A sling operation, using Marlex polypropylene mesh, for treatment of recurrent stress incontinence

Landmarks in vaginal mesh development: polypropylene mesh for treatment of SUI and POP

Vaginal meshes used in the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) have produced highly variable outcomes, causing life-changing complications in some patients while providing others with effective, minimally invasive treatments. The risk:benefit ratio when using vaginal meshes is a complex issue in which a combination of several factors, including the inherent incompatibility of the mesh material with some applications in pelvic reconstructive surgeries and the lack of appropriate regulatory approval processes at the time of the premarket clearance of these products, have contributed to the occurrence of complications caused by vaginal mesh. Surgical mesh used in hernia repair has evolved over many years, from metal implants to knitted polymer meshes that were adopted for use in the pelvic floor for treatment of POP and SUI. The evolution of the material and textile properties of the surgical mesh was guided by clinical feedback from hernia repair procedures, which were also being modified to obtain the best outcomes with use of the mesh. Current evidence shows how surgical mesh fails biomechanically when used in the pelvic floor and materials with improved performance can be developed using modern material processing and tissue engineering techniques.

Bladder neck placement of a synthetic polypropylene sling for the treatment of stress urinary incontinence

INTRODUCTION

Pubo-vaginal sling placed at the bladder neck is the gold standard treatment for stress urinary incontinence (SUI). The synthetic mid-urethral sling (MUS) is now widely used, as morbidity rates with this technique are substantially reduced. This is an initial report on long-term outcomes of a polypropylene sling (PPS) placed in the traditional bladder neck location.

METHODS

A retrospective analysis of all patients who underwent PPS insertion at our institution between 2006 and 2014 was conducted. Patient and urodynamic demographics were recorded. Subjective and objective measures of success were determined by postoperative pad usage and validated incontinence questionnaires.

RESULTS

A total of 170 patients were followed for a median of four years (range 1-8). The mean age was 51 years (±10). Subjective response was assessed in 57% of patients; the overall subjective cure rate was 85.3% (n=145), subjective improvement rate was 4.1% (n=7), and the subjective failure rate was 10.6% (n=18). The mean Urogenital Distress Inventory (UDI)-6 score was 6.5 (±5.6) out of a maximum score of 24 and the Incontinence Impact Questionnaire (IIQ)-7 score was 5.5 (±6.3) out of a maximum score of 28. There was no significant difference in objective outcome measures in those with an abdominal leak-point pressure (ALPP) < or >60 cmH₂O.

CONCLUSIONS

Bladder neck placement of a PPS resulted in cure rates of 85% in this series. SUI secondary to intrinsic sphincter deficiency (ISD) and urethral hypermobility were treated with equal success. Bladder neck PPS placement has a role in the treatment of SUI. Our data may well reassure rectus fascia sling (RFS) surgeons who wish to take advantage of faster postoperative recovery using the less invasive PPS placed at the bladder neck.

Minimally invasive treatment for female stress urinary incontinence (SUI): a review including TVT, TOT, and mini-sling

Treatment for female stress urinary incontinence (SUI) has progressed rapidly over the past ten years in the search for less invasive methods to treat this disease. There have been over 100 procedures described in the literature to date to treat female SUI; however, only two procedures have stood the test of time and have adequate cure rates: the retropubic colposuspension (Burch, MMK) and the sling. The laparoscopic approach to minimize the Burch procedure was described in the 1990s, but the evolution of the retropubic tension-free vaginal tape sling (TVT) in the late 1990s revolutionized the treatment of female SUI. More recently, the transobturator technique (TOT) and the single-incision mini-sling have been reported in attempts to further reduce the risks of sling placement. The current chapter reviews the history of treatment of female SUI and the development of these newer, less-invasive techniques. The procedures themselves are described, the risks of mesh complications reviewed, and the literature reviewed for current data on the different approaches and procedures.

Rising use of synthetic mesh in transvaginal pelvic reconstructive surgery: a review of the risk of vaginal erosion

Recently, the use of surgical mesh in pelvic floor surgery has become increasingly popular. While the reduction of surgical failure rates in vaginal reconstructive surgery is of critical importance, the addition of graft materials must be shown to improve anatomical outcomes and at least maintain, if not improve, lower urinary tract, bowel, and sexual function, as well as quality of life for the patient. Synthetic materials still have several disadvantages including vaginal erosion. Several factors contribute to the wide range of vaginal erosion rates, including patient characteristics such as age and estrogen deficiency; operative technique; implant size; and the specific properties of the graft material, such as pore size, stiffness, elasticity, and basic tissue compatibility. It is the aim of this article to present a critical review of the risk of vaginal erosion with use of synthetic grafts during vaginal reconstructive surgery.

