Female stress urinary incontinence and the mid-urethral sling: Is obstruction necessary to achieve dryness?

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.

Synthetic mid-urethral slings for the treatment of stress urinary incontinence in women with neurogenic lower urinary tract dysfunction: a systematic review

INTRODUCTION AND HYPOTHESIS

The aim of our study was to evaluate the efficiency and safety of synthetic mid-urethral slings (sMUS) for the treatment of stress urinary incontinence (SUI) in women with neurogenic lower urinary tract dysfunction (NLUTD).

METHODS

A systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. MEDLINE, Embase and Cochrane controlled trials databases were systematically searched from January 1995 to April 2021. Studies including adult women with NLUTD who had a sMUS for SUI were considered for inclusion. Primary outcome was success of the surgery according to study criteria. Secondary outcomes were complications, especially de novo urgency, urinary retention, tape exposure and revision for complications.

RESULTS

A total of 752 abstracts were screened and 9 studies were included, representing 298 patients. The mean age was 52 years and median follow-up was 41.3 months. sMUS insertion was successful in 237 patients (79.5%). The median rate of de novo urgency was 15.7% (range 8.3-30%). In patients with spontaneous voiding, the median rate of retention was 19.3% (range 0-46.7%) and 21 out of 26 patients required intermittent self-catheterisation. Four cases of tape exposure were reported, and 8 patients underwent a revision for complications.

CONCLUSIONS

This review suggests that sMUS might offer interesting success rates and acceptable morbidity and could be considered for the treatment of SUI in women with NLUTD. Further studies are required to define which patients would be more likely to benefit from this intervention, as well as its place among the other surgical treatments for SUI.

The evolution of incontinence into resolved, refractory and de novo urgency urinary incontinence following sling placement at time of prolapse repair in a large urodynamic cohort

PURPOSE

To improve counseling in women at risk of refractory and/or de novo urgency urinary incontinence (UUI) following sling placement at time of prolapse repair, we created an outcome model to characterize changes in storage dysfunction.

MATERIALS AND METHODS

We identified 139 women who underwent urodynamics followed by sling or no sling placement at the time of prolapse repair over a 6-year period. Our primary outcome was the presence of UUI following sling placement. Data were analyzed in SAS using chi-square, Fisher's exact, Student's t-test, and Kaplan-Meier methods.

RESULTS

At baseline, the sling group had significantly higher subjective (62/81 [76.5%] vs. 18/58 [31.0%]; p<0.001), objective (62/81 [76.5%] vs. 6/58 [10.3%]; p<0.001), and occult (41/81 [50.6%] vs. 6/58 [10.3%]; p<0.001) stress urinary incontinence (SUI); and rates of subjective and objective UUI were similar to the no sling group prior to surgery. After surgery (mean follow-up 859 days) there was no difference with or without sling, in the rate of SUI (subjective, objective) and further SUI treatments (bulking agent, repeat sling). Higher rates of de novo (13/81 [16.0%] vs. 6/58 [10.3%]; p=0.454) and refractory (31/81 [38.3%] vs. 14/58 [24.1%]; p=0.048) UUI were noted in the sling group following surgery. On Kaplan-Meier analysis, a greater proportion of women in the no sling group did not report UUI at longest follow-up (hazard ratio 0.63; 95% confidence interval 0.37-1.06; p=0.081).

CONCLUSIONS

Women should be counseled on the risk of de novo and refractory UUI following sling placement at time of prolapse repair.

TVT-O vs TVT-S for female stress urinary incontinence: A systematic review and meta-analysis

BACKGROUND

Tension-free vaginal tape obturator (TVT-O) and tension-free vaginal tape secur (TVT-S) are common surgeries for the treatment of stress urinary incontinence (SUI), several randomised controlled trials (RCTs) have compared the effects of TVT-O and TVT-S, yet the results remained inconsistent. Therefore, we attempted to conduct this systematic review and meta-analysis to analyse the role of TVT-O and TVT-S in patients with SUI.

METHODS

We searched PubMed databases from inception date to Jan 15, 2020 for RCTs that compared TVT-O and TVT-S in SUI patients. Two authors independently screened and extracted data from the published articles. Summary odd ratios (OR) or mean differences (MD) with 95% confidence intervals (95% CI) were calculated for each outcome by fixed- or random-effects model.

RESULTS

Seven RCTs with a total of 755 patients were identified, with 373 patients for TVT-O and 382 patients for TVT-S. TVT-O preceded TVT-S in the objective cure at 12 months (OR = 1.72, 95% CI 1.21-2.45), subjective cure (OR = 1.98, 95% CI 1.08-3.62); but TVT-S have more advantage in the incidence of postoperative thigh pain (OR = 18.94, 95% CI 7.01-51.15); no significant differences on the duration of operative procedure (OR = -1.09, 95% CI -2.37-0.18), urinary retention (OR = 0.77, 95% CI 0.36-1.62) and urinary infection (OR = 1.80, 95% CI 0.63-5.13) were found.

CONCLUSIONS

TVT-O should be preferred for patients with SUI even though with higher risks of postoperative thigh pain when compared with TVT-S, more related studies are needed to identify the role of TVT-O and TVT-S for the treatment of SUI.

Underactive Bladder and Bladder Outlet Procedures in Women

Purpose of review

This review outlines current options for women suffering from both stress urinary incontinence (SUI) and underactive bladder (UAB). This is often a challenging patient population; however, many treatment options are available including behavioral, pharmacologic, and surgical. Therapies can be divided into those specifically targeting either the bladder or the bladder outlet.

Recent findings

For patients with SUI and UAB, several clinical trials have helped to formulate current guidelines. Also, a number of novel techniques and therapeutic agents are currently under investigation. Current surgical treatments frequently employed for SUI include midurethral slings and urethral bulking agents. In contrast, the current treatments for UAB are limited to either sacral neuromodulation in women with Fowlers syndrome or in the majority, clean intermittent catheterization. Recent studies have investigated the use of adjustable urethral slings and novel modes of neuromodulation with varying degrees of success.

Summary

Choosing the best treatment plan for SUI combined with UAB involves a thorough understanding of a patient's preferences and goals. Fortunately, women have many options that can significantly benefit their quality of life.

Impact of Hysterectomy on Urethral Suspension with Transobturator Sling for Treatment of Stress Urinary Incontinence in Women

Urinary stress incontinence is a condition that increases with age, influenced by many factors, mainly anatomical pathological ones, determined by changes of muscular pelvic floor, but also by hormonal and local neurological modifications. The aim of the study was an overview of the efficacy of stress urinary incontinencetherapy with transobturatorurethralsling suspension in patients with or without prior hysterectomy. Additionally, we evaluated the effectiveness and the rate of side effects of this method. The study group consisted of 100 patients and, within it, 32 patients (group A)underwent a hysterectomy.We noticed an improvement of symptoms, a reduced discomfort and an increase of quality of life, more prominent in group B (patients without previous hysterectomy) (p=0,0012, p=0,17 respectively, p=0,03). We consider that transobturator approach in treating stress urinary incontinence is a simple, rapid and effective procedure and, not lastly, modern technique that assures a significant improvement of symptomsand quality of life for the patients; positioning the sling along to the insufficient pubourethral ligaments reinforces the structures supporting the urethra; this approach is minimally-invasive with rapid recovery, reduced hospitalization, is cost effective and involves minimal risks of infection, bleeding, etc. moreover, the transobturator tension free sling has some advantages (no pain or tension). The rate of success of the treatment is significantly lower in patients with prior hysterectomy.

Urodynamic factors associated with the large capacity bladder and incomplete emptying after prolapse repair (2009-2015)

AIMS

To identify the clinical and urodynamic factors associated with the large capacity bladder and incomplete bladder emptying after prolapse repair.

METHODS

We identified 592 women who underwent anterior and/or apical prolapse repair at our institution from 2009 to 2015. Women were stratified by urodynamic capacity. The primary outcome was incomplete emptying at the longest follow-up (postvoid residual [PVR] > 200 mL). Data were analyzed in the Statistical Analysis System software.

RESULTS

Two hundred and sixty-six women (mean age, 61 years) had preoperative urodynamic tracings available for review. After surgery, there were 519 PVRs in 239 women recorded at up to 2949 days (mean, 396) and nine time points (median, 2; IQR, 1-3). The receiver operator curve for predicted probability of longest follow-up PVR greater than 200 mL (area under curve = 0.67) identified the 600 mL cutpoint which defined large capacity bladder. Large capacity bladders (capacity, >600 mL [n=79] vs ≤600 mL, [n=160]) had a mean: detrusor pressure at maximum flow (21 vs 22 cm H₂ O; P = 0.717), maximum flow rate (19 vs 17 mL/s; P = 0.148), significantly elevated PVR (202 vs 73 mL; P < 0.001), and significantly lower voiding efficiency (VE) (74 vs 82%, P < 0.05). Following prolapse repair, elevated PVR was associated with large capacity (PVR 101 vs 49 mL, P < 0.05). Large bladders had a two- to three-fold risk of longest follow-up PVR greater than 200 mL (14.3%-20.3% [capacity, >600 mL] vs 4.1%-7.0% [capacity, ≤600 mL]). VE was similar after surgery regardless of the capacity (87% vs 88%, P = 0.772).

CONCLUSIONS

The decision to pursue prolapse repair should be individualized and take into account, the bladder capacity and goals for PVR improvement after surgery.

Surgical Management of Female Voiding Dysfunction

Surgical intervention for female voiding dysfunction is common, involving a single or multifaceted approach affecting multiple organ systems in the pelvis. Surgical success relies on knowledge of surgical history, anatomic approaches, and judicious use of supports or materials. Owing to the varied repairs used over the last few decades, it is important for the general surgeon to understand both current and historic approaches. This understanding will help in planning future pelvic surgery as well as in evaluating current ramifications of prior surgery.