Repeat surgery after failed midurethral slings: a nationwide cohort study, 1998–2007

Midterm postoperative results of mid-urethral slings. Role of ultrasound in explaining surgical failures

INTRODUCTION

Surgical treatment for stress urinary incontinence (SUI) with mid-urethral sling (MUS) is considered to have a high success rate. However, between 5% and 20% of MUS fail, with inadequate surgical implantation being a possible cause of SUI persistence or recurrence. Misplacement of a MUS can be determined by pelvic floor ultrasound (PF-US). The aim of this study was to investigate the role of PF-US in patients with persistent or recurrent urinary incontinence (UI) symptoms after MUS surgery for SUI with a midterm follow-up.

MATERIALS AND METHODS

A historical cohort study including women undergoing MUS surgery for SUI between 2013 and 2015 was designed. The primary outcome was to correlate the sonographic parameters of MUS with SUI cure (negative International Continence Society-Uniform Cough Stress Test, Incontinence Questionnaire-Short Form < 5 points and no symptoms of SUI), at 5 years postsurgery. Secondary outcomes were changes of maximum urethral closure pressure (MUCP) and symptoms of urgency urinary incontinence (UUI) at 1 and 5 years after surgery.

RESULTS

Eighty-seven patients (80 transobturator-MUS, 7 retropubic-MUS) were included. At 5 years all patients referred improvement of UI and objective cure of SUI was demonstrated in 81.2%. The MUS was sonographically correct in 67 (98.5%) of the 68 patients with cure of SUI. The MUS was considered incorrectly placed in only 4 (28.6%) of the 14 patients with noncured SUI. MUCP decreased from 61.9 to 48.8 cmH₂ O at 5 years of follow-up (p < 0.01) and up to 53% of women had UUI symptoms after surgery, with a nonsignificant decrease compared to baseline.

CONCLUSION

Patients cured of SUI had sonographically correct MUS by PF-US. Less than one-third of cases of SUI persistence or recurrence after MUS surgery could be explained by a sonographically incorrect sling. Low urethral resistance and/or UUI symptoms could help to explain the remaining failures. Complete functional and anatomic studies, including urodynamics and PF-US, should be performed before deciding on the next management strategy in patients with SUI persistence or recurrence after MUS.

Comparing risk of repeat surgery for stress urinary incontinence after mid-urethral slings and polyacrylamide hydrogel

INTRODUCTION

Over the last two decades synthetic mid-urethral slings (MUS) have become established as the main surgical method for correcting stress urinary incontinence (SUI). However, transurethral injections with polyacrylamide hydrogel are gaining popularity. We used surgical codes from a national registry to explore potential differences in risk of later surgery for SUI comparing retropubic slings, obturator slings, and polyacrylamide hydrogel injections.

MATERIAL AND METHODS

This cohort study used surgical codes from The Norwegian Patient Registry. All women recorded as having had surgery for SUI coded as retropubic sling, obturator sling, or polyacrylamide hydrogel injection from 2008 until end-of-study censoring in 2017, were included. Main outcome was time to any recorded new SUI procedure later in the study period. Unadjusted comparison between groups was done using Kaplan-Meier. A Cox regression analysis was then performed to adjust for hospital unit size and patient age at surgery.

RESULTS

The unadjusted analyses showed significant differences between the chosen index method and the risk of later SUI surgery favoring retropubic slings (p < 0.01). The proportions of patients without any recorded new SUI procedure at 1 and 5 years were 99.3% and 97.7% for retropubic MUS, 98.7% and 96.1% for obturator MUS, and 82.7% and 72.4% for polyacrylamide hydrogel injections. The majority of women having a repeat procedure for SUI after a polyacrylamide hydrogel injection underwent repeat treatment within 1 year (63%). After adjusting for age at time of surgery and hospital size, obturator slings (hazard ratio 1.8, 95% CI 1.4-2.4) and polyacrylamide hydrogel (hazard ratio 23.1, 95% CI 17.6-30.3) remained associated with a higher risk of later incontinence surgery.

CONCLUSIONS

Both retropubic and obturator slings have low long-term risks of repeat incontinence surgery compared with polyacrylamide hydrogel injections. Retropubic slings were found to have superior longevity of the surgical result.

Outcomes collected in female pelvic floor surgical procedure registries and databases: a scoping review

INTRODUCTION AND HYPOTHESIS

The objective was to overview the literature on the existing pelvic floor procedure registries and databases and to identify patient demographic, clinical and/or patient-reported data items for inclusion in the Australasian Pelvic Floor Procedure Registry (APFPR) Minimum Data Set (MDS).

