Transobturator tape versus retropubic tension-free vaginal tape for stress urinary incontinence: 5-year safety and effectiveness outcomes following a randomised trial

Midurethral Sling Mesh Exposure Confers a High Risk of Persistent Stress Urinary Incontinence

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the relationship between mesh exposure and persistent stress urinary incontinence (SUI) post-midurethral sling (MUS) surgery.

METHODS

Extensive data collection including patient demographics, obstetric history, existing medical conditions, previous surgeries, and surgical outcomes, encompassing both perioperative and postoperative complications.

RESULTS

Out of 456 patients who underwent the MUS procedure within the specified period, the persistence of SUI was noted in 6.4% of cases. Mesh exposure was observed in 8.8% of these cases. Notably, 25% of patients with mesh exposure suffered from persistent SUI, in stark contrast to 4.6% of those without mesh exposure (p < 0.0001). Further, multivariate analysis indicated that patients with mesh exposure had an approximately 6.5-fold increased likelihood (95% CI: 2.71-15.44) of experiencing persistent SUI compared with those without mesh exposure.

CONCLUSIONS

Mesh exposure is a significant independent risk factor for persistent SUI post-MUS surgery. Patients with mesh exposure are about 6.5 times more prone to persistent SUI than those without. Although mesh exposure is typically managed with expectant measures, vaginal estrogen or mesh excision, current evidence does not support surgical revision of MUS affected by mesh exposure or additional incontinence procedures during mesh excision.

Sonography as a Diagnostic Tool in Midurethral Sling Complications: A Narrative Review

Despite the established safety and efficacy of midurethral slings (MUS), which are the current gold standard treatment for stress urinary incontinence (SUI), the potential for postoperative complications remains a significant concern for both healthcare professionals and patients. Meanwhile, sonography has emerged as a significant diagnostic tool in urogynecology, and one of the applications of this imaging modality may be the evaluation of complications arising from MUS procedures. This review, based on a comprehensive literature search, focuses on the use of pelvic floor ultrasound (US) in the context of MUS complications. It includes analyses of randomized controlled trials, prospective, and retrospective studies, covering preoperative and postoperative investigations, to assess complications such as persistent and recurrent SUI, urinary retention and obstructive voiding, de novo urgency/overactive bladder, vaginal exposure, sling erosion, pain, and hematoma. The review critically examines the existing literature, with a particular focus on recent publications. Despite the variability in findings, it appears that for each of the discussed complications, the application of pelvic floor US can significantly support the diagnostic and therapeutic process. The paper also identifies potential future directions for the development of US applications in diagnosing MUS complications.

Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register

BACKGROUND

Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them.

OBJECTIVE

This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence.

STUDY DESIGN

This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery.

RESULTS

A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence.

CONCLUSION

The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

Long-term outcomes of surgical interventions for stress urinary incontinence: a systematic review and network meta-analysis

BACKGROUND

Stress urinary incontinence is common among women, and surgical interventions have significantly improved patients' symptoms. The long-term effectiveness of these surgeries is increasingly drawing attention, yet it remains sparsely documented in the literature.

OBJECTIVE

To compare the long-term effectiveness and safety of retropubic tension-free vaginal tape (TVT-RP), tension-free vaginal tape-obturator (TVT-O), transobturator tape (TOT), single-incision sling (SIS), Burch colposuspension, and pubovaginal sling (PVS).

METHODS

A comprehensive and systematic literature review was conducted in PubMed, EMBASE, MEDLINE, Cochrane Library, Medicine, and clinicaltrials.gov from inception to May 2023. Selected trials were evaluated for potential bias using the Cochrane tool. Treatment modalities were compared using network meta-analysis to assess objective success rate, subjective success rate, and complications as outcomes.

RESULTS

A total of 37 studies involving 5720 patients were included. No significant statistical differences were found among the interventions regarding objective success rate. PVS had the highest surface under the cumulative ranking curve SUCRA value (93.1). For subjective success rate, TVT-RP, TVT-O, and PVS demonstrated superiority over SIS, with PVS having the highest SUCRA value (80.1). SIS had lower overall complication and pain rates compared to other methods, with statistical significance. There were no differences in reoperation rate, exposure rate, and urinary tract infection occurrence among the surgical approaches.

CONCLUSIONS

In terms of long-term effectiveness and safety, TVT-RP and TVT-O appear to be the preferred options for patients opting for synthetic slings, while for patients seeking nonsynthetic slings, PVS may represent the optimal choice.

Risk factors for stress urinary incontinence recurrence after midurethral sling revision

OBJECTIVES

The purpose of this study was to report the rate of stress urinary incontinence (SUI) recurrence after sling revision, and to determine predictive factors of SUI recurrence.

METHODS

We conducted a retrospective cohort study in a single academic center between 2005 and 2022, of patients who underwent sling revision. Four surgical techniques were used for sling revision (loosening, section, partial, and total excision). The primary endpoint was recurrence of SUI at 3 months postoperatively, and the other outcome of interest was the rate of subsequent anti-incontinence surgical procedure.

