Artificial graft slings at the midurethra: Physiology of continence

Demands and properties of alloplastic implants for the treatment of stress urinary incontinence

Surgical treatment of stress urinary incontinence changed dramatically with the introduction of the tension-free vaginal tape. Owing to its high efficacy and minimal patient discomfort this new minimally invasive procedure quickly obtained widespread acceptance and superseded the abdominal colposuspension as the gold standard. In the course of success of the original method a number of tension-free vaginal tapes flooded the market, varying in approach and material. These variations may strongly influence the safety, efficacy and long-term results of tension-free vaginal tape and its major modification, the transobturator technique. Therefore, it is the aim of this review to closely illuminate available materials and complications associated with this procedure. An extensive Medline search of the published literature up until 2006 on the subject of stress urinary incontinence was carried out. All sources identified were reviewed with particular attention to the method applied, the properties of the mesh materials and clinical complications. Apart from several technical variations, there are marked differences between the different vaginal sling materials, ranging from absorbable collagens over polypropylene to allografts. Although performed globally in substantial and increasing numbers, minimally invasive techniques for the surgical treatment of stress urinary incontinence are lacking sufficient safety data.

Can we predict if overactive bladder symptoms will resolve after sling surgery in women with mixed urinary incontinence?

Persistent overactive bladder and urgency urinary incontinence after sling surgery (pubovaginal sling or midurethral sling) in women with mixed urinary incontinence (MUI) is devastating to patients and frustrating to surgeons who perform anti-incontinence surgery. To better predict the outcomes of sling surgery in women with MUI, preoperative parameters need to be examined to accurately predict postsurgical outcomes. In this review article, we will explore recent literature exploring possible preoperative predictors of persistent overactive bladder and urgency urinary incontinence after sling surgery in women with MUI.

Complications of sling surgery among female Medicare beneficiaries

OBJECTIVE

To analyze Medicare claims data to determine short-term complications after sling surgery among female beneficiaries aged 65 years and over.

METHODS

We analyzed the 1999-2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures between January 1, 1999, and July 31, 2000, (the index period) were identified by Physicians Current Procedural Terminology Coding System (4th edition) and tracked for 12 months. Main outcome measures were complications as identified by International Classification of Diseases (9th revision) (ICD-9) diagnosis codes and Current Procedural Terminology procedure codes in the first postoperative year.

RESULTS

A total of 1,356 sling procedures were performed during the index period. In the 3 months after the procedure, 12.5% of women developed surgical or urologic complications, and 33.6% were diagnosed with urinary tract infections. Within 1 year of the procedure, 6.9% of subjects had a new diagnosis of outlet obstruction, and 8.0% underwent treatments to manage outlet obstruction. There was a high incidence of new diagnoses of urge incontinence (15.2%) and treatment of pelvic prolapse (23.2%). Both cystoscopy and urodynamic testing, which may serve as indicators of possible complications, were performed frequently during the first year after surgery (32.4% and 30.5%, respectively). Patient race, age, and comorbidity each had a significant influence on outcomes.

CONCLUSION

Complication rates within 1 year after sling surgery among Medicare beneficiaries were found to be higher than those reported in the clinical literature. The high rates of postoperative urinary tract infections, prolapse, and outlet obstruction suggest the need for quality improvement measures in the management of women with incontinence and pelvic prolapse.

LEVEL OF EVIDENCE

III.

Long-Term Durability of the Distal Urethral Polypropylene Sling Procedure for Stress Urinary Incontinence: Minimum 5-Year Followup of Surgical Outcome and Satisfaction Determined by Patient Reported Questionnaires

PURPOSE

We report on the long-term outcomes of the distal urethral polypropylene sling.

MATERIALS AND METHODS

We performed a prospective study of all consecutive patients who underwent a distal urethral polypropylene sling procedure between November of 1999 and April of 2000 for treatment of SUI. Surgical outcome was determined by patient self-assessment, and included symptom, bother and quality of life questionnaires. Physicians were blinded to patient responses. All patients had a minimum 5-year followup. Every patient treated was included in reporting outcomes in the intent to treat analysis.

RESULTS

There were 69 patients treated a minimum of 5 years before the analysis. Cases lost to followup were defined as treatment failures. At a minimum followup of 5 years patient determined subjective success rate was 88%. More than 5 years after surgery 72% of patients reported no symptoms of SUI and 74% reported never being bothered by SUI. Patients reported an overall mean improvement of symptoms of 81%, and quality of life due to urinary symptoms between pleased and mostly satisfied.

CONCLUSIONS

The distal urethral polypropylene sling procedure has low morbidity and excellent durability in treating patients with SUI.

Mixed incontinence: Stressing about urge

Urgency and urinary urge incontinence are troublesome and complex symptoms that can complicate the diagnosis and treatment of stress urinary incontinence. Despite this fact, first-line intervention frequently is directed toward the incompetent bladder neck using surgical approaches. Persistent urgency or detrusor instability following anti-incontinence surgery reduces patient satisfaction and overall continence in most series. This article discusses current theories explaining the etiology of mixed incontinence. It also reviews the results of anti-incontinence surgery for mixed incontinence and discusses management strategies. Possible predictors of outcome after sling surgery in this complex group of patients also are presented.