Transobturator midurethral sling: What should patients expect after surgery?

Tunable tension tape versus transobturator tape in treatment of stress urinary incontinence in women: Randomized controlled trial

INTRODUCTION

The synthetic mid-urethral slings are currently considered to be the most widely used technique for the surgical treatment of stress urinary incontinence (SUI). The most challenging aspect of the existing approaches is to achieve the optimal tension of the sling which treatment results are directly dependent on. To solve this problem, sling systems enabling an adjustment of the tension in the early postoperative period were created. A comparative study of the effectiveness and safety of such a system and a nonadjustable sling seems to be a relevant task.

MATERIALS AND METHODS

A double-blind, randomized, multicenter trial enrolled 320 patients with a mean age of 55.2 ± 11.2 years and confirmed SUI. Patients were randomized into two groups: the first group underwent a standard synthetic suburethral sling (transobturator tape [TOT]) procedure and the second group underwent a tunable tension tape sling (TTT) procedure. All patients underwent stress test, uroflowmetry and ultrasound scan to determine the postvoid residual volume. Urinary Distress Inventory Short Form 6, International Consultation on Incontinence Questionnaire-Short Form, Pelvic Organ Prolapse Incontinence Sexual Questionnaire 12 questionnaires were used to assess subjective efficacy.

RESULTS

Enhancement of prosthesis tension in the second group was required in 44 (28%) patients. Due to the possibility of tightening of the sling in the early postoperative period, the operation was effective in 143 (89%) patients in the adjustable sling group and in 109 (68%) patients in Group 1, p < 0.001. Loosening of the sling tension was performed in 25 (16%) patients in Group 2. The signs of obstructive voiding symptoms at the follow-up time of 36 months remained in Group 1 in 13 (8%) patients. Subjective satisfaction with treatment on the PGI-I scale was higher in Group 2: 100 (62%) versus 132 (82%), p < 0.001.

CONCLUSION

A synthetic mid-urethral TTT is superior to a standard nonadjustable sling in long-term effectiveness and safety.

Urgency and urgency incontinence following stress urinary incontinence surgery: A review of evaluation and management

The presence of urgency urinary incontinence (U/UUI) after sling surgery is a common reason for dissatisfaction and imposition on quality of life. We aimed to evaluate and analyze the pathophysiology, evaluation, and treatment of U/UUI after sling surgery. A MEDLINE review was performed for relevant, English-language articles relating to storage and emptying symptoms after sling surgery. U/UUI may persist, be improved, or worsen in women with preoperative mixed urinary incontinence and may appear de novo in those women originally presenting with pure stress urinary incontinence (SUI). While the exact mechanism is not clear, partial bladder outlet obstruction (BOO) should always be suspected, especially in those women with worsened or de novo symptoms soon after sling surgery. Initial workup should elucidate the temporality, quality, and bother associated with symptoms and to evaluate the woman for urinary tract infection (UTI), pelvic organ prolapse (POP), or perforation of the lower urinary tract. The utility of urodynamics in attaining a definitive diagnosis of BOO is inconclusive. Treatment options include reevaluation of the patient after sling incision or after addressing UTI, POP, and perforation of the bladder or urethra. Women also typically undergo a multitiered approach to storage lower urinary tract symptoms outlined in the American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Overactive Bladder Guidelines. While improvement is typically seen with multimodality treatment, all women should be counseled regarding need for additional treatment for U/UUI, BOO, and SUI in the future.

The American Society of Anesthesiologists Physical Status (ASA-PS) Risk Group Classification Can Be Used to Anticipate Functional Recovery Outcomes after the Surgical Treatment of Female Urinary Incontinence with Transobturator Suburethral Tape

INTRODUCTION

Stress urinary incontinence (SUI) has an incidence of 15-80% in women. One of the most widely used surgical techniques for treatment is the placement of a suburethral transobturator tape (TOT). Although this technique has a relatively low morbidity rate, it is not exempt from intraoperative or postoperative complications, which can have an impact on functional recovery, understood as the return to routine life prior to the intervention.

AIMS

To assess the time for functional recovery in women operated on for SUI by TOT; to identify complications and related factors, according to anaesthetic risk, which condition the time to functional recovery; and proposals for improvements in the prevention of possible complications and in reducing functional recovery time.

MATERIALS AND METHODS

A non-concurrent prospective observational multicenter study of 891 women undergoing TOT for stress urinary incontinence since 1 April 2003, who were successful in achieving urinary continence (completely dry). Study groups: GA (n = 443): patients with ASA I risk. GB (n = 306): patients with ASA II risk. GC (n = 142): patients with anaesthetic risk ASA III. Investigated variables: age, body mass index, follow-up time, secondary diagnoses, surgical history, obstetric-gynecological history, toxic habits, and complications derived from surgery: bleeding, pain, infection. Descriptive statistics, Student's t test, Chi2, Fisher, ANOVA, multivariate analysis, significance for p < 0.05.

RESULTS

Mean age was 60.10 years (SD13.38), with no difference between groups. Mean body mass index (BMI) was 26.55 kg/m² (SD 4.51), lowest in GA. GB had more HT (38.6%) than GC (23.23%), more type 2 diabetes (19.83% versus 10.56%), and more respiratory disorders (6.97% versus 2.11%). There were more women with anxiety in GB (19.3%) than in GC (6.33%) (p = 0.0221) and GA (10.51%) (p = 0.0004). There was more hypothyroidism in GB (16.08%) compared to GC (2.11%) and GA (9.07%). There was more history of curettage in GC (11.97%) versus GB (5.63%); and more pelvic surgery in GB (71.31%) and GC (66.9%) compared to GA (32.57%). There were more concomitant treatments with benzodiazepines in GC (27.46%) and GB (28.41%) than in GA (8.86%), and more parapharmacy treatments in GB (17.96%) than in GC (6.33%). Following the operation, 113 patients had some sign or symptom that required medical attention: in GA 48 (10.83%), in GB 49 (16.06%), in GC 16 (13.22%). Mean days until functional recovery in patients with complications: in GA 5.72 (SD2.05); bleeding 3 (SD1), pain 6.40 (SD1.34), and infection 7.33 (SD0.57), with fewer days for bleeding than for pain or infection. GB: 27.96 (SD 28.42), bleeding 3 (SD0), pain 46.69 (SD31.36), infection 10.83 (SD3.90); lowest for patients with bleeding. GC: 9.44 (SD 2.50); for bleeding 7.66 (SD2. 08), pain 10.66 (SD1.15), infection 10 (SD3.46); no differences. Overall, for women with bleeding, the time was 4.16 days (SD1.94); less in GA and GB than in GC. Pain, at 31.33 days (SD 30.70), was the factor that most delayed functional recovery; in GB women, it took longer to return to work due to pain (45.96, SD31.36) compared to GA (6.4, SD 1.34) and GC (10.66, SD1.15). In women with infection, overall mean time was 10.11 days (SD 3.61) with no difference between groups.

CONCLUSIONS

Mean time for the return to normal activity in patients who underwent TOT for SUI is 5 days if there are no complications, and 16.91 days if there are any. The ASA-SP risk group classification can be used to anticipate functional outcomes. An ASA-PS risk-based functional recovery forecasting protocol should be adapted, especially ASA II patients who may present with long-term disabling postoperative pain. Preventive management measures are proposed that favour functional recovery.

Does Pharmacological Treatment Reduce the Incidence of Lower Urinary Tract Symptoms (LUTS) after Transobturator Sling?

Aim

Lower urinary tract symptoms (LUTS) frequently affect patients immediately after midurethral sling (MUS) placement. The objective of the study was to assess if solifenacin or mirabegron decreases incidence of LUTS in women who underwent transobturator MUS.

Methods

A prospective randomized trial was conducted on patients undergoing ambulatory transobturator midurethral sling due to stress urinary incontinence (SUI). All participants were questioned before and after surgery for occurrence of bothersome LUTS. A total of 328 patients who underwent transobturator MUS were randomly assigned to one of three groups: prophylaxis with 10 mg of solifenacin, prophylaxis with 50 mg of mirabegron, or without any additional treatment. LUTS evolution and efficacy of solifenacin and mirabegron were analyzed based on results of assessments made during follow-up visits at 1 and 6 weeks after surgery. Comparison of the prevalence of LUTS was done using chi² test.

Results

Prevalence of urgency and frequency episodes increased notably 1 week after sling placement and then came down to baseline levels. Solifenacin and mirabegron significantly reduced the incidence of urgency after 1 week, but after 6 weeks the beneficial effect was observed only in case of solifenacin. Treatment with mirabegron reduced the percentage of patients suffering from frequency after 6 weeks. Although prevalence of nocturia did not raise after sling placement, both treatments significantly reduced the incidence of this complaint after 6 weeks. Pharmacological treatment did not modulate the course of hesitancy and terminal dribbling.

Conclusions

Treatment with solifenacin or mirabegron may significantly reduce the incidence of undesired LUTS after MUS.

Predictors for De Novo Overactive Bladder after Readjustable Mid-Urethral Sling Procedure in Women with Stress Urinary Incontinence due to Intrinsic Sphincter Deficiency

Purpose

This study identified noninvasive factors that predict overactive bladder (OAB) after readjustable mid-urethral sling surgery (Remeex system) in women with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).

Materials and Methods

We retrospectively reviewed the medical records of 130 women with SUI due to ISD [Valsalva leak-point pressure (VLPP) <60 cm H₂O] who underwent the Remeex procedure between February 2011 and March 2017. Patients were classified according to OAB symptoms before and 6 months after the Remeex procedure: Group 1, without preoperative and postoperative OAB (n=46); Group 2, without preoperative OAB and with postoperative OAB (de novo OAB, n=15); Group 3, with preoperative OAB and without postoperative OAB (n=25); Group 4, with preoperative and postoperative OAB (n=44). Noninvasive clinical and urodynamic factors were evaluated as predictors of de novo OAB.

Results

The four groups significantly differed with respect to age (p=0.036), peak urinary flow rate (PUFR) one month after surgery (post-PUFR, p=0.001), and postvoid residual (PVR) one month after surgery (post-PVR, p=0.005). No significant differences were detected for body mass index, diabetes, multiparity, menopause, previous hysterectomy, previous incontinence surgery, previous pelvic organ prolapse surgery, pyuria, preoperative PUFR, preoperative PVR, maximal cystometric capacity, VLPP, maximum urethral closure pressure, detrusor pressure at PUFR, and detrusor overactivity (p>0.05). Post-PUFR decreased significantly compared with preoperative PUFR in Groups 1, 2, and 4 (p=0.002, p=0.001, and p=0.001, respectively). Pairwise comparisons of post-PUFR and post-PVR revealed statistically significant differences between Group 2 and other groups (p<0.0125). Multivariate logistic regression analyses showed that post-PUFR was the only significant predictor of de novo OAB (odds ratio = 0.823, 95% confidence interval 0.727-0.931, p=0.002).

Conclusions

Reduced PUFR after the Remeex procedure is a promising predictor of risk for de novo OAB. This metric is noninvasive and easy to measure.