RESULTS

Sixty-nine patients were included for analysis. SUI recurred in 46.4% of patients. Fifteen patients underwent a subsequent anti-incontinence procedure (21.8%). The time to revision was significantly longer in the group with recurrent SUI (median: 84.5 vs. 44.8 months; p = 0.004). The recurrence rate differed significantly depending on the revision technique: 7.7% after sling loosening, 22.2% after sling section, 60% after partial excision, and 66.7% after complete sling removal (p = 0.001). The risk of SUI recurrence was lower for those whose indication of reoperation was voiding dysfunction (27.3% vs. 66.7%; p = 0.002), and was higher for those who underwent a trans-obturator tap rather than a tension-free vaginal tape revision (68.4% vs. 35.7%; p = 0.02). In multivariate analysis, only the revision technique remained significantly associated with the risk of recurrence of SUI (complete excision vs. section: odds ratio = 4.66; p = 0.04).

CONCLUSION

The risk of SUI recurrence may differ widely according to the techniques used, and it seems that the less extensive the surgical procedure is, the lower the risk is.

Long-term Safety of Synthetic Midurethral Sling Implantation for the Treatment of Stress Urinary Incontinence in Adult Women: A Systematic Review

Context

Midurethral slings (MUSs) are the most used therapy for the treatment of stress urinary incontinence (SUI). While warning signals about potential complications have been raised worldwide, there is a lack of safety data especially in the long term.

Objective

Our objective was to evaluate synthetic MUS safety outcomes at long term in adult women.

Evidence acquisition

We included all studies evaluating MUSs in adult women with SUI. All synthetic MUSs have been considered: tension-free vaginal tape (TVT), transobturator tape (TOT), and mini-slings. The primary outcome was the reoperation rate at 5 yr.

Evidence synthesis

Of 5586 references screened after duplicate removal, 44 studies (8218 patients) were included. Among these, nine were randomized controlled trials and 35 were cohort studies. The overall reoperation rates at 5 yr varied between 0% and 19% for TOT (11 studies), 0% and 13% for TVT (17 studies), and 0% and 19% for mini-slings (two studies). The overall reoperation rates at 10 yr varied between 5% and 15% for TOT (four studies) and between 2% and 17% for TVT (four studies). There were few safety data beyond 5 yr: 22.7% of the articles reported a follow-up at ≥10 yr and 2.3% at ≥15 yr.

Conclusions

The incidence rates of reoperations and complications are heterogeneous, and data beyond 5 yr are rare.

Patient summary

There is an urgent need to improve safety monitoring of mesh as our review highlights that available safety data are heterogeneous and of insufficient quality to guide the decision.

Clinical Outcomes of Mid-Urethral Sling (MUS) Procedures for the Treatment of Female Urinary Incontinence: A Multicenter Study

Introduction: Stress urinary incontinence (SUI) has a significant impact on the quality of life of many women. Due to embarrassment, most women do not seek medical attention for this condition. The treatment of this problem includes preventive therapies, and in the more advanced stage of urinary incontinence, surgery is a solution. Despite doubts regarding the implantation of urological tapes, the use of tension-free minimally invasive methods constitutes the “gold standard” in the treatment of stress urinary incontinence in women. Objective: The purpose of this article was to evaluate the efficacy and safety of ultralight, polypropylene urogynecological tape (Dallop® NM ULTRALIGHT, Tricomed S.A., Poland) in the surgical treatment of female stress urinary incontinence and mixed urinary incontinence. Methods: This is a multicenter, retrospective cohort study. The included women were adults with stress urinary incontinence (Grade 2 with a positive cough test or Grade 3) or had mixed urinary incontinence and who had undergone “retropubic” or “transobturator” surgery and completed a postoperative follow-up. Results: The study included 68 women from three hospitals. All women completed <6-month and >6-month follow-ups. The median age was 55 (range 36−80). The average value of BMI in the “retropubic” group was 28.6 ± 5.58, and in the “transobturator” group, it was 26.1 ± 4.60. Sixty-three percent (63%, n = 43) of patients were operated on using the “transobturator” method, while thirty-seven percent (37%, n = 25) were operated on using the “retropubic” method. Both the “retropubic” and “transobturator” groups had comparable results in the treatment of SUI. The study showed efficiencies of 84% for the “transobturator” method and 80% for the “retropubic” method. In the “retropubic” group, intraoperative complications were reported in three patients (7%), in comparison to none in the “transobturator” group. There were no tape-related adverse events or infections reported in any case. Conclusions: The presented research confirms the safety and efficacy of retropubic and transobturator tape methods in both short- and long-term follow-up—the success rate was over 80%. In addition to the surgical method used, the experience of the surgeons also has an impact on the final outcome of the surgery. The conducted multi-center study offers the opportunity to eliminate the influence of the human factor on the effectiveness of the procedure.

