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Garcia C, Homewood D, Gani J, O'Connell HE. Perspectives on technology: urethral slings in a post-mesh world. BJU Int 2024; 134:337-350. [PMID: 38822540 DOI: 10.1111/bju.16388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
OBJECTIVES To detail the history of synthetic mid-urethral slings (SMUSs) and fascial slings, their efficacy, associated complications, and changes to practice that have occurred after the issuing of the 2011 US Food and Drug Administration (FDA) Safety Communication statement on transvaginal mesh (TVM), and to highlight the need for surgical registries and high-quality randomised controlled data to guide recommendations for continence procedures, in view of current concerns regarding mesh. METHODS A literature search was conducted in EMBASE, PubMed, and the Cochrane Database of systematic reviews to identify articles published from 2011 onward, following the FDA Safety Communication regarding TVM. RESULTS Prior to the formal FDA Safety Communication in 2011, TVM was considered a safe option for the treatment of both pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The 2011 FDA safety communications and ensuing widely publicised litigation against TVM manufacturers have shifted both surgeon and patient acceptance of mesh products. Several efforts by medical and government bodies have been made to establish ways to monitor the surgical outcomes and safety of mesh products. The Australasian Pelvic Floor Procedure Registry is one such example. Although SMUSs have a long and established safety profile, perceptions of mesh products for SUI have also been negatively affected. The extent of this, however, has yet to be adequately measured through qualitative and quantitative data. The available data suggest it has been difficult for patients and consumers to distinguish between TVM morbidity for POP vs SUI. Furthermore, there remains a lack of high-quality randomised or real-world registry data to definitively exclude the SMUS from the SUI treatment algorithm. Since SMUSs are a viable option for SUI treatment, the concept of a 'post-mesh world' remains contentious. CONCLUSION Controversies surrounding SMUSs have changed the treatment landscape of SUI. Against the background of significant litigious action following the FDA warnings against mesh use, there has been significant reduction in the uptake of synthetic mesh products. Although there are ample data related to surgical outcomes and safety for both autologous fascial and retropubic SMUSs in carefully selected patients, informed consent and surgical training will be of paramount importance as newer synthetic materials reach clinical maturity.
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Affiliation(s)
- Cindy Garcia
- North Shore Private Hospital, Sydney, NSW, Australia
| | - David Homewood
- Department of Urology, Western Health, Melbourne, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
- International Medical Robotics Academy, Melbourne, VIC, Australia
| | - Johan Gani
- Department of Urology, Western Health, Melbourne, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
- Epworth Healthcare, Melbourne, VIC, Australia
| | - Helen E O'Connell
- Urological Society of Australia and New Zealand, Edgecliff, NSW, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
- Epworth Healthcare, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, Australia
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Larouche M, Zi Zheng MM, Yang EC, Konci R, Belzile E, Gill PK, Geoffrion R. Synthetic vs nonsynthetic slings for female stress and mixed urinary incontinence: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 231:166-186.e8. [PMID: 38432418 DOI: 10.1016/j.ajog.2024.02.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/18/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE This study aimed to systematically review objective and subjective success and surgical outcomes of suburethral sling surgery for female patients with stress or mixed urinary incontinence using synthetic vs nonsynthetic material with corresponding surgical approaches (retropubic or transobturator). DATA SOURCES We systematically searched Medline, Embase, EBM Reviews, ClinicalTrials.gov, and Web of Science Core Collection using standardized Medical Subject Headings (MeSH) without date restrictions (PROSPERO-registered). We double-screened studies and used backward citation chaining. STUDY ELIGIBILITY CRITERIA We included peer-reviewed randomized controlled trials and prospective or retrospective comparative studies examining outcomes of retropubic or transobturator synthetic vs nonsynthetic (autologous, allograft, or xenograft) slings for female stress or mixed urinary incontinence, with available English or French full texts. We excluded minislings (single insertion point). We allowed slings for recurrent stress or mixed urinary incontinence, and slings concomitant with prolapse surgery, with at least 6 weeks of postoperative follow-up. We excluded systematic reviews, meta-analyses, review studies, case-control studies, case reports, studies that did not describe surgical approach or material, and studies of combination slings. METHODS We evaluated study quality using RoB, the Cochrane risk-of-bias tool for randomized controlled trials, and the Newcastle-Ottawa scale for observational studies. We used pooled relative risk with 95% confidence intervals to estimate the effect of sling material type on each outcome through meta-analysis and meta-regression, as appropriate. RESULTS We screened 4341 abstracts, assessed 104 full texts, and retained 35 articles (30 separate studies). For retropubic synthetic vs nonsynthetic slings, there was no difference in the number of objectively or subjectively continent patients. The rates of reoperation for stress urinary incontinence and overall were higher with nonautologous retropubic slings than with synthetic slings. Compared with autologous slings, retropubic synthetic slings were associated with higher subjective continence in populations with ≥25% recurrent stress urinary incontinence (relative risk, 1.27; 95% confidence interval, 1.12-1.43). There were no differences in continence between transobturator synthetic and nonsynthetic slings. Subjective satisfaction was better in the transobturator synthetic group than in the autologous sling group (relative risk, 1.42; 95% confidence interval, 1.03-1.94). CONCLUSION Synthetic and nonsynthetic slings have comparable objective and subjective success, with synthetic materials generally showing better operative outcomes and fewer complications.
