Long-term outcomes of retropubic tension-free vaginal tape for stress urinary incontinence after a transobturator tape failure: a retrospective study

Hemoglobin A1c and Reoperation After Surgery for Stress Incontinence or Prolapse

IMPORTANCE

Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications.

OBJECTIVE

The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP).

STUDY DESIGN

We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8.

RESULTS

Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years.

CONCLUSION

Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

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.

Experience in application of modified sling in treatment of Moderate Stress Urinary Incontinence

Objective

To observe the clinical significance of modified sling in the treatment of moderate stress urinary incontinence (SUI).

Methods

From January 2016 to January 2019, eighty patients with moderate urinary incontinence who were hospitalized in our hospital were randomly divided into two groups. 40 patients in the experimental group underwent modified sling transvaginal tension-free mid-urethral suspension. Modification method of the sling: cut the sling to a remaining length of about 6~7cm, properly connect the barbed sutures (V-LOCK) on both sides of the sling, and insert the urinary incontinence sling from the urethra to the obturator membrane, from the obturator membrane to the thigh. The inner skin area is replaced by the V-LOCK line. The 40 patients in the control group were unmodified ordinary slings. The operation time, the local pain of the inner thigh after the operation, and the improvement of postoperative urinary incontinence symptoms were compared and analyzed between the two groups.

Results

Both groups of patients were successfully operated. The operation time was 16.36 minutes in the experimental group and 27.18 minutes in the control group. The difference in operation time between the two groups was statistically significant (p=0.00); the catheter was pulled out on the third day after the operation. One patient in the group had urinary effort, four patients still had urinary incontinence symptoms, the remaining 35 patients had good urinary control (effective rate 87.5%), five patients in the control group still had urinary incontinence, two patients had urinary effort, and the remaining 33 patients had urinary control Good, (effective rate 87.5%), there was no significant difference in surgical effectiveness between the two groups (p=0.53); follow-up for 12 to 36 months, no significant long-term complications occurred, the pain score of the inner thigh of the experimental group was significantly lower than that of the control group ,statistically significant (p=0.04).

Conclusion

The efficacy of the modified sling in the treatment of moderate SUI is the same as that of the traditional sling, but the operation time is shorter, the operation is simpler, and the local pain is significantly reduced.

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.