The practice of Burch Colposuspension versus Mid Urethral Slings for the treatment of Stress Urinary Incontinence in developing country

OBJECTIVES

To compare the effectiveness and complications of Burch colposuspension and Mid Urethral Slings (MUS) for the treatment of Stress Urinary Incontinence (SUI).

METHODS

We conducted a cross-sectional study of 162 patients who underwent surgery for SUI with Burch colposuspension (n=40), tension free vaginal tape (TVT) (n= 59) or transobturator tape (TOT) (n=63), from 2006 to 2014 at the Aga Khan University Hospital- Karachi. All three groups were assessed in terms of demographics, cure rates, intraoperative and postoperative complications at one and five years using incontinence impact questionnaire-short form-7 (IIQ-7) and urogenital distress inventory -short form-6 (UDI-6).

RESULTS

Mean age of the participants in Burch, TVT and TOT group was 44.1 ± 7.4, 48.3 ± 8.9, 53.0 ± 9.4 respectively. Majority of patients in TVT group were premenopausal (59.3%) and postmenopausal in TOT group (53.9%). Most abdominal hysterectomies were done in Burch group (40) while vaginal hysterectomies and anterior and posterior colporrhaphy in TOT group (55). All the procedures had both subjective and objective cure rate of more than 82% at one year, with TVT having the highest success rate of 96.61%. The objective cure rate in Burch, TVT and TOT group at five years was 74.19%, 90.30% and 81.25% respectively. Intraoperative complications included hemorrhage in one patient during Burch procedure and bladder perforation in two cases of TVT, with no significant difference in short or long-term complications with either procedure.

CONCLUSIONS

All the three procedures have equal efficacy and complication rates. Even though TVT is the new gold standard but in view of current debate regarding mesh related complications, there is a need to readdress Burch colposuspension for treatment of SUI.

Focusing on long-term complications of mid-urethral slings among women with stress urinary incontinence as a patient safety improvement measure: A protocol for systematic review and meta-analysis

BACKGROUND

There are 3 different types of mid-urethral sling, retropubic, transobturator and single incision performed for women with stress urinary incontinence. Prior studies comparing these three surgeries merely focused on the successful rate or efficacy. But nevertheless, what is more clinically important dwells upon investigating postoperative complications as a safety improvement measure.

METHODS

A systematic review via PubMed, Ovid, and the Cochrane Database of Systematic Review and studies were applied based on the contents with clearly identified complications. Selected articles were reviewed in scrutiny by 2 individuals to ascertain whether they fulfilled the inclusion criteria: complications measures were clearly defined; data were extracted on study design, perioperative complications, postoperative lower urinary tract symptoms, postoperative pain, dyspareunia, and other specified late complications.

RESULTS

A total of 55 studies were included in the systemic review. Perioperative complications encompassed bladder perforation, vaginal injury, hemorrhage, hematoma, urinary tract infection. There were postoperative lower urinary tract symptoms including urine retention and de novo urgency. Furthermore, postoperative pain, tape erosion/ extrusion, further stress urinary incontinence surgery, and rarely, deep vein thrombosis and injury of inferior epigastric vessels were also reported.

CONCLUSIONS

Complications of mid-urethral sling are higher than previously thought and it is important to follow up on their long-term outcomes; future research should not neglect to address this issue as a means to improve patient safety.

Effect of surgeon volume on long-term quality of life outcomes following tension-free vaginal tape surgery

INTRODUCTION AND HYPOTHESIS

The role of the general obstetrician/gynaecologist completing routine urogynaecology procedures is controversial, and some research has suggested that these patients should be referred to high-volume subspecialists. In response to recent public and regulatory scrutiny of vaginal mesh procedures, credentialling guidelines have been released in Australia requiring surgeons to demonstrate a minimum caseload prior to performing tension-free vaginal tape (TVT) surgery for incontinence. Hence, a retrospective cohort study was conducted to evaluate the long-term quality of life outcomes of TVT procedures for high- and low-volume surgeons.

METHODS

One hundred seventy patients who had undergone TVT surgery between 1 May 2011 and 1 May 2016 in the Sunshine Coast health district were invited to complete the UDI-6 (Urinary Distress Inventory) and IIQ-7 (Incontinence Impact Questionnaire) surveys. Perioperative information was accessed from available health records. Mean UDI-6 and IIQ-7 scores were compared for high- and low-volume groups, and the groups were assessed for confounding factors.

RESULTS

Of the 170 patients eligible, 83 completed the surveys (47.2%). No differences in UDI-6 or IIQ-7 scores were found between high- and low-volume surgeons (p > 0.05). High-volume surgeons completed more concomitant procedures amongst survey respondents (p < 0.05), though this was not reproduced when considering all 170 patients eligible for the study. There were no significant differences in age, ASA (American Society of Anaesthesiologists) score or complication rate amongst survey respondents.

CONCLUSIONS

Amongst the patients surveyed, high- and low-volume surgeons had similar long-term quality of life outcomes for TVT surgery, without any significant difference in complication rate.