METHODS

We conducted a literature search on the MEDLINE, Embase, CINAHL and PsycINFO databases in addition to Google Scholar and grey literature to identify studies in the period January 2008 to January 2020. All were English studies of registries and databases on female adults undergoing surgery for pelvic floor disorders including stress urinary incontinence (SUI) and pelvic organ prolapse (POP). Studies were assessed on demographic and clinical patient characteristics, procedure or treatment type, health-related quality of life, adverse events and safety outcomes, captured by pelvic floor procedure registries or databases that have been established to date.

RESULTS

From 1662 studies, 29 publications describing 22 different pelvic floor registries and databases were included for analysis, 12 (55%) of which were multicentre. Six (27%) registries and databases involved solely SUI, eight (36%) were regarding POP, and the remaining eight (36%) focussed on both conditions. The majority of registries and databases captured similar details on patient characteristics, comorbidities and other clinical features, procedure or treatment type, health-related quality of life, adverse events, safety and efficacy.

CONCLUSION

The findings of this scoping review will assist in determining the MDS for the APFPR, an initiative of the Australian government, to improve health and quality of life outcomes of women who undergo pelvic floor reconstructive procedures.

What to do after a mid-urethral sling fails

PURPOSE OF REVIEW

After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated.

RECENT FINDINGS

Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling.

SUMMARY

MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.

A Danish national population-based cohort study of synthetic midurethral slings, 2007-2011

INTRODUCTION AND HYPOTHESIS

Synthetic midurethral slings (MUSs) have shown similar cure rates in several short- and medium-term follow-up studies. Recently, long-term follow-up studies have indicated that the cure rate is higher following the retropubic midurethral sling (RPMUS) compared with the transobturator midurethral sling (TOMUS) procedure. The aim was to evaluate the efficacy of synthetic MUSs and to examine the influence of department and surgeon volume and patient-related factors on the cure rate of synthetic MUSs.

METHODS

A retrospective cohort study based on a national population over a 5-year period (2007-2011) using data from the Danish Urogynaecological Database (DugaBase).

RESULTS

A total of 4519 women with first-time MUS were registered in the DugaBase. Cure was achieved in 1242/1639 (75.78%) at a 3-month follow-up. RPMUSs were more frequently in use in high-volume departments compared with the other departments and more often implanted by high- than low-volume surgeons. Women treated by a medium- (adjusted OR 1.82; 95% CI 1.01-3.28, "frequency") or high-volume surgeon (1.98; 1.18-3.32, "frequency") had an increased probability of cure compared with women treated by a low-volume surgeon. The difference was only significant for women who received a TOMUS.

CONCLUSIONS

This national population-based cohort study confirmed a high cure rate of synthetic MUSs at short-term follow-up. It is the largest study to indicate a learning curve for TOMUS. Patients were not actively involved in which synthetic MUS was to be performed as the choice of surgical option was made at the departmental level.

Influence of body mass index on short-term subjective improvement and risk of reoperation after mid-urethral sling surgery

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the impact of body mass index (BMI) on the subjective improvement and risk of reoperation after first-time mid-urethral sling surgery.

METHODS

Data were retrieved from the national Danish Urogynaecological Database, including women with first-time surgery with mid-urethral polypropylene slings from 2011 to 2016. The subjective improvement was assessed by the difference in symptoms based on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) completed pre- and 3 months postoperatively. A reoperation was defined as any new surgical procedure for stress urinary incontinence performed within the study period.

RESULTS

During the study period, 6,414 mid-urethral sling procedures were performed; 80.0% of these women filled out both pre- and post-surgical International Consultation on Incontinence Questionnaire (ICI-Q) forms. 42.4% had a BMI < 25, 34.6% had BMI 25-30, 16.9% had BMI 30-35, and 6.0% BMI >35. The subjective improvement after surgery was high in all BMI categories and there were no differences between the categories. The overall cumulative hazard proportion at 2 years of follow-up was 1.9% (CI 95%: 1.6-2.3) and after 5 years 2.4% (CI 95%: 2.0-2.9). Adjusted for age, smoking, and use of alcohol, the cumulative hazard proportion after 2 years of follow-up was 3.2% (CI 95%: 1.6-6.2) for women with BMI >35 and after 5 years 4.0% (CI 95%: 2.0-7.7), which was the highest proportion of reoperation in the study. The crude hazard ratio was 1.84 (CI 95%: 0.89-3.83) women with BMI >35 and the adjusted hazard ratio was 1.94 (CI 95%: 0.92-4.09).

CONCLUSIONS

We found high subjective improvement after the first-time surgery unrelated to BMI. Women with a BMI over 35 had the highest proportion of reoperations, although this was not statistically significant.

Cumulative Incidence of a Subsequent Surgery After Stress Urinary Incontinence and Pelvic Organ Prolapse Procedure

OBJECTIVE

To assess the 5-year risk and timing of repeat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures.

METHODS

We conducted a retrospective cohort study using a nationwide database, the 2007-2014 MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases (Truven Health Analytics), which contain deidentified health care claims data from approximately 150 employer-based insurance plans across the United States. We included women aged 18-84 years and used Current Procedural Terminology codes to identify surgeries for SUI and POP. We identified index procedures for SUI or POP after at least 3 years of continuous enrollment without a prior procedure. We defined three groups of women based on the index procedure: 1) SUI surgery only; 2) POP surgery only; and 3) Both SUI+POP surgery. We assessed the occurrence of a subsequent SUI or POP procedure over time for women younger than 65 years and 65 years or older with a median follow-up time of 2 years (interquartile range 1-4).

RESULTS

We identified a total of 138,003 index procedures: SUI only n=48,196, POP only n=49,120, and both SUI+POP n=40,687. The overall cumulative incidence of a subsequent SUI or POP surgery within 5 years after any index procedure was 7.8% (95% confidence interval [CI] 7.6-8.1) for women younger than 65 years and 9.9% (95% CI 9.4-10.4) for women 65 years or older. The cumulative incidence was lower if the initial surgery was SUI only and higher if an initial POP procedure was performed, whether POP only or SUI+POP.

CONCLUSIONS

The 5-year risk of undergoing a repeat SUI or POP surgery was less than 10% with higher risks for women 65 years or older and for those who underwent an initial POP surgery.

Multimodal vaginal toning for bladder symptoms and quality of life in stress urinary incontinence

Introduction and hypothesis

Treatment options for women with stress urinary incontinence (SUI) have limitations. We hypothesized that multimodal vaginal toning therapy would improve bladder symptoms and quality of life in women with postpartum SUI and sexual function complaints.

Methods

Patients self-administered 24 sessions of multimodal vaginal toning therapy lasting 10 min each over 50 days. Outcomes included 1-h pad weight test, Urogenital Distress Inventory Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7), Female Sexual Distress Scale-Revised 2005 (FSDS-R), Female Sexual Function Index (FSFI), pelvic floor muscle strength, patient satisfaction, and adverse events.

Results

Of the 55 patients enrolled (safety population), 48 completed the study per-protocol (PP population). A total of 38 (79%) patients had a positive 1-h pad weight test at baseline. In this group, urine leakage was moderate or severe in 82% of patients at baseline, but in only 18% after treatment. Treatment success was 84%, defined as >50% improvement in pad weight relative to baseline. In the PP population, mean UDI-6 score improved by 50% (p < 0.001) and IIQ-7 score improved by 69% (p < 0.001). Sexual function quality of life improved by 54% for FSDS-R and 15% for FSFI (both p < 0.001). Pelvic floor muscle strength significantly improved (p < 0.001). Patient satisfaction with therapy was reported in 83% of patients. In the safety population, 2 (3.6%) adverse events were reported—1 urinary tract infection and 1 report of discomfort due to excessive warmth.

Conclusions

Multimodal vaginal toning therapy yields clinically meaningful improvements in bladder symptoms, pelvic floor muscle strength, and quality of life in women with SUI.

Objective outcome and quality-of-life assessment in women with repeat incontinence surgery

AIMS

To evaluate subjective and objective outcome after repeat surgery for stress urinary incontinence (SUI).

METHODS

Patients who underwent a midurethral tape after failed Burch colposuspension or failed midurethal tape between 1999 and 2014 were invited for follow-up. Urogynecological examination and urodynamics was performed, and objective cure was defined as a negative cough stress test; subjective cure was defined as negotiation of SUI symptoms. Quality-of-life (QoL), sexual health, and subjective success was assessed with the King's Health Questionnaire, Incontinence Outcome Questionnaire, Female Sexual Function Index, and the Patient Global Impression of Improvement (PGI-I) score.

RESULTS

Overall 52 women underwent repeat incontinence surgery. Out of the 44 women still alive, 33 (75%) were available for follow-up. All 33 women completed the questionnaires; 23 women (70%) attended the clinic and also had an urogynecological examination. At a median follow-up of 11 years, subjective cure was 67% (22/33), objective cure was 65% (16/23), and subjective success according to PGI-I was 78% (18/23), with no significant differences between groups. No erosions of suture or tape material into the bladder, urethra, or vagina were seen. Two women had received a third anti-incontinence operation with TVT after failed tape after failed Burch, and were continent at follow-up. Two women with tape after colposuspension required division of the tape and both were continent at the time of follow-up. With regard to QoL and sexual health, no significant differences were seen for most domains.

CONCLUSIONS

Midurethral tapes are an option for women with recurrent SUI after previous colposuspension or midurethral tape.