Fifteen of the 36 patients (41.6%) at the 20-year follow-up reported the onset of de novo overactive bladder (OAB) (p = 0.004). No significant vaginal bladder or urethral erosion or de novo dyspareunia was recorded and no patient required tape release or resection during this period. The cause of death of seven out of ten women who died in the last year of the follow-up period was coronavirus disease 19 (COVID 19).

Conclusions

The 20-year results of this study showed that TVT is a highly effective and safe option for the treatment of SUI. The impact of COVID 19 on the mortality rate of elderly women has drastically reduced the number of eligible patients for future evaluations in our region.

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence

OBJECTIVE

To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m2), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]

INTRODUCTION

Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term.

OBJECTIVES

In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected.

RESULTS

Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women.

CONCLUSION

Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

Long-term outcomes of transobturator suburethral tapes for female stress urinary incontinence

AIMS

The aim is to evaluate long-term effectiveness and safety of transobturator midurethral slings (TO-MUS) for treating female stress urinary incontinence (SUI). Possible risk factors for failure and complications are also evaluated.

METHODS

A descriptive retrospective study was performed among women with SUI treated at a tertiary urogynecology unit between January 2004 and December 2006. Women with stress-predominant mixed urinary incontinence or with associated pelvic organ prolapse were also included. Postoperative follow-up was performed at 1, 6, and 12 months and yearly thereafter. Outcomes were classified as cured, improved or failed.

RESULTS

Of 896 women operated on over the study period, 565 were suitable for the analysis. Of them, 327 women completed the 5-year, 225 the 7-year, and 172 the 10-year follow-up periods. Success rates were 77.6%, 73.8%, and 73.2% at 5, 7, and 10 years, respectively. On multivariate Cox regression models age, body mass index, and previous incontinence surgery were related to failure. Complications of any type were described in 24.9% of patients, although most of them were mild. Only concomitant prolapse surgery was related to intraoperative and peroperative complications and the inside-out route to an increased odds of groin pain (odds ratio = 4.0).

CONCLUSIONS

This study showed that TO-MUS is an effective and safe procedure in the long-term. The expected outcomes and possible side effects profile should be discussed in detail during the counseling process before opting for a treatment option.

Long-term efficacy and complications of a multicentre randomised controlled trial comparing retropubic and transobturator mid-urethral slings: a prospective observational study

OBJECTIVE

There are concerns regarding the risks of mid-urethral slings (MUS) for stress urinary incontinence (SUI), particularly because of the lack of long-term data. We compare patient-reported outcomes of a multicentre randomised controlled trial of retropubic (TVT, GYNECARE™) versus transobturator (TOT, MONARC™) tape surgery at 12 years.

DESIGN AND SETTING

A multicentre study was performed in 11 tertiary referral centres.

POPULATION

A cohort of 180 participants from the original trial, the majority of whom had mixed urinary incontinence.

METHODS

Postal questionnaire survey of patient-reported outcome measures using the International Consultation on Incontinence Questionnaire, Patient Global Impression of Improvement questionnaire (PGI-I) and a numeric rating scale pain questionnaire.

MAIN OUTCOME MEASURES

Comparison of the efficacy and complications between the TVT and TOT procedures in the long term.

RESULTS

A total of 110/180 responses were received: 55 for TVT and 55 for TOT. The mean follow-up was 12.8 ± 0.29 years (SD). TVT was significantly superior to TOT: 41.8% TVT with no SUI, versus 21.8% TOT (P = 0.04). Urgency urinary incontinence (UUI) was the most bothersome urinary symptom: 14.5% of respondents reported UUI after TVT and TOT. This was an improvement from the baseline levels: 61.8% TVT and 76.4% TOT. Seventeen patients (9 TVT and 8 TOT) out of 121 reported moderate or severe pain with severe pain in 3 with TVT and 2 with TOT. Overall, 80% TVT and 77% TOT participants reported their symptoms as improved on the PGI-I.

CONCLUSIONS

TVT is superior to TOT for SUI cure. Efficacy is reduced by 12 years. There is low incidence of severe vaginal or groin pain. Careful patient counselling on long-term outcomes is required. The Retropubic tape appears to be an effective treatment for the majority of women with SUI.

TWEETABLE ABSTRACT

Retropubic tape has superior efficacy to transobturator tape. Complications are comparable with low rates.

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study

BACKGROUND

There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making.

OBJECTIVE

This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling.

STUDY DESIGN

A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding.

RESULTS

The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00).

CONCLUSION

This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Basic Evaluation of Urinary Incontinence

Urinary incontinence is a significant, quality of life health condition affecting millions of women. Incontinence is increasingly common as the population ages, and women present with varying degrees of bother. With basic in-office evaluation, most subtypes of urinary incontinence can be defined, evaluated, and treated. Basic in-office evaluation involves a detailed history with a review of current medical problems and medications, a physical examination, and selective in-office testing.

Healthcare professional's choice for surgical management of stress urinary incontinence in a U.K. tertiary hospital

OBJECTIVE

In July 2018, NHS England, introduced a pause on vaginal mesh, including the mid-urethral sling (MUS) for treatment of stress urinary incontinence (SUI). NICE guidelines recommend MUS as one of the surgical options for SUI. The aim of our study was to investigate healthcare professionals choices for surgical treatment of SUI, if conservative measures failed.

STUDY DESIGN

The urogynaecology department at our tertiary level hospital devised a questionnaire using SurveyMonkey. This was distributed via email to 1058 healthcare professionals of different medical backgrounds. The surgical options were based on the NICE guideline and its patient decision making aid. We also used surgical information from the British society of Urogynaecology (BSUG) and British association of urological surgeons (BAUS).

RESULTS

We received 214 responses of which 204 were complete. Twenty six percent of replies were from obstetricians and gynaecologists, 36 % had over 20 years experience and 79 % were female. Forty four percent had no previous knowledge of surgical options. Mid-urethral sling was the most popular choice based on description, success and specific complications. Urethral bulking agent was the only option that increased in popularity after describing complications. Twenty two percent would avoid surgery due to the risk of complications.

CONCLUSION

This is the first study evaluating healthcare professionals surgical choice for SUI. Despite negative media publicity and NHS pause on MUS, it was still the most popular choice before and after informing of specific complications. The urethral bulking agent was the only surgical treatment, which increased in popularity after considering complications.

Do Women Who Self-report More Exercise Have Increased Rates of Symptomatic Stress Urinary Incontinence After Midurethral Slings?

OBJECTIVES

There is a paucity of data on postoperative exercise and how it relates to surgical failure, specifically after midurethral sling (MUS) surgery. We aimed to assess if women with higher self-reported activity levels as measured by strenuous exercise are more likely to experience stress urinary incontinence (SUI) symptoms after MUS than women with lower self-reported activity.

METHODS

This is a secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss: the OPTIMAL Trial, a randomized trial comparing sacrospinous ligament suspension versus uterosacral ligament suspension, both with concomitant retropubic MUS. Participants completed a validated assessment of activity preoperatively and postoperatively. Women in the upper quartile for strenuous exercise (≥90 minutes per week) were compared with the remaining participants. Symptomatic SUI was defined as retreatment or reoperation for SUI and/or any positive response to Pelvic Floor Disorders Inventory stress incontinence questions 20 to 22.

RESULTS

A total of 351 participants in the OPTIMAL study received MUS along with their prolapse repair and had postoperative exercise and Pelvic Floor Disorders Inventory data. At 2 years, 87 (29%) of 305 exercised strenuously for at least 90 minutes per week, and 63 (23%) of 277 experienced SUI. Women who were less active at 2 years were significantly more likely to experience SUI than women who were more active (26.6% vs 12.8%, P = 0.0138).

CONCLUSIONS

In this study, symptomatic SUI occurred more frequently in women with lower self-reported exercise levels 2 years after MUS surgery.

A low cost artisan tension-free tape technique cures pelvic organ prolapse and stress urinary incontinence - proof of concept

INTRODUCTION

The primary cause of pelvic organ prolapse (POP) is weak cardinal/uterosacral (CL/USL) ligaments and for stress urinary incontinence, weak pubourethral ligaments (PUL).

MATERIAL AND METHODS

A 1 cm wide tape cut from a mesh sheet was applied tension-free to reinforce already plicated CL/USLs for cure of prolapse and directly to PUL for cure of stress urinary incontinence (SUI). 40 tapes were inserted, 10 midurethrally for SUI and 30 for 2nd/3rd degree prolapse: 15 to uterosacral ligaments and 15 to cardinal ligaments.

RESULTS

At 12 months follow-up there was 72% cure for POP, 70% for SUI and improvement in urge/nocturia symptoms in 82% of patients.At 36 months 8/15 patients were evaluated. Anatomic cure for POP III was 2/4, for POP I-II 6/6.

CONCLUSIONS

Though a 'proof of concept' study, our results may be sufficient to provide, in time, an alternative individual pathway for surgeons wishing to provide more certainty to a prolapse repair than 'native tissue' for an individual patient. The method questions whether expensive mesh kits are really necessary: our data though small, actually part of a learning curve, was within 15 percentage points of more sophisticated, more expensive tensioned slings. Intraoperative complications were low with no tape erosions seen at 12 months. Further validation with larger prospective and comparative trials is required.

Urethral bulking agent found in a urethral caruncle which did not respond to topical oestrogens: A case report

Background

Urethral caruncles are lesions occurring at the urethral orifice, around the posterior lip of the urethra. They are the most common benign growth of the female urethra. They are often asymptomatic and found incidentally on clinical examination. When symptomatic they commonly present with bleeding. Treatment includes vaginal oestrogens or, failing that, surgical excision. We present an unusual finding after excision of a urethral caruncle.

Case

A patient with a background of stress urinary incontinence had numerous pelvic surgeries, including colposuspension, tension-free vaginal tape (TVT) and Macroplastique (a urethral bulking agent). She developed bleeding from a 3 cm urethral caruncle, which did not improve with vaginal oestrogens. She proceeded to have a surgical excision of the caruncle. Histology revealed a foreign material with surrounding foreign-body-type multinucleate giant cell reaction. The material was compatible with Macroplastique.

Conclusion

This case report describes an unusual and unexpected histological finding. Macroplastique is injected in the urethra, 10–15 mm from the bladder neck. We suspect the caruncle dragged the Macroplastique material out through the urethral meatus. If urethral caruncles are not adequately treated with vaginal oestrogens, surgery should be considered.

•

Urethral caruncles are lesions occurring at the urethral orifice, around the posterior lip of the urethra

•

They are the most common benign growths of the female urethra

•

When symptomatic they commonly present with bleeding.

•

Treatment includes topical oestrogens or failing that, surgical excision.

•

The presence of a urethral bulking agent in a caruncle, which did not respond to topical oestrogen, is reported.

It's not that mesh, is it? What providers should know about the transvaginal mesh controversy

The U.S. Food and Drug Administration recent ban on surgical mesh intended for the transvaginal repair of pelvic organ prolapse has called into question the safety of surgical mesh implants in general. As the media firestorm around vaginal mesh kits has continued to grow, important details about the specific type of mesh involved have been lost in the public discourse surrounding the controversy. This has left healthcare providers across the nation in the difficult position of addressing patient anxieties about the use of mesh in gynecologic surgery. This review seeks to educate women's health providers on the historical background and various uses of the different types of mesh in gynecologic surgery.

Long-term outcomes of transobturator midurethral slings: A critical evaluation of a real-world population

AIMS

The American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction stress urinary incontinence (SUI) guidelines strongly recommend the midurethral sling (MUS) for the index female patient with SUI. While numerous studies report long-term outcomes and complications for the retropubic MUS, these are largely absent for the transobturator MUS and are assessed in this study.

METHODS

This is an Institutional Review Board approved retrospective chart review of all women who underwent a transobturator MUS at a single institution from 2004 to 2010. Pre- and postoperative assessment included a cough-stress test, SEAPI assessment, and validated quality-of-life (QoL) questionnaires. SUI resolution was defined as no subjective or objective SUI, and no additional surgery to achieve stress continence.

RESULTS

Of 437 women, 305 (70%) had a minimum follow-up of 48 months (mean 88; median 92). SUI was resolved in 69% of the entire cohort and 58% of the 78 women who had MUS only. The median time to SUI recurrence was 38 months in the entire cohort and 18 months in the MUS only group. Perioperative complications were infrequent and typically associated with concomitant surgery. A statistically significant improvement was observed in SEAPI scores and all QoL indices postoperatively.

CONCLUSIONS

Long-term resolution of SUI after the transobturator MUS is achieved by 69%, which is commensurate with success rates reported in the literature. Overall, women experience a significant improvement in their QoL after transobturator MUS; however, late recurrences and delayed sequelae may occur. Thus, long-term follow-up is warranted in this population.

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.

Short-, mid-, and long-term incontinence outcomes in women undergoing mid-urethral sling procedures: a retrospective cohort study

INTRODUCTION AND HYPOTHESIS

The primary aim was to compare subjective treatment success among women in short-, mid-, and long-term follow-up after mid-urethral sling (MUS). Symptom severity, condition-specific quality of life (QOL), and patient satisfaction were also examined.

METHODS

Women undergoing a primary MUS between 2001 and 2010 were identified by CPT code. Eligible subjects were mailed the Urogenital Distress Inventory (UDI-6), Pelvic Floor Impact Questionnaire (PFIQ-7), Patient Global Impression of Improvement (PGI-I), and Patient Satisfaction Questionnaire (PSQ). Follow-up intervals were short term (≤ 36 months), mid term (37-70 months), and long term (119-200 months). The primary outcome of treatment success was defined as responses of "not at all" or "somewhat" to both stress urinary incontinence (SUI) subscales on the UDI-6.

RESULTS

Of 896 respondents, 361 were assessed in the short-term (23.3 ± 7.2 months), 251 in the mid-term (49.8 ± 9.1 months), and 284 in the long-term group (147.9 ± 20.6 months). Treatment success was 75.4% in the short-, 62.3% in the mid-, and 67.0% in the long-term groups (p < 0.01). Logistic regression showed women with mid- and long-term follow-up were nearly half as likely as their short-term counterparts to report treatment success (adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] 0.36, 0.74). UDI-6 and PFIQ-7 scores differed significantly among the short-, mid- and long-term groups (p < 0.01). Patient satisfaction was similar, 83.3% in the short-, 76.6% in the mid-, and 78.2% in the long-term follow-up (p = 0.31).

CONCLUSION

Women with short-term follow-up had the highest subjective treatment success rates; mid- and long-term follow-up was lower, but sustained after 3 years. Symptom severity and impact on QOL were lowest in the short-term group. However, high satisfaction was noted across all groups.

Real story behind transvaginal mesh

Much of the debate over the use of transvaginal mesh for incontinence and prolapse has been conducted on social media, in the tabloid press and through a very public Senate inquiry. It has been a very emotionally charged debate with surgeons variously accused of scandalous behavior, financial impropriety, surgical experimentation and misogyny. What really happened, how did we get here and what can we learn from these complex events?

Is electronic follow-up using a mobile phone application after mid-urethral sling placement feasible and efficient?

PURPOSE

To assess and report the feasibility and efficacy of electronic follow-up in patients after mid-urethral sling (MUS) operation.

METHODS

All 235 patients after MUS operation for stress urinary incontinence (SUI) were divided into the WeChat follow-up (WFU) and the outpatient follow-up (OFU) groups. Patients completed electronic or paper-validated questionnaires. Demographic and clinical characteristics, questionnaire scores, loss to follow-up rate, patient satisfaction, and complications were compared and analyzed.

RESULTS

Overall, 189 patients completed the follow-up assessment. The OFU group showed a higher rate of loss to follow-up (25.6% vs. 13.2%, p = 0.016). The mean preoperative International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) scores were 18.22 ± 2.64 and 18.06 ± 2.75 in the WFU and OFU groups, respectively (p = 0.672). The mean postoperative ICIQ-UI SF scores were 3.70 ± 1.65 and 3.86 ± 1.48, respectively (p = 0.489). There were 84.8% of WFU patients and 80% of OFU patients reported "very much better" or "much better" on the Patient Global Impression of Improvement (PGI-I) scale (p = 0.381). Patient satisfaction rate was higher in the WFU group than in the OFU group (87.9% vs. 74.4%, p = 0.018). Seventeen patients reported postoperative complications (9 and 8 patients in the WFU and OFU groups, respectively, p = 0.961).

CONCLUSIONS

It appears that electronic follow-up using a mobile phone application is feasible and efficient for patients after MUS operation, and may be associated with improved rates of satisfaction and retention.

Outcomes of a Staged Midurethral Sling Strategy for Stress Incontinence and Pelvic Organ Prolapse

OBJECTIVE

To evaluate the proportion of women who experienced resolution of stress urinary incontinence (SUI) symptoms after surgery for pelvic organ prolapse (POP) without a concomitant incontinence procedure.

METHODS

We conducted a retrospective observational study of women with preoperative subjective and objective SUI who underwent minimally invasive sacrocolpopexy or uterosacral ligament suspension from 2009 to 2015. We excluded cases with incontinence procedures. The primary outcome was the proportion of women with subjective resolution of SUI postoperatively, defined as the absence of patient reported SUI symptoms during follow-up. Secondary outcomes included the proportion of women who underwent a subsequent staged midurethral sling (MUS) procedure and factors associated with resolution of SUI and staged MUS placement.

RESULTS

Of 93 women, most were white (n=90, 98%) with stage III POP (n=55, 59%). Mean age was 59.5±8.9 years and body mass index 28.7±4.7. Seventy-three patients (78%) underwent minimally invasive sacrocolpopexy, and 20 (22%) underwent uterosacral ligament suspension. Median follow-up was 8.3 months (interquartile range 3.4-26.7). Postoperatively, 28 (30%) patients reported resolution of SUI, and 65 (70%) reported persistent SUI. Of the 93 patients, 47 (51%) were treated for persistent SUI and 34 (37%) underwent a staged MUS procedure. Among the staged MUS procedures, 27 (79%) were placed within 12 months. Median time to staged MUS procedure was 5.5 months (interquartile range 4.2-9.9). After controlling for degree of preoperative SUI bother, obese women were less likely to experience resolution of SUI after prolapse repair (odds ratio 0.28, 95% CI 0.08-0.95). We did not identify any factors that were significantly associated with undergoing a staged MUS procedure on univariate analyses (P>.05).

CONCLUSION

Preoperative SUI resolved in nearly a third of women after prolapse surgery without a concomitant incontinence procedure. In a population typically offered a concomitant MUS procedure at the time of prolapse repair, a staged approach may result in nearly two-thirds fewer patients undergoing MUS procedures. This information may be helpful during preoperative shared decision making.

Women living with a midurethral sling in their 80s: long-term outcomes

INTRODUCTION AND HYPOTHESIS

Surgical outcomes of elderly women who have been treated using midurethral slings could be influenced by confounding factors, such as age-related comorbidities. Aim of this study is to assess elderly patients (>75 years) who underwent a transobturator sling procedure with a follow-up of at least 13 years.

METHODS

This is a prospective follow-up observational study including elderly women of current age ≥ 75 years old who underwent TVT-O placement at least 13 years prior to the study period. Main outcome measures were the objective and subjective cure rates at the follow-up visit. Secondary outcome measures included: patient-reported success rate, de novo urgency symptoms rate, evaluation of other subjective parameters related to the lower urinary tract function, and assessment of the health-related quality of life.

RESULTS

Seventy-two out of 85 women (84.7%) meeting the inclusion and exclusion criteria were assessed at the follow-up visit. The mean follow-up period was 13.7 years (SD = 0.8). The overall objective and subjective cure rates were 80.5% (58 out of 72) and 84.7% (61 out of 72) respectively, whereas 9.7% of the patients (7 out of 72) reported being subjectively improved. The patient-reported success rate was 91.7% (66 out of 72). De novo urgency rate was 23.7% (9 out of 38), whereas 26.5% of the patients (9 out of 34) reported aggravation of preexisting urgency.

CONCLUSIONS

In women of advanced age, the TVT-O procedure is a highly effective and long-lasting treatment. The safety profile of the TVT-O was not influenced by geriatric conditions, whereas the long-term presence of a polypropylene sling did not appear to trigger the onset of medical disorders.

Surgeon volume and reoperation risk after midurethral sling surgery

BACKGROUND

Emerging research supports that fewer complications occur in patients who undergo surgery by higher surgical volume surgeons. The midurethral sling surgery has been involved in recent warnings and litigation, which further supports a need to understand features that enhance its safety and efficacy.

OBJECTIVE

The purpose of this study was to measure the impact of a surgeon's volume on their patient's rate of reoperation after midurethral sling surgery.

STUDY DESIGN

This was a retrospective cohort study that evaluated all surgeons who performed synthetic mesh midurethral sling surgery for stress urinary incontinence at a large managed care organization with >4.5 million members from 2005-2016. Physicians Current Procedural Terminology and International Classification of Diseases, version 9/10, codes were used to identify the procedures and the reoperations that were performed. The system-wide medical record was queried for demographic and perioperative data. The primary outcome was the overall reoperation rate after midurethral sling surgery. Concentration curves were used to identify the impact of a surgeon's surgical volume on their rate of reoperation. Demographics, characteristics, and reoperation of patients were compared with the use of chi-square test for categoric variables and Wilcoxon rank sum test for continuous variables. Poisson regression models with a robust error variance were used to calculate the unadjusted and the adjusted risk ratios of reoperation with the use of age, body mass index, marital status, race, parity, vaginal estrogen use, sling type, smoking, diabetes mellitus, and menopausal status as covariates.

RESULTS

Two hundred twenty-seven surgeons performed 13,404 midurethral sling surgeries over the study period; patients had a mean of 4.4 years of follow up. Higher-volume surgeons (>40 procedures/year, ≥95th percentile) performed 47% of the surgeries in this cohort and had an overall lower rate of reoperation (3.6% vs 4.2%; 95% confidence interval, 0.67-0.94; P=.04) compared with lower-volume surgeons. Higher-volume surgeons had a lower rate of reoperation for surgical failure (2.7% vs 3.6%; 95% confidence interval, 0.55-0.92; P<.01). Rates of reoperation for complications were similar between the 2 groups (1.1% vs 0.9%; 95% confidence interval, 0.82-1.13; P=.32). For patients whose condition required a reoperation secondary to complication, the rates of reoperation for urinary retention (0.9% vs 0.6%; P=.06), mesh exposure (0.2% vs 0.3%; P=.31), hemorrhage/bleeding (0.1% vs 0.0%; P=.11), pain (0.1% vs 0.1%; P=.52), and infection (0.0% vs 0.0%; P=.37) did not differ between higher- and lower-volume surgeons. The risk ratio for reoperation that compared higher- and lower-volume surgeons was 0.83 (95% confidence interval, 0.67-0.98; P=.01) in the adjusted model.

CONCLUSION

Although the reoperation rates were low for both higher- and lower-volume surgeons, higher-volume surgeons had lower overall rates of reoperation after midurethral sling surgery. This effect is seen most dramatically in reoperation for surgical failure, in which patients who have surgery with a higher-volume surgeon are 25% less likely to have postoperative stress urinary incontinence that leads to reoperation.