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Affiliation(s)
- Maryse Larouche
- St. Mary's Research Centre, Montreal, Canada; Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | - Mei Mu Zi Zheng
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, Canada
| | - Emily C Yang
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rea Konci
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | | | - Prubjot Kaur Gill
- University of British Columbia Library, University of British Columbia, Vancouver, Canada
| | - Roxana Geoffrion
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, Canada.
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Farag F, Osman NI, Pang KH, Castro-Diaz D, Chapple CR, Cruz F, Gamé X, Goldman H, Greenwell T, Hampel C, Scailteux LM, Roovers JP, Welk B, Heesakkers J. Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials? Eur Urol Focus 2023:S2405-4569(23)00244-4. [PMID: 37973453 DOI: 10.1016/j.euf.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/24/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
CONTEXT The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue. OBJECTIVE To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data. EVIDENCE ACQUISITION PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed. EVIDENCE SYNTHESIS Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE). CONCLUSIONS Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence. PATIENT SUMMARY In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.
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Affiliation(s)
| | - N I Osman
- Royal Hallamshire Hospital, Sheffield, UK
| | - K H Pang
- Royal Hallamshire Hospital, Sheffield, UK
| | - D Castro-Diaz
- Hospital Universitario de Canarias/Universidad de La Laguna, La Laguna, Spain
| | - C R Chapple
- Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield, Sheffield, UK
| | - F Cruz
- Faculty of Medicine of University of Porto, i3S institute and Hospital São João, Porto, Portugal
| | - X Gamé
- Département d'Urologie, Transplantation Rénale et Andrologie, CHU Rangueil, Toulouse, France
| | - H Goldman
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Lerner College of Medicine, Cleveland, OH, USA
| | - T Greenwell
- University College London Hospitals, London, UK
| | - C Hampel
- Urologische Abteilung, Marien-Hospital Erwitte, Erwitte, Germany; Neuro-Urologie/Urologie Universitätsklinikum Bonn und Neuro-Urologie, Neurologisches Rehabilitationszentrum der Godeshöhe e. V., Bonn, Germany
| | - L M Scailteux
- Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, Rennes, France
| | - J P Roovers
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - B Welk
- Division of Urology, Department of Surgery, Western University, London, Ontario, Canada
| | - J Heesakkers
- Maastricht University Medical Center, Maastricht, The Netherlands
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Zilberlicht A, Karmakar D, DwyeR PL, Murray C, Kugelman N. Predictors of Surgical Failure of Open Burch Colposuspension Versus Retropubic Midurethral Sling for Stress Urinary Incontinence. Urology 2023; 177:69-73. [PMID: 37141976 DOI: 10.1016/j.urology.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To identify and compare long-term predictors for 'surgical failures' in matched groups of Midurethral sling (MUS) and Burch colposuspension (BC). METHODS A secondary analysis of patients with urodynamic stress incontinence who were treated either by open BC or retropubic MUS. The study had a cohort of 1344 women with a ratio of 1:3 (BC: MUS). We defined surgical success or failure by combining Patient Reported Outcome Measures and the need for repeat surgery. Risk factors for failure identified by multivariate analysis. RESULTS Of the 1344 women included, 336 had BC, and 1008 had MUS. Patients were followed-up for 13.1 and 10.1 years, and the rate of failure was 22% and 20%, for BC and MUS, respectively (P = 0.35). Significant predictors for MUS failure were Body mass index (BMI) > 30, preoperative anticholinergic medication use, smoking, diabetes, and previous surgery for incontinence (Hazard ratio 3.6, 2.6, 2.5, 1.8, 2.3, respectively). BMI > 25, preoperative use of anticholinergic medication, age > 60, previous surgery for incontinence, and loss of follow-up>5 years (Hazard ratio: 3.2, 2.8, 2.6, 2.5, 2.1, respectively), were significant predictors of BC failure. CONCLUSION This study shows similar predictors for surgical failure for BC and MUS, with high BMI, mixed urinary incontinence, and previous continence procedures being the most important.