Is There Outcome Reporting Heterogeneity in Trials That Aim to Assess the Effectiveness of Surgical Treatments for Stress Urinary Incontinence in Women?

CONTEXT

Inconsistent reporting of effectiveness outcomes in surgical trials of stress urinary incontinence (SUI) has hindered direct comparisons of various surgical treatments for SUI.

OBJECTIVE

To systematically review the verbatim outcome names, outcome definitions, and tools used to measure the outcomes in surgical trials of SUI in women.

EVIDENCE ACQUISITION

Trials of women with SUI who have undergone surgical interventions were included. We conducted a systematic review (SR) on outcomes reported in randomized controlled trials of surgical management published in 2014-2019, covering the following databases: MEDLINE, EMBASE, CENTRAL, and CDSR. Verbatim outcome names extracted from the included studies were categorized and then grouped into domains using the Williamson-Clarke (W/C) outcome taxonomy. A matrix was also created to visualize and quantify the dimensions of outcome reporting heterogeneity in SUI trials.

EVIDENCE SYNTHESIS

A total of 844 verbatim outcome names were extracted, of which, 514 varied terms were reduced to 71 standardized outcome names. They were further categorized into 11 domains from the W/C taxonomy. There were 7.24 different terms on average to describe each outcome, and the four outcomes with the most heterogeneity evident in terms used to describe them were "urinary retention", "reoperation", "subjective cure rate" and "quality of life". Each of them had ≥20 different terms. Only 28% of the outcome definitions were reported and a variety of measuring tools was noted, particularly in subjective outcomes. High heterogeneity was found in the outcome names, outcome definitions, choice and number of measuring instruments of the outcomes, and choice and number of outcomes reported across studies.

CONCLUSIONS

This SR provides objective evidence of heterogeneity in outcome reporting in SUI surgical trials. Our categorization of outcomes highlights the difficulties in summarizing the current evidence base. A core outcome set, developed using the methods advocated by the Core Outcome Measures in Effectiveness Trials (COMET) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) initiatives, is required.

PATIENT SUMMARY

In this research, we have highlighted the diversity in outcomes reporting in stress urinary incontinence (SUI) surgical trials and have categorized the outcomes. We support the development of a core outcome set for SUI, which will promote future clinical researchers to measure the same outcome in the same way in all trials. This will, in turn, help researchers summarize the evidence more effectively and aid decision making for patients and doctors.

Evaluation of the Effect of Surgeon's Operative Volume and Specialty on Likelihood of Revision After Mesh Midurethral Sling Placement

One in 20 women undergo midurethral sling revision within 10 years, and annual operative volume of the inserting surgeon is a risk factor.

OBJECTIVE:

To estimate rates of revision surgery after insertion of mesh midurethral slings and explore whether physician specialty, annual operative volume, or hospital type are associated with this outcome.

METHODS:

A population-based retrospective cohort of women undergoing midurethral sling procedures over a 13-year interval (2004–2017) in Alberta, Canada was created using administrative health data. The primary outcome was subsequent surgery for revision of midurethral sling, defined by a composite of surgical procedures. Exposures included annual number of midurethral sling procedures performed by the surgeon, surgeon specialty, facility type, patient age, and concomitant prolapse repair. Mixed effects logistic regression using linear spines was used to test a-priori hypothesis that annual surgical volume would be inversely related in a nonlinear fashion to risk of revision.

RESULTS:

In the cohort of 19,511 women, cumulative rates of revision surgery were 3.84% (95% CI 3.54–4.17) at 5 years and 5.26% (95% CI 4.82–5.74) at 10 years. The first year after midurethral sling placement was the most vulnerable window, with 0.40% (95% CI 0.31–0.49) undergoing revision within 30 days and 2.15% (95% CI 1.95–3.52) within 1 year. Concomitant prolapse repairs (odds ratio [OR] 1.24, 95% CI 1.04–1.48) and surgeon's annual volume were associated with revision. After 50 cases per year, odds of revision declined with each additional case (OR 0.99/case, 95% CI 0.98–0.99, OR 0.91/10 cases, 95% CI 0.84–0.98) and plateaued at 110 cases per year. Surgeon specialty, hospital type, and patient age were not associated with outcome.

CONCLUSION:

One in 20 women undergo revision surgery within 10 years after midurethral sling placement. Higher physician surgical volume is associated with decreased risk, with the decline occurring at a threshold of 50 cases annually. Minimum caseload parameters for surgeons performing midurethral sling procedures may improve quality of these procedures.

Do we need better information to advise women with stress incontinence on their choice of surgery? Report from the ICI-RS 2018

AIMS

The regulatory warnings about the safety of the synthetic midurethral slings (MUS) had a significant effect on how patients and physicians approach surgical management of stress urinary incontinence (SUI). In this changing landscape, the purpose of this research Think Tank (TT) was to provide an update of the current knowledge about the safety and efficacy of SUI surgery, to review patient goals and expectations and to identify factors affecting the decision making for surgery.

METHODS

This is a consensus report of the proceedings of TT3: "Do we need better information to advise women with stress incontinence on their choice of surgery?" from the annual International Consultation on Incontinence-Research Society (ICI-RS), June 2018.

RESULTS

Despite the body of evidence supporting the continued use of MUS, the short follow-up of most of the studies and the lack of "real life" data regarding pain and sexual dysfunction make the development of recommendations challenging. Women with SUI are often happy to "trade" efficacy for a procedure with less associated morbidity and therefore it is not always the procedure with the highest success rate that is ultimately chosen. However, a number of factors influence treatment decision and there is limited evidence about what level of all these factors women are willing to tolerate for a given success rate, or how much success they are willing to trade for a lower complication rate.

CONCLUSIONS

The ICI-RS proposed research questions which may be able to assist in improving the counseling and management of women with SUI.

Management of vaginal mesh exposure: A systematic review

Objectives: To identify various predisposing factors, the clinical presentation, and the management of vaginal mesh-related complications, with special emphasis on mesh exposure and the indications for and results of vaginal mesh removal.

Methods: A systematic literature review was performed using a search strategy based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. PubMed was queried for studies regarding aetiology, risk factors, and management of vaginal mesh exposure from 1 January 2008 to June 2018. Full-text articles were obtained for eligible abstracts. Relevant articles were included, and the cited references were used to identify relevant articles not previously included.

Results: A total of 102 abstracts were identified from the PubMed search criteria. An additional 45 studies were identified based on review of the cited references. After applying eligibility criteria and excluding impertinent articles, 58 studies were included in the final analysis.

Conclusion: Numerous studies have found at least some degree of symptomatic improvement regardless of the amount of mesh removed. Focal areas of exposure or pain can be successfully managed with partial mesh removal with low rates of complications. With partial mesh removal, many patients will ultimately require subsequent mesh removal procedures. For this reason, complete mesh excision is an alternative for patients with diffuse vaginal pain, large mesh exposure, and extrusion of mesh into adjacent viscera. However, when considering complete mesh removal, it is important to counsel patients regarding possible complications of removal and the increased risk of recurrent stress urinary incontinence and pelvic organ prolapse postoperatively.

Abbreviations: MUS: midurethral sling; OR: odds ratio; POP: pelvic organ prolapse; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analyses; SUI: stress urinary incontinence; TOT: transobturator; TVT: tension-free vaginal tape

Management of complications arising from the use of mesh for stress urinary incontinence-International Urogynecology Association Research and Development Committee opinion

INTRODUCTION AND HYPOTHESIS

Management of pain or mesh exposure complications after stress incontinence surgery has become a new issue over the last 20 years with the introduction of mesh techniques to treat stress incontinence. There is much debate regarding the incidence of complications and how best to treat them.

METHODS

A working subcommittee from the International Urogynecology Association (IUGA) Research and Development (R&D) Committee was formed. An initial document was drafted based on a literature review. The review focused on complications of vaginal mesh inserted for stress incontinence. After evaluation by the entire IUGA R&D Committee revisions were made. The final document represents the IUGA R&D Committee Opinion.

RESULTS

The R&D Committee Opinion reviews the literature on the management of complications arising from the use of mesh for stress urinary incontinence. The review concentrated on the assessment and treatment of pain and exposure.

CONCLUSIONS

Complications after surgery for stress incontinence using mesh may not be common occurrences for individual surgeons. Complications may be difficult to manage and outcomes are variable. Specialist centres and a multidisciplinary approach may optimise treatment and reporting of outcomes.

Ultrasonographic Assessment with Three-Dimensional Mode of the Urethral Compression Effect following Sling Surgery with and without Mesh Surgery

Background

The aim of this study was to assess anatomical changes in the urethra at rest and during straining following sling surgery with and without transvaginal mesh surgery (TVM) in women with stress urinary incontinence (SUI) with or without pelvic organ prolapse (POP) using three-dimensional ultrasonography.

Methods

76 women with SUI with or without pelvic organ prolapse after sling surgery. They underwent sling surgery alone (S group, n=36) or concomitant TVM (M group, n=40). All patients underwent urinalysis, pelvic examinations, urodynamic study, 3D perineal ultrasonography, and personal interviews before and 1 year after surgery. The urethral area was calculated from the axial plane of perineal ultrasonography by multiplying π by the long and short axes of the urethral lumen.

Results

The axial area of the middle and distal urethra during straining was significantly smaller than at rest in both groups (P<0.001). In addition, the length of the short axis of the proximal urethra was significantly shorter in those undergoing sling surgery alone during straining compared with those undergoing concomitant sling and mesh surgery (P<0.001).

Conclusions

There was a greater impact on the proximal urethra in women who underwent sling surgery alone than those who underwent sling and TVM surgery together.

TVT versus TOT in the treatment of female stress urinary incontinence: a systematic review and meta-analysis

BACKGROUND

To evaluate the evidence available on the effects and safety of tension-free vaginal tape (TVT) versus transobturator tape (TOT) for female stress urinary incontinence therapy based on randomized controlled trials (RCTs).

METHODS

PubMed, Cochrane, Embase, Wanfang, China National Knowledge Infrastructure, and Weipu database were searched up to July 2017 to identify relevant studies, including qualified RCT and quite-RCT and literature sources. Relative risks (RRs), mean difference (MD), and 95% CI were calculated in our review.

RESULT

Twenty-eight RCTs were involved in the meta-analysis with 2,505 patients in the TVT group and 2,477 patients in the TOT group. The aggregated results indicated that TOT significantly decreased the operative time (MD, -1.27; 95% CI: -1.77 to -0.76) and hospital stay (MD, -0.62; 95% CI: -1.08 to -0.17) when compared with TVT. Besides, the complications (RR, 0.86; 95% CI: 0.64-1.16) and blood loss (MD, -0.29; 95% CI: -0.71 to 0.14) were decreased in TOT but with no statistical significance; the change of VAS score (MD, 0.07; 95% CI: -0.05 to 0.19), IIQ-7 score (MD, 0.06; 95% CI: -0.03 to 0.15), and UDI-6 score (MD, 0.15; 95% CI: -0.19 to 0.48) were larger in TOT group than in TVT group, but still, with no statistical significance. However, there was no significant difference of cure rate (RR, 1.00; 95% CI: 0.96-1.04) and satisfied rate (RR, 1.00; 95% CI: 0.96-1.04) between the 2 groups.

CONCLUSION

TOT may have more valid effects than TVT in operative time and hospital stay. Besides, TOT method showed fewer complications and blood loss than TVT, but there was no significant difference between them. The scores of VAS, incontinence impact questionnaire short form-7 (IIQ-7), and urogenital distress inventory short form-6 (UDI-6) were higher in TOT than TVT, but still no significant difference was observed. However, more studies with higher quality and larger sample size that are multicentric and have longer follow-up in the form of RCTs are warranted to confirm the current findings.

Management of stress urinary incontinence in spinal cord injured female patients with a mid-urethral tape - a single center experience

Context/Objective Stress urinary incontinence (SUI) affects the quality of life of females with spinal cord injury (SCI), has a negative impact on functional independence and disturbs their psychosocial interaction. Our aim was to assess the efficacy of mid-urethral tapes (MUT) in managing stress urinary incontinence in this population. Design Retrospective cohort study. Participants SCI females with upper motor neuron lesion and urodynamically proven stress or mixed urinary incontinence that was treated with a mid-urethral tape and followed up for at least 12 months. Interventions Mid-urethral tapes such TVT, TOT and mini-Arc. Patient reported outcomes based on the daily use of pads and ICIQ modular questionnaire scores. Outcome measures The primary endpoint was defined as the success rate of MUT surgery in managing stress incontinence at 12. The secondary endpoints included the improvement rate at 12 months, the complication rates and the need for additional treatments. Results 38 females were studied. At 12 months the overall patient reported success rate was 52.6%. 16% reported significant improvement. 68.4% felt the quality of life to improve. Nine patients develop tape related complications (five de novo urgency, one vaginal extrusion, one frequent dysreflexia and one worsening of incontinence). Conclusion Mid-urethral tapes are effective in the management of stress urinary incontinence in female patients with spinal cord injury. There are demonstrable improvements in both continence and quality of life.

TVT Abbrevo and Miniarc suburethral sling in women with stress urinary incontinence - A randomised controlled trial

INTRODUCTION

Single incision slings (SIS) were introduced in an attempt to decrease the complications associated with retropubic and transobturator slings. The TVT Abbrevo is a modification of the TVT-O with a reduced length and less immediate postoperative pain. The Miniarc SIS has been shown to be equivalent to outside-in transobturator sling, Monarc at 12 month follow-up.

OBJECTIVE

To evaluate objective and subjective outcomes of MiniArc SIS and TVT Abbrevo midurethral sling (MUS) in women with stress urinary incontinence.

METHODS

Female subjects who were assessed and referred for stress urinary incontinence surgery were eligible to participate in this study. Exclusion criteria included women with intrinsic sphincter deficiency previous failed midurethral or fascial sling, untreated detrusor overactivity or significant voiding dysfunction. Patients' randomisation was performed with computer-generated blocks of 4-8, with concealed allocation. Assuming an objective cure rate of 90% for TVT AbbrevoTMwith a power of 80%, a sample size of 79 in each arm was required to detect a clinical difference of 15%, using a one sided alpha of 0.05. The target recruitment number was 220 allowing for an attrition rate of 15%. Institution ethics approval (11261B) was obtained and the trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611001151921). Routine preoperative assessment was conducted for objective data, whilst patient reported outcome tools (PRO) were utilised for subjective outcomes. These include ICIQ UI SF, ICIQ OAB, IIQ7, EQ5D, PISQ12, PGIs & PGII. TVT AbbrevoTM or MiniarcTMwere performed in a standardized fashion, together with any concomitant prolapse surgery. Review was conducted at 6 weeks and at 6 and 12 months. Objective cure was defined as a negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with physical exertion. All Data was collected and outcomes were analysed statistically.

RESULTS

Between February 2011 and January 2016,a total of 246 women were randomized to receive MiniArc (121) or TVT Abbrevo (125). Baseline characteristics were clinically balanced in both groups. At 6 months subjective (94.4% vs 95.7% p=0.74) and Objective (92.9% vs 95.9% p=0.49) cure rates were high and not statistically different. At 12 months there were also no differences in subjective (73.6% vs 76.9% p=0.73) or objective (90.5% vs 96.0% p=0.21) cure rates. No differences were found in functional outcomes or when adjusted for potential confounding factors such as age, parity, BMI or menopausal status.

CONCLUSION

We found no significant differences in subjective and objective cure rates at 6 and 12months between MiniArc and TVT Abbrevo.

Updated Systematic Review and Meta-analysis of the Comparative Data on Colposuspensions, Pubovaginal Slings, and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence

CONTEXT

Retropubic (RP-TVT) and transobturator miurethral (TO-TVT) midurethral sling (MUS) are popular surgical treatments for female stress urinary incontinence. The long-term efficacy and safety of the procedures is still a topic of intense clinical research and several randomised controlled trials (RCTs) have been published in the last years OBJECTIVE: To evaluate the efficacy and safety of MUS compared with other surgical treatments for female stress urinary incontinence.

EVIDENCE ACQUISITION

A systematic review and meta-analysis of the literature was performed using the Medline, Scopus, and Web of Science databases to update our previously published analyses.

EVIDENCE SYNTHESIS

Twenty-eight RCTs were identified. In total, the meta-analyses included 15 855 patients. Patients receiving MUS had significantly higher overall (odds ratio [OR]: 0.59, p=0.0003) and objective (OR: 0.51, p=0.001) cure rates than those receiving Burch colposuspension. Patients undergoing MUS and pubovaginal slings had similar cure rates. Patients treated with RT-TVT had higher subjective (OR: 0.83, p=0.03) and objective (OR: 0.82, p=0.01) cure rates than those receiving TO-TVT. However, the latter had a lower risk of intraoperative bladder or vaginal perforation (OR: 2.4, p=0.0002), pelvic haematoma (OR: 2.61, p=0.002), urinary tract infections (OR: 1.31, p=0.04) and voiding lower urinary tract symptoms (OR: 1.66, p=0.002). Sensitivity analyses limited to RCTs with follow-up durations >60 mo demonstrated similar outcomes for RP-TVT and TO-TVT. No significant differences in efficacy were identified comparing inside-to-out and outside-to-in TO-TVT but vaginal perforations were less common with the former (OR: 0.21, p=0.0002).

CONCLUSIONS

The present analysis confirms the superiority of MUS over Burch colposuspension. The studies comparing insertion of RT-TVT and TO-TVT showed higher subjective and objective cure rates for the RP-TVT but at the cost of higher risks of some complications and voiding lower urinary tract symptoms. Efficacy of inside-out and outside-in techniques of TO-TVT insertion was similar, although the risk of vaginal perforation was lower in the inside-to-out TO-TVT.

PATIENT SUMMARY

Retropubic and transobturator midurethral slings are a popular treatment for female stress urinary incontinence. The available literature suggest that those slings are either more effective or safer than other older surgical procedures. Retropubic tapes are followed with slightly higher continence rates as compared with the transobturator tapes but are associated with higher risk of intra- and postoperative complications.

The Risk of Recurrent Urinary Incontinence Requiring Surgery After Suburethral Sling Removal for Mesh Complications

OBJECTIVE

We sought to examine the risk of recurrent stress urinary incontinence (SUI) after suburethral sling mesh removal or excision.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients who were continent before removal or excision of synthetic midurethral slings; this cohort of 278 subjects was much larger than seen in previous such studies. Patients with preoperative incontinence, additional vaginal mesh placements, prior mesh revision/excision, existing SUI, and prior pelvic radiation or fistula were excluded. Only patients with follow-up detailing continence status within 1 year of mesh removal were examined.

RESULTS

Of 278 patients, 117 (70 retropubic and 47 transobturator) midurethral sling removals met inclusion criteria. Demographic data were comparable between groups. Presenting symptoms were also similar, with similar extrusion rates. Chronic pain was the reason for mesh removal in 80% of cases. In 1 year of follow-up, 38.6% (27/70) retropubic and 34.0% (16/47) transobturator sling removals had SUI requiring an anti-incontinence procedure. Total sling mesh removal was performed in 51.4% of retropubic vaginal mesh and 51.1% of transobturator mesh cases.

CONCLUSION

In this continent population with sling complications, approximately 1/3 developed significant SUI within 1 year of mesh removal requiring anti-incontinence surgery, regardless of the amount or type of mesh removed. Total mesh removal did not increase SUI risk.

Recurrence rate of stress urinary incontinence in females with initial cure after transobturator tape procedure at 3-year follow-up

PURPOSE

To assess recurrence rates of urinary incontinence in women with initial cure after transobturator tape (TOT) procedure at 3-year follow-up.

MATERIALS AND METHODS

Between June 2006 and May 2013, a total of 402 consecutive patients underwent the TOT procedure for female stress urinary incontinence (SUI) at Dongguk University Ilsan Hospital. Of the 402 patients, 223 had sufficient medical records for analysis. Therefore, they were followed-up for 3 years postoperatively. Patient characteristics, urinary symptoms, physical examination, and urodynamic parameters were evaluated. The primary end point of "cure" was defined as the absence of any complaint of urinary leakage without needing pads for usual activities.

RESULTS

Of the 223 patients, 196 patients (87.9%) were initially cured within 6 months postoperatively. Of the 196 patients, 70 (35.7%) had recurrent urinary incontinence at 3 years postoperatively, 51 (26.0%) had SUI, 16 (8.2%) had urgency urinary incontinence, and 3 (1.5%) had mixed urinary incontinence. In univariate analysis, preoperative urinary obstructive symptom was found to significant contributor to the recurrence of urinary incontinence at 3-year postoperatively (p=0.004).

CONCLUSIONS

In our study, 35.7% of the women with initial cure after TOT experienced the recurrence of urinary leakage during the 3-year follow-up. The cure rate of TOT was decreased as time went by, although the initial cure rate was high.

Five years after midurethral sling surgery for stress incontinence: obesity continues to have an impact on outcomes

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the impact of preoperative body mass index ≥30 on objective and subjective cure rates 5 years after midurethral sling surgery.

METHODS

Secondary analysis of the 5-year results of a randomized clinical trial evaluating tension-free vaginal tape vs transobturator tape surgery. Women (n = 176) were classified as obese or non-obese based on preoperative height and weight. Women self-reported symptoms and quality of life, and underwent standardized physical examinations and pad-testing. Categorical data were analyzed using Chi-squared or Fisher's exact tests, continuous data by Mann-Whitney U test. Primary outcome was objective cure defined as <1 g urine lost on pad-test at 5 years post-surgery. Secondary outcomes were subjective cure of incontinence, urinary urge incontinence symptoms, and quality of life scores.

RESULTS

Non-obese women had a higher rate of objective cure, 87.4 % (n = 83 out of 95) compared with 65.9 % (n = 29 out of 44) in the obese group (P = 0.003, risk difference [RD] 21.5 %, 95 % CI 5.9-37.0 %). Subjectively, non-obese women also reported higher rates of cure, 76.7 % (n = 89 out of 116) compared with 53.6 % (n = 30 out of 56) of obese women (P = 0.002, RD 23.2 %, 95 % CI 8.0-38.3 %). Overall rates of urge incontinence symptoms were similar in the two groups, but rates of bothersome symptoms were higher for obese women (58.9 % vs 42.1 %, P = 0.039, RD 16.8 % 95 % CI 1.1-32.6).

CONCLUSIONS

Five years after surgery, obese women continued to experience lower rates of cure compared with non-obese women.

Surgical treatment of stress urinary incontinence-trans-obturator tape compared with tension-free vaginal tape-5-year follow up: an economic evaluation

OBJECTIVE

To conduct an economic evaluation of the use of trans-obturator tape (TOT) compared with tension-free vaginal tape (TVT) in the surgical treatment of stress urinary incontinence in women.

DESIGN

Cost-utility and cost-effectiveness analyses from a public-payer perspective, conducted alongside a randomised clinical trial.

SETTING

Health services provided in Alberta, Canada.

SAMPLE

A total of 195 women participated in the randomised clinical trial, followed to 5 years postsurgery.

METHODS

Comparisons were undertaken between study groups for cost and two health-outcome measures. Multiple imputation was used to estimate the 14% of missing data. Bootstrapping was used to account for sampling uncertainty. Sensitivity analyses were based on complete case analyses and the removal of a TVT patient with extreme health service cost.

MAIN OUTCOME MEASURES

The 15D instrument was used to calculate quality-adjusted life-years (QALYs) for the primary analysis. Absence of serious adverse events was also analysed. Costs were based on inpatient and outpatient hospital use data and practitioner fee-for-service claims data.

RESULTS

The TOT group had a nonsignificant average saving of $2368 (95% CI -$7166 to $2548) and incremental gain of 0.04 QALYs (95% CI -0.06 to 0.14) compared with TVT. TOT was dominant in over 71% of bootstrap replications and cost-effective over a wide range of willingness-to-pay. Cost-effectiveness analysis using the absence of an serious adverse events provided similar results.

CONCLUSION

The results suggest that TOT is cost-effective compared with TVT in the treatment of stress urinary incontinence.

TWEETABLE ABSTRACT

The results of a 5-year cost-effectiveness analysis suggest that trans-obturator tape is cost-effective compared with tension-free vaginal tape in the treatment of stress urinary incontinence.