Urodynamic changes after tension-free sling procedures: Mycromesh-Plus® vs TVT sling®

Assortments of suburethral sling procedures have become increasingly important in the treatment of stress urinary incontinence (SUI). This study compared a consecutive series of patients undergoing two types of no-tension, midurethral sling procedures: a traditional pubovaginal technique and graft (modified polytetrafluoroethylene graft; Mycromesh-Plus [MMP]) and the more recently introduced tension-free vaginal tape (TVT) sling. We observed for differences in success rates, urodynamic parameters, and complications of the two procedures. One group received a MMP sling, which was placed at the midurethra without tension. The other group underwent a minimally invasive TVT sling. Multichannel urodynamic studies were performed pre- and postoperatively. Cure rates for SUI were similar for the two groups (95 vs 95%). Urgency and urge incontinence symptoms improved substantially in both groups. Comparison of pre- and postoperative urodynamic indices demonstrated no differences in changes in average functional urethral lengths, changes in maximum urethral closure pressures, or improvement in pressure transmission ratios. Both groups showed a decrease in urethral mobility postoperatively. However, the TVT group demonstrated a lesser degree of change. While the TVT group did spontaneously void earlier than the MMP group (5.7 vs 9.7 days, p < 0.05), this did not result in significantly different postvoid residual volumes (71 vs 101 mL). Complications, including need for self-catheterization and sling revision or removal, and urinary tract infections also were fewer in the TVT group. This study demonstrated that the TVT sling affords an equivalent cure of SUI with similar urodynamic changes but significantly fewer complications than the more traditional MMP sling.

Long-lasting evolution of ptosis control after reduction mammaplasty using the hammock technique

BACKGROUND

The hammock technique combines inferior pedicle mammaplasty with retropectoral and inferior suspensions to prevent displacement of breast tissue toward the inferior mammarian pole. This study aimed to assess the long-lasting internal suspension with the author's mammary reduction technique.

METHODS

From 1987 to 2005, the hammock technique was performed for 623 breast reduction patients (1,201 breasts), including 318 women (636 breasts) who underwent the technique between 1994 and 2005. From the latter group, the author retrospectively reviewed the case histories of 281 patients who had come for long-term follow-up evaluation. All had significant ptosis associated with breast hypertrophy. Preoperative and postoperative examinations included evaluation of postoperative bottoming out by monitoring of three measurements: the sternal notch-to-nipple length, the inferior areolar border-to-inframammary fold length, and the distance between the inframmary fold and the projection of the lowest breast contour on the chest wall.

RESULTS

The evaluation data on postoperative ptosis are derived from a control study at 30 months, 5 years, and 7 years or more for 281 women (562 breasts) of the 318 who underwent surgery using this technique over the 11-year period. Review after 2.5 to 7 years or more shows that inferior areolar border-inframammary fold distance increases no more than 10 mm.

CONCLUSIONS

The hammock technique suspension achieves true permanent breast lifting through dermis strips from the inferior pedicle itself. This procedure also gives predictable results, a low morbidity rate, and good breast shape.

The use of synthetic sub-urethral slings in the treatment of female stress urinary incontinence

We set out to review the existing literature regarding the use of synthetic suburethral sling products for the treatment of female stress urinary incontinence. Products currently implanted are examined and scrutinized, and evidence regarding their efficacy and complication rates is noted. Additionally, specifics of presently utilized synthetic materials, including construction method and biocompatibility, are explored and directly correlated to currently marketed products. This investigation was undertaken with the use of the Medline database. Studies pertaining to synthetic or surgical mesh, as well as each specific suburethral sling product, are included. Our findings and ultimately our recommendations stem from the preponderance of evidence supporting the continued use of knitted, macroporous polypropelene mesh slings. Several existing marketed products detailed in the study fit this description. Specific reference is made to recent reports of vaginal erosions and deep space infections related to several specific products. A cautionary note is also made regarding the implantation of transobturator sling products currently marketed without the necessary pre-market testing, potentially placing the public at risk. From the currently available literature on biomaterials, it seems clear that knitted macroporous polypropylene is the material of choice for suburethral implantation. With respect to the means and techniques by which these mesh materials are suburethrally implanted, the surgeon's choice often dictates which method is used, but recent experience has demonstrated that the transobturator approach can be equally as effective as the traditional tension-free vaginal tape, with less-associated morbidity. Ongoing randomized controlled trials will further clarify and distinguish between methods.

Surgery insight: management of failed sling surgery for female stress urinary incontinence

Sling surgery has replaced Burch colposuspension as the most common surgery for women with stress urinary incontinence (SUI). While incontinence surgery has become a routine part of urologic care, the management of surgical complications and recurrent incontinence can be quite difficult. It is important that the urologic surgeon is well informed about the most common complications that are associated with sling surgery, and how to best manage them. In addition, the management of recurrent incontinence following sling surgery should follow a stepwise approach, with appropriate diagnostic studies, conservative treatment if possible, and surgery if necessary. While sling surgery in the patient with urethral hypermobility is often straightforward, reoperation for recurrent incontinence can be more technically challenging. In the patient with a fixed and incompetent urethra, periurethral bulking agents, pubovaginal sling, spiral sling, or artificial urinary sphincter placement may be indicated.

Evolution of biological and synthetic grafts in reconstructive pelvic surgery

Surgery is an evolving science in the attempt to make surgical procedures more effective, safer, and less invasive. Recurrence and subsequent re-operation for stress incontinence and prolapse has been reported to be necessary in one of three patients, so there is a need for improvement [1]. In reconstructive pelvic surgery (RPS), the use of biological and synthetic grafts for the transabdominal and transvaginal treatment of pelvic organ prolapse (POP) or stress urinary incontinence (SI) has improved long-term support and function after surgery. However, the potential benefits of using grafts need to be carefully balanced against the risks of using materials foreign to the patient's body. Pelvic organ prolapse develops secondary to defective endopelvic fascial and muscular support. The levator ani provides resting tonic muscular support for all three pelvic compartments. Once neuromuscular damage occurs, extra strain is placed on the connective tissue supports, which may also subsequently fail. To date, there is no surgery that adequately addresses the issue of neuromuscular damage of the pelvic floor musculature. In conventional POP surgery, defective support is repaired by suturing of the patient's own connective tissue, fascia, or ligaments. The rationale for the use of grafts is to reinforce and strengthen pelvic organ repairs similar to the use of grafts to strengthen abdominal hernia repair.

Minimally invasive surgical techniques for stress incontinence surgery

Minimally invasive techniques for surgical correction of stress incontinence date back to the late 1950s. Since that time there have been many developments to attempt to emulate the good results achieved by open surgery with less surgical morbidity. Needle suspensions have attempted to reposition the bladder neck in the same way as a colposuspension. However, although numerous variations have been described, they do not have the long-term outcomes of colposuspension. These variations, their complications and long-term outcome are discussed. Sling surgery, especially the tension-free vaginal tape (TVT), has probably had the largest impact on incontinence surgery in recent years, offering a procedure with low morbidity and, thus far in the medium term, outcomes comparable with those of more invasive procedures. This has led the TVT procedure to become the most common procedure performed worldwide for stress incontinence. With the benefit of lessons learnt from the use of synthetic material in the genitourinary tract, some worries remain with regard to the long-term complications of TVT. Other non-synthetic material should not be forgotten, and the advantages and disadvantages of various sling materials are compared. Injectables have an established place in the treatment of sphincter deficiency, though long-term results are poor compared to those of other procedures. Various materials used and the technique for their injection are discussed.

Vaginal mesh extrusion associated with use of Mentor transobturator sling

OBJECTIVES

To describe my experience of vaginal mesh extrusion using the monofilament polypropylene transobturator sling, the Mentor ObTape. The Mentor ObTape was the first transobturator sling developed as an alternative to the retropubic commercially available suburethral slings for providing mid-urethral support as treatment of female stress urinary incontinence.

METHODS

Thirty patients underwent transobturator suburethral sling placement for anatomic stress urinary incontinence using the ObTape from October 2003 to January 2005. A retrospective chart review was performed to retrieve data on the safety, efficacy, complications, and outcomes using this product.

RESULTS

Six patients (20%) to date have presented with defective vaginal healing manifested by extrusion of the sling material. Five patients required surgical removal of the sling material, and one underwent a trial of conservative management. No urethral erosions were noted.

CONCLUSIONS

In my experience, the Mentor ObTape sling, which uses a nonwoven, minimally elastic, micropore, monofilament polypropylene mesh, incurs an unacceptably high rate of defective vaginal wound healing and mesh extrusion.

HIGH INCIDENCE OF VAGINAL MESH EXTRUSION USING THE INTRAVAGINAL SLINGPLASTY SLING

PURPOSE

The intravaginal slingplasty (IVS) is a tension-free vaginal tape variant that uses a multi-filament polypropylene tape to support the mid urethra for the treatment of female stress urinary incontinence. Numerous cases of defective vaginal wound healing have been described in the international urogynecological literature. We describe our experience of vaginal mesh extrusion using the IVS sling.

MATERIALS AND METHODS

A total of 35 patients underwent suburethral sling procedures for anatomical stress urinary incontinence using the IVS system from November 2002 to September 2003. A retrospective chart review was performed to retrieve data on safety and efficacy, complications and outcomes using this product.

RESULTS

Six patients (17%) to date have presented with defective vaginal healing manifested by extrusion of the sling material. Mean time to presenting symptoms was 9 months (range 2 to 15). All patients required surgical removal of the sling material. No urethral erosions were noted.

CONCLUSIONS

Our experience suggests that the IVS sling system, which uses a multi-filament polypropylene suburethral mesh, incurs an unacceptably high rate of defective vaginal wound healing and mesh extrusion.

Complications of transvaginal silicone-coated polyester synthetic mesh sling

OBJECTIVES

To report a premarket multicenter trial to test the feasibility of a transvaginal silicone-coated polyester synthetic mesh sling in women with anatomic incontinence.

METHODS

Fifty-one patients in four centers underwent transvaginal placement of a silicone-coated polyester synthetic mesh sling (American Medical Systems) during an 8-month period. Of the 51 patients, 31 were part of a prospective institutional review board-approved feasibility trial in three centers funded by American Medical Systems (group 1) and 20 underwent implantation by a single surgeon and their data were retrospectively reviewed (group 2). The studies were done concomitantly, and all slings were fixed transvaginally with bone anchors. All patients in group 1 were followed up at 4 weeks, 6 months, and 1 year (as applicable) with repeat questionnaires, physical examinations, and pad tests.

RESULTS

In group 1, 20 patients completed 6 months of follow-up. Ten patients (32%) required a second surgical procedure at an average of 183 days (range 68 to 343) postoperatively. Eight patients (26%) had vaginal extrusion of the mesh, one (3%) required sling lysis, and one (3%) required sling removal because of infection. In group 2, 8 patients (40%) underwent sling removal for vaginal extrusion at a mean of 160 days (range 83 to 214).

CONCLUSIONS

Transvaginally placed silicone-coated mesh slings used for the treatment of urinary incontinence demonstrated an unacceptably high vaginal extrusion rate in this study. Once identified, this study was immediately terminated, and this product was not marketed for this application in the United States.

Voiding function after a modified no-tension pubovaginal sling

Voiding dysfunction following sling procedures for correction of genuine stress urinary incontinence (GSI) is a frequently reported complication. This study sought to determine if voiding dysfunction could be reduced by eliminating sling tension against the urethra. Participants were diagnosed with GSI and randomized to one of two surgical groups. One received a conventional suburethral sling and the other received a modified sling placed at the mid-urethra without tension. Voiding trials after surgery monitored for voiding dysfunction. Multichannel urodynamic studies were performed pre- and post-operatively. Cure rates for GSI were similar for the two groups (91.7 vs. 88.5%). The 27 patients in the modified group voided an average of 5 days earlier than the 21 patients in the conventional group. Conventional group patients were more likely to have urinary retention (125 vs. 49 cc, p=0.03). The modified group had a lesser change in average closure pressure following surgery. Results suggested a higher increase in urethral resistance in the conventional group (0.72 vs. 1.88 cm H2O ml(-2) sec2). No differences were seen in symptomatic urinary urgency or urge incontinence following surgery. This study demonstrated a no-tension sling at the mid-urethra to afford equivalent cure of GSI with significant reduction of voiding dysfunction.

High rate of vaginal extrusion of silicone-coated polyester sling

OBJECTIVES

To report the results of a pilot study evaluating the suitability of silicone-coated polyester as a suburethral sling material for female stress incontinence surgery.

METHODS

Ten women with stress or mixed urinary incontinence were prospectively evaluated with history and physical examination, pad test, urodynamic studies, and the Incontinence-Quality of Life questionnaire. The 2 x 7-cm sling was secured with transvaginal bone anchors placed through an anterior vaginal wall incision. Patients were evaluated at 1, 6, and 12 months by history and physical examination, pad test, and the Incontinence-Quality of Life and Success Rate and Overall Patient Satisfaction questionnaires.

RESULTS

Ten patients (mean age 62.3 years) underwent successful placement of the suburethral sling. The Incontinence-Quality of Life scores improved from a mean total score of 43.3 +/- 14.6 preoperatively to 97.7 +/- 14.4 at 1 year postoperatively (P <0.001). The Success Rate and Overall Patient Satisfaction questionnaires completed at 1 year demonstrated a mean satisfaction rating of 8.9 +/- 1.7 (scale 1 to 10), and the mean reported improvement in incontinence was 90% +/- 16.3%. The mean pad weight decreased from 103.1 +/- 33.2 g preoperatively to 1.6 +/- 1.01 g at 1 year (P <0.007). Two patients (20%) developed vaginal extrusion of the suburethral sling at 6 and 10 months. The slings were removed surgically. Both women healed without incident and reported continued continence at 1 year without additional surgical intervention.

CONCLUSIONS

Placement of a suburethral sling using transvaginal bone anchors and silicone-coated polyester is an effective surgical treatment for stress urinary incontinence at 1 year. The high rate of vaginal extrusion in our series limits its utility.

Broad based tension-free synthetic sling for stress urinary incontinence: 5-year outcome

PURPOSE

The use of nonabsorbable synthetic material has been questioned due to reports of erosion and infection. We present the 5-year followup outcome of stress urinary incontinence (SUI) treated using polypropylene mesh as a pubovaginal sling.

MATERIALS AND METHODS

A retrospective analysis was performed of 58 consecutive patients who underwent pubovaginal sling procedures using polypropylene mesh since April 1996 for types II and III SUI at our institution. The technique included a single midline anterior vaginal wall incision with full-thickness flaps. Broad based polypropylene mesh was used to support the vesicourethral junction entering the retropubic space through the endopelvic fascia and bone anchors were used for fixation. Patient satisfaction was evaluated during followup office visits and/or telephone interview by an individual not involved in any surgeries. All procedure failures were evaluated by urodynamics.

RESULTS

Of the 58 patients 49 were available for analysis. Average followup was 59.34 months (range 29 to 77). Of the 49 patients 40 (81.63%) were dry and 2 (4.08%) improved (1 pad daily). De novo urgency and urgency related incontinence was reported in 1 case each. Three patients (8.16%) had recurrent SUI, while prolonged retention developed with subsequent urethrolysis required in 2 (4.08%). None of the patients have experienced infection, nonhealing or erosion of the synthetic slings to date.

CONCLUSIONS

In our experience polypropylene mesh used as a broad based tension-free sling was successful for treating all types of SUI. In our opinion technique and case selection have a bearing on outcomes.

Laparoscopic Two-Team Slings for Women with Stress Urinary Incontinence

STUDY OBJECTIVE

To review long-term success and complication rates of laparoscopic two-team sling procedures in women with stress urinary incontinence or mixed incontinence confirmed by urodynamic testing and cystoscopy.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Tertiary urogynecology unit at a university-affiliated teaching hospital.

PATIENTS

One hundred seventy-five women.

INTERVENTIONS

Laparoscopic two-team sling procedure.

MEASUREMENTS AND MAIN RESULTS

The extraperitoneal approach to the space of Retzius was accomplished using a balloon device, and the intraperitoneal approach involved a transverse incision through the anterior parietal peritoneum 6 cm above the symphysis. A 1.5- to 2.0-cm wide strip of polypropylene mesh was inserted through a vertical incision along the anterior vaginal wall, perforating the urogenital diaphragm under laparoscopic guidance. The mesh was sutured to Cooper's ligaments bilaterally with 0 polypropylene sutures. Mean operating time was 80.1 +/- 30.0 minutes, mean estimated blood loss was 160 +/- 146 ml, and mean hospital stay was 2.4 +/- 1.2 days. Patients were followed at 6 weeks, 6 months, 1 year, and yearly (mean 17.8 mo, range 1-5 yrs).

CONCLUSION

Laparoscopic two-team sling procedures can be performed safely in women with recurrent stress incontinence and those with risk factors for failure of retropubic urethropexy. Long-term success rates are excellent (91.1%) with few complications.

The surgical results of the pubovaginal sling procedure using polypropylene mesh for stress urinary incontinence

OBJECTIVE

To investigate the surgical results after a pubovaginal sling procedure using polypropylene mesh in women with stress urinary incontinence (SUI).

PATIENTS AND METHODS

Sixty-four women with different types of SUI underwent a pubovaginal sling procedure, using polypropylene mesh. The sling was placed at the level of the proximal half of the urethra and tied with adequate tension, but not obstructing the bladder outlet. A video-urodynamic study and transrectal ultrasonography were undertaken before and after surgery. The surgical results were assessed and the urodynamic changes compared at different stages.

RESULTS

At a median follow-up of 24 months, 52 patients (81%) were completely continent, 10 (16%) had an improvement but with mild SUI, and two had persistent SUI requiring a second sling procedure. The treatment result was considered satisfactory by 55 patients (86%). The video-urodynamic study showed no significant change in voiding pressure, cystometric capacity and residual urine volume after surgery. The bladder neck opening time was increased at 7 days and the maximum flow rate increased at 3 months after surgery. Transrectal ultrasonography showed that all the polypropylene mesh slings were located beneath the bladder neck and proximal urethra, with no notable granuloma formation around the sling.

CONCLUSION

The pubovaginal sling procedure is effective in treating female SUI, using polypropylene mesh as the sling material. The video-urodynamic results showed that a pubovaginal sling of polypropylene mesh causes no bladder outlet obstruction when the correct surgical technique is used.

Urinary retention after tension-free vaginal tape procedure: incidence and treatment

OBJECTIVES

To review our experience with persistent urinary retention after the tension-free vaginal tape (TVT) procedure and report our treatment results. Ulmsten recently introduced the TVT procedure for female stress urinary incontinence. Although the morbidity is minimal, no surgical procedure is without risks, and experience will better define the morbidity of the TVT procedure.

METHODS

Since November 1998, we have collectively performed 600 TVT procedures. Of these, 17 patients (2.8%) developed urinary retention or symptoms consistent with obstruction (including hesitancy, straining to void, or feeling of incomplete emptying) lasting more than 1 week from the date of the procedure. We reviewed the operative record, noting the operative time, estimated blood loss, presence of bladder penetration, and any reported complications. All 17 patients subsequently underwent transvaginal release on an outpatient basis.

RESULTS

Seventeen patients (mean age 56 years, range 38 to 81) underwent sling release a mean of 64 days (range 6 to 228) after the TVT procedure. All patients voided to completion within 24 hours of release and reported no further subjective complaints of outlet obstruction. None of the subjects reported de novo urge incontinence or urgency. In each patient, the estimated blood loss was minimal; the operative time averaged 15 minutes. One urethral injury occurred and was managed intraoperatively without sequelae. Sixteen patients who underwent sling release have remained dry; the remaining patient, in whom a urethral injury was repaired, redeveloped stress incontinence and underwent an uncomplicated successful transvaginal sling procedure.

CONCLUSIONS

Outlet obstruction is a risk of the TVT procedure and occurred with an incidence of 2.8% in our experience. The TVT mesh can be released by a simple vaginal incision under local anesthesia with rapid return to normal voiding. Although the number of patients studied was small, stress incontinence did not recur after uncomplicated release in our series.

Comparison of video urodynamic results after the pubovaginal sling procedure using rectus fascia and polypropylene mesh for stress urinary incontinence

PURPOSE

Video urodynamic changes were compared after the pubovaginal sling procedure using rectus fascia or polypropylene mesh in women with stress urinary incontinence.

MATERIALS AND METHODS

A total of 50 women with various types of stress urinary incontinence were treated with the pubovaginal sling procedure using randomly abdominal rectus fascia in 24 or polypropylene mesh in 26. The sling was placed at the level of the bladder neck and tied with sufficient tension to prevent urinary leakage without obstructing the bladder outlet. Video urodynamics were performed preoperatively, and 7 to 14 days and 3 to 6 months postoperatively in all cases. Surgical results and urodynamic changes after the pubovaginal sling procedure were compared in the 2 groups. Long-term results were evaluated at a mean followup of 2 years.

RESULTS

Complete continence was achieved in 23 patients (95.8%) in the rectus fascia group and 26 (100%) in the polypropylene mesh group, including 1 initial failure with reoperation, at a median followup of 24 and 23 months, respectively. The subjective success rate was 91.6% for rectus fascia and 92.3% for polypropylene mesh. The main cause of dissatisfaction was persistent urge incontinence and dysuria in 2 cases each. In each group video urodynamics revealed a mild but nonsignificant decrease in maximum urinary flow and a significant increase in bladder neck opening time at 7 to 14 days versus baseline. However, these parameters returned to baseline within 3 to 6 months postoperatively. Voiding pressure, cystometric capacity and post-void residual urine also showed no significant change in either group after the pubovaginal sling procedure. Patients treated with a polypropylene mesh sling had a shorter operative time and hospital stay, a higher spontaneous voiding rate after catheter removal and a lower incidence of wound pain after surgery. One patient treated with polypropylene mesh had sling margin extrusion. The incidence of new onset detrusor instability and persistent dysuria was similar in the 2 groups. Transrectal sonography of the sling showed that it was located beneath the bladder neck and proximal urethra in all patients in each group.

CONCLUSIONS

The results of this study show that the pubovaginal sling procedure using rectus fascia or polypropylene mesh as the sling material had similar effectiveness for treating female stress incontinence but the polypropylene group had more rapid recovery. Postoperatively video urodynamics demonstrated that the pubovaginal sling using either sling material did not cause bladder outlet obstruction with proper surgical technique.

Short-term complications of pubovaginal sling procedure for genuine stress incontinence in women

OBJECTIVES

To evaluate the complication rate intraoperatively and within the first 30 postoperative days of the pubovaginal sling procedure.

METHODS

From January 1992 to September 1996, we prospectively analyzed 90 women with type II and III genuine stress incontinence (age 38 to 84 years, average Valsalva leak point pressure 57.5 cm H2O) who underwent the pubovaginal sling procedure at our institute. Sixty percent of patients had no previous surgical treatment for their incontinence. Thirty-three percent of our patients have significant comorbidity (chronic obstructive lung disease, diabetes, coronary artery disease, peripheral vascular disease).

RESULTS

The complication rate within the first 30 postoperative days was 19%, which included pneumonia (1.1%), deep venous thrombosis (1.1%), urinary retention (3.3%), wound infection (7.7%), intraoperative bladder laceration (3.3%), urinary tract infection (1.1%), and superficial thrombophlebitis (1.1%). A similar complication rate was noted among our patients with no previous surgical treatment for their incontinence.

CONCLUSIONS

The complication rate of our prospective series of pubovaginal sling procedures was comparable to that of the other surgical procedures for genuine stress incontinence reported in the literature. We conclude that even though the pubovaginal sling procedure is a relatively complex surgery, in view of its satisfactory long-term success rate reported in the recent literature, pubovaginal sling procedure should also be considered a primary surgical treatment for genuine stress incontinence in a selected population of women.

Surgical management of recurrent stress urinary incontinence: A 12-year experience

OBJECTIVE

The goal of the study was to evaluate the surgical procedures used to manage recurrent stress urinary incontinence in a tertiary referral center, to compare the procedures with respect to efficacy and failure rates, and to identify risk factors for failure.

STUDY DESIGN

The health records of patients who underwent surgical treatment of recurrent stress urinary incontinence performed by the senior author (H.P.D.) between 1984 and 1995 were reviewed. The objective cure rate was evaluated by means of urodynamic studies and physical assessment, and the subjective cure rate was determined by means of historical report. In light of our selection criteria, the time to failure, the number of previous anti-incontinence procedures needed to give the best cure rate, and the risk factors for failure of the 3 predominantly used surgical techniques were determined. The statistical methods used were the chi(2) test with 95% confidence interval, the Cox proportional hazard model with logistic regression, and survival analysis.

RESULTS

One hundred ninety-eight female patients were surgically treated for recurrent stress urinary incontinence between January 1, 1984, and December 31, 1995. Four surgical techniques were used: (1) the combined abdominovaginal (2-team) polypropylene (Marlex; Phillips Petroleum Company, Bartlesville, Okla) sling (group 1, n = 70), (2) the modified urethral Marlex sling (group 2, n = 68), (3) Burch retropubic colpourethropexy (group 3, n = 49), and (4) suburethral Marlex sling (group 4, n = 11). The study population consisted of 118 patients. The rest of the original 198, including all the patients in group 4, were excluded. Objective and subjective cure rates of 69% and 89%, 66% and 96%, and 69% and 88% were calculated for groups 1, 2, and 3, respectively. By 6 years after the operation 100% of the failures in groups 1 and 2 had occurred, and 88% of the group 3 failure occurred within 2 years after the operation. Cure rates of 77%, 73%, and 38% (P =.320) were achieved with the 2-team sling procedure (group 1) after 1, 2, and 3 previous anti-incontinence operations, respectively, whereas cure rates of 81%, 25%, and 0% (P =.001) were obtained with the Burch procedure (group 3) after 1, 2, and 3 previous anti-incontinence operations, respectively. This indicates that the Burch procedure should be avoided after >1 previous operation, whereas the 2-team sling can be used after >/=3 previous anti-incontinence procedures. Statistical significance could not be determined for group 2 because that procedure was not used to treat any patient with 3 previous operations. Age was a marginal risk factor for failure in group 1. No statistically significant risk factors were identified for group 2. The number of previous anti-incontinence procedures was the major risk factor for failure in group 3 when age, parity, gravidity, weight, hormone replacement therapy, number of previous anti-incontinence procedures, and urethral closure pressure were covariables.

CONCLUSION

According to our data, both sling procedures and Burch retropubic colpourethropexy can be used to surgically manage recurrent stress urinary incontinence with selection criteria such as those that we used. In our opinion comparative prospective studies of different surgical techniques with similar selection criteria, long-term follow-up of >/=10 years, and the inclusion of urodynamic studies may be the most ethical way to determine the right operations for recurrent stress urinary incontinence.

Tolerance of synthetic tissues in touch with vaginal scars: review to the point of 287 cases

With an experience of 287 vaginal way operations using synthetic material, the authors make a review about the tolerance of the tissues. Three tissues were used (polytetrafluoroethylene, Dacron and Lyodura). The procedures are: Mouchel, big and small slings, Stamey and para vaginal refect procedures. At 30 months, the tolerance is 70% for Mouchel and 90% for sling procedures. The rejection rate with Dacron is globally 19.3% vs. 30.3% for Gore Tex . The authors describe materials' history, clinical symptoms and histopathologic signs of the intolerance. They think that the synthetic tissue tolerance is proportional to the exhibit surface and to the distance which separates it from the scar. The substratum of the intolerance process answers with two explanations: infection and foreign body reaction. Different theories are explained. Infection can be an ethiologic factor in early rejection. With rigid material, a small ulcer is formed and serves as a nidus for an ascending infection. Foreign material acts as an adjuvant by decreasing the number of bacteria necessary to produce an infection. The tissue reaction may be an immune response to Dacron, a delayed hypersensitivity reaction, or a graft vs. host antigen-antibody reaction. The ideal synthetic mesh material for pelvic surgery has yet to be developed.

Anterior colporrhaphy reinforced with Marlex mesh for the treatment of cystoceles

This study assesses the use of Marlex mesh in conjunction with anterior colporrhaphy for the correction of cystocele with or without urinary stress incontinence. A retrospective review was carried out of 12 years' experience with 142 patients undergoing a modified anterior colporrhaphy reinforced with Marlex mesh. All patients had preoperative urodynamics. Pre- and postoperative symptoms were compared and patients were examined for recurrent prolapse and mesh complications. Mean follow-up time was 3.2 years. No patients experienced recurrent anterior vaginal wall prolapse. Three patients developed mesh erosions into the vagina. There was a 74% success rate in the treatment of urinary stress incontinence. Marlex mesh used as a reinforcement for anterior colporrhaphy is effective in preventing recurrent anterior wall descent, with minimal complications.

Pubovaginal slings: past, present and future

Renewed interest in the pubovaginal sling procedure for stress urinary incontinence has occurred in response to recent reports of poor durability and inconsistent efficacy associated with simple cystourethropexy. Many of the failures are felt to represent patients with an unrecognized component of intrinsic sphincteric deficiency. Historically slings have a favourable cure rate, but have been perceived as having unacceptably high rates of prolonged urinary retention and secondary detrusor instability. This article reviews the preoperative evaluation and indications for pubovaginal slings, describes the evolution of the current techniques, and discusses choice of sling material, surgical approach, results and complications. It is hoped that this review will stimulate interest in this versatile but technically challenging procedure.

The use of mesh in gynecologic surgery

The aim of this review was to compare properties of the most commonly used synthetic meshes and describe their use in gynecologic procedures. An Ovid search of the English literature from 1966 to the present was carried out, together with a hand search of Index Medicus from 1950 to 1965. Articles involving the use of mesh in surgical procedures or comparative studies of the different mechanical properties of mesh are included. Overviews from urogynecologic texts and surgical texts are also included. All studies in this review consisted of retrospective case series (21 suburethral sling articles, 15 sacrocolpopexy articles, and five pelvic sling articles). No randomized prospective trials were available. Outcome variables, including cure rates and mesh-related complications, are reviewed and compared. Conclusions show that long-term success of the suburethral sling with synthetic mesh ranges from 61% to 100%, and the success rate of the abdominal sacrocolpopexies using mesh ranges from 68% to 100%. Mesh-related complications rates are frequent, with up to a 35% removal rate and 10% sinus tract formation for suburethral slings and 9% erosion rate for sacrocolpopexy. The ideal synthetic mesh material for pelvic surgery, one that induces minimal foreign-body reaction with minimal risk of infection, rejection and erosion, has yet to be developed.

The surgical management of urinary incontinence in myelodysplastic children

Over a 4-year period, 69 patients with intractable urinary incontinence secondary to myelodysplasia have undergone surgical therapy to try to achieve continence. Preoperative evaluation used uroradiological and urodynamic studies, including measurement of leak point pressure and leak point volume. Twenty-one patients had a procedure to increase outlet resistance, 30 patients had bladder augmentation, and 18 patients had both procedures performed. Fifty-seven of the 69 patients have achieved total continence for a success rate of 83%.

Vaginal wall sling

We describe a new technique for the treatment of urinary incontinence due to intrinsic sphincteric damage in which a sling constructed from vaginal wall is used to provide compression and support of the urethra. A rectangular island of in situ anterior vaginal wall underlying the urethra and bladder neck is developed, the 4 corners are anchored with polypropylene sutures and a ligature carrier is used to transfer the sutures to a suprapubic location. An anterior vaginal wall flap proximal to the island is advanced to cover the island. When the sutures are tied the resulting sling will support the urethra and increase urethral resistance by compression, restoring continence. The advantages are its simplicity, need for only a small incision, short operative time and hospital stay, and reliance on healthy, well vascularized, in situ tissue. Continence has been achieved in 29 of 32 cases. All patients voided spontaneously except for those with neuropathic urethral incompetence who required self-catheterization.

Use of preoperative uroflowmetry and simultaneous urethrocystometry for predicting risk of prolonged postoperative bladder drainage

To select patients at increased risk of needing prolonged postoperative bladder drainage after incontinence surgery, the data obtained from preoperative uroflowmetry and voiding urethrocystometry were analyzed in a group of 43 patients for presence and/or absence of reduced flow rates and detrusor contraction during voiding. All patients with adequate detrusor contraction and flow rates were able to resume spontaneous voiding by the seventh postoperative day. One third of patients voiding without detrusor contraction needed prolonged bladder drainage (p less than 0.05). Presence of normal flow rates reduced their risk to 20 per cent while reduced flow rates enhanced their risk to 100 per cent (p less than 0.05). Changes observed in urethral pressure, abdominal pressures, and flow rates individually were not significant predictors of the need for prolonged bladder drainage.

The Marlex sling operation for the treatment of recurrent stress urinary incontinence: a 16-year review

Between 1968 and 1983, 281 patients with recurrent stress urinary incontinence and nine patients with primary stress urinary incontinence were treated with a two-team (suprapubic vaginal) Marlex urethral sling operation. Selection was based on the patient's history and the clinical demonstration of an anatomic defect in the closure mechanism of the urethra. The operative technique as described in 1970 remains unchanged. The bladder neck is released from the scar and replaced in a midretropubic position on a hammock of Marlex mesh attached to Cooper's ligaments. Patients with a sloughed urethra had a sling operation in conjunction with the reconstruction of a neourethra. The overall success rate based on a minimum 5-year follow-up of 208 patients was 77.4%. There was a high failure rate in the sloughed urethra group. Significant overall complications include bladder neck obstruction and chronic cystitis.

Primary management of urinary stress incontinence by the Marshall-Marchetti-Krantz vesicourethropexy

To evaluate clearly the Marshall-Marchetti-Krantz cystourethropexy in defined populations we did a retrospective study of 151 women who underwent the procedure as a first attempt to correct stress incontinence. Of 140 patients for whom data were available 126 (90 per cent) were cured, 12 (8.6 per cent) were improved and 2 (1.4 per cent) failed. Preoperative cystoscopy was normal in 83 women (67.5 per cent). The most common abnormality was inflammatory change (82.5 per cent). Preoperative findings failed to correlate with postoperative irritative symptoms, indicating that surgical correction of documented mechanical instability is warranted. Concurrent medical problems, such as obesity and chronic obstructive pulmonary disease, were not associated with failures. Significant complications occurred in 11.4 per cent of the patients but there were no deaths. In view of a 90 to 98 per cent success rate with long-term followup (average 45.7 months) the Marshall-Marchetti-Krantz operation should be considered the procedure of choice in cases of primary stress incontinence. In addition, comparisons with other well defined groups and with modifications of the original procedure will be facilitated.