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Affiliation(s)
- Ariel Zilberlicht
- Department of Obstetrics & Gynecology, Carmel Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Peter L DwyeR
- Department of Urogynaecology, Mercy Health, Melbourne, Victoria, Australia
| | | | - Nir Kugelman
- Department of Obstetrics & Gynecology, Carmel Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Alexandridis V, Lundmark Drca A, Ek M, Westergren Söderberg M, Andrada Hamer M, Teleman P. Retropubic slings are more efficient than transobturator at 10-year follow-up: a Swedish register-based study. Int Urogynecol J 2023:10.1007/s00192-023-05506-4. [PMID: 36995417 DOI: 10.1007/s00192-023-05506-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/07/2023] [Indexed: 03/31/2023]
Abstract
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.
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Affiliation(s)
- Vasileios Alexandridis
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Obstetrics and Gynecology, Jan Waldenströms gata 47, 205 02, Malmö, Sweden.
| | - Anna Lundmark Drca
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Marion Ek
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Pia Teleman
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Brosina de Leon E, Cardoso MN, de Brito E, dos Santos MM, Almeida FA. The development of a physical therapy service to treat urinary incontinence: Results of a RE-AIM evaluation. Front Glob Womens Health 2022; 3:1004140. [DOI: 10.3389/fgwh.2022.1004140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
BackgroundA conservative physiotherapy service development addressed to treat urinary incontinence for older women was studied using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.DesignWe conducted a pragmatic case study design based on RE-AIM.Settings/participantsIncluded women ≥ 60 years of age, with self-reported UI symptoms.ResultsA total of 34 older women were enrolled in the service with a mean age of 61.53 years. There was a significant improvement in the strength of the pelvic floor muscles, power, endurance, and fast contraction capacity after the intervention, however, it was observed a high dropout rate. Program implementation was supported by Physical Therapy teams who engaged in care coordination. The program has been maintained for over 4 years.ConclusionOur findings demonstrate that UI patients would benefit from physiotherapy treatment and that this intervention is feasible. This RE-AIM evaluation provides lessons learned and strategies for future adoption, implementation, and maintenance of a Physical Therapy pelvic service.
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Abrar S, Razzak L, Mohsin R. The practice of Burch Colposuspension versus Mid Urethral Slings for the treatment of Stress Urinary Incontinence in developing country. Pak J Med Sci 2021; 37:1359-1364. [PMID: 34475912 PMCID: PMC8377912 DOI: 10.12669/pjms.37.5.4017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/24/2021] [Accepted: 05/02/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To compare the effectiveness and complications of Burch colposuspension and Mid Urethral Slings (MUS) for the treatment of Stress Urinary Incontinence (SUI). METHODS We conducted a cross-sectional study of 162 patients who underwent surgery for SUI with Burch colposuspension (n=40), tension free vaginal tape (TVT) (n= 59) or transobturator tape (TOT) (n=63), from 2006 to 2014 at the Aga Khan University Hospital- Karachi. All three groups were assessed in terms of demographics, cure rates, intraoperative and postoperative complications at one and five years using incontinence impact questionnaire-short form-7 (IIQ-7) and urogenital distress inventory -short form-6 (UDI-6). RESULTS Mean age of the participants in Burch, TVT and TOT group was 44.1 ± 7.4, 48.3 ± 8.9, 53.0 ± 9.4 respectively. Majority of patients in TVT group were premenopausal (59.3%) and postmenopausal in TOT group (53.9%). Most abdominal hysterectomies were done in Burch group (40) while vaginal hysterectomies and anterior and posterior colporrhaphy in TOT group (55). All the procedures had both subjective and objective cure rate of more than 82% at one year, with TVT having the highest success rate of 96.61%. The objective cure rate in Burch, TVT and TOT group at five years was 74.19%, 90.30% and 81.25% respectively. Intraoperative complications included hemorrhage in one patient during Burch procedure and bladder perforation in two cases of TVT, with no significant difference in short or long-term complications with either procedure. CONCLUSIONS All the three procedures have equal efficacy and complication rates. Even though TVT is the new gold standard but in view of current debate regarding mesh related complications, there is a need to readdress Burch colposuspension for treatment of SUI.
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Affiliation(s)
- Saida Abrar
- Dr. Saida Abrar Clinical Fellow Urogynecology and Pelvic Reconstructive Surgery, Department of OBGYN, Aga Khan University Hospital Karachi, Karachi, Pakistan
| | - Lubna Razzak
- Dr. Lubna Razzak Clinical Fellow Urogynecology and Pelvic Reconstructive Surgery, Department of OBGYN, Aga Khan University Hospital Karachi, Karachi, Pakistan
| | - Raheela Mohsin
- Dr. Raheela Mohsin Rizvi Associate Professor Urogynecology, Department of OBGYN, Aga Khan University Hospital Karachi, Karachi, Pakistan
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Chang OH, Cadish LA, Kailasam A, Ridgeway BM, Shepherd JP. Impact of the availability of midurethral slings on treatment strategies for stress urinary incontinence: a cost-effectiveness analysis. BJOG 2021; 129:500-508. [PMID: 34314554 DOI: 10.1111/1471-0528.16850] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To perform a cost-effectiveness analysis for the surgical and non-surgical management of stress urinary incontinence (SUI) with and without the availability of midurethral sling. DESIGN Cost-effectiveness analysis. SETTING USA, 2019. POPULATION Women with stress urinary incontinence. METHODS We modelled SUI treatment pathways with and without the availability of midurethral slings, including no treatment, incontinence pessary, pelvic floor muscle physical therapy, urethral bulking injection, open and laparoscopic Burch colposuspension, and pubovaginal autologous sling. Time horizon was 2 years after initial treatment. MAIN OUTCOME MEASURES Costs (2019 US$) included index surgery, surgical retreatment, and complications including urinary retention, de novo urgency and mesh exposure. The incremental cost-effectiveness ratio (ICER) was calculated for non-dominated treatment strategies. RESULTS The least costly treatment strategies were incontinence pessary, pelvic floor physical therapy, no treatment and midurethral sling, respectively. Midurethral slings had the highest effectiveness. The strategy with the lowest effectiveness was no treatment. The three cost-effective strategies included pessary, pelvic floor muscle physical therapy and midurethral slings. No other surgical options were cost-effective. If midurethral slings were not available, all other surgical options were still dominated by pelvic floor muscle physical therapy. Multiple one-way sensitivity analyses confirmed model robustness. The only reasonable threshold in which outcomes would change, was if urethral bulking costs decreased 12.6%. CONCLUSIONS The midurethral sling is the most effective SUI treatment and the only cost-effective surgical option. TWEETABLE ABSTRACT Midurethral sling is the only cost-effective surgical treatment option for stress urinary incontinence.
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Affiliation(s)
- O H Chang
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Women's Health Institute, Cleveland, OH, USA
| | - L A Cadish
- Providence Saint John's Health Center, Santa Monica, CA, USA
| | - A Kailasam
- Trinity Health of New England, Hartford, CT, USA
| | - B M Ridgeway
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Women's Health Institute, Cleveland, OH, USA
| | - J P Shepherd
- Trinity Health of New England, Hartford, CT, USA
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Karmakar D, Dwyer PL, Murray C, Schierlitz L, Dykes N, Zilberlicht A. Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study. Am J Obstet Gynecol 2021; 224:593.e1-593.e8. [PMID: 33316277 DOI: 10.1016/j.ajog.2020.11.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/12/2020] [Accepted: 11/29/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making. OBJECTIVE This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling. STUDY DESIGN A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding. RESULTS The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00). CONCLUSION This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.
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Affiliation(s)
- Debjyoti Karmakar
- Department of Urogynaecology, Mercy Health, Melbourne, Victoria, Australia.
| | - Peter L Dwyer
- Department of Urogynaecology, Mercy Health, Melbourne, Victoria, Australia
| | - Christine Murray
- Department of Urogynaecology, Mercy Health, Melbourne, Victoria, Australia
| | - Lore Schierlitz
- Department of Urogynaecology, Mercy Health, Melbourne, Victoria, Australia
| | - Nicola Dykes
- Department of Urogynaecology, Mercy Health, Melbourne, Victoria, Australia
| | - Ariel Zilberlicht
- Department of Urogynaecology, Mercy Health, Melbourne, Victoria, Australia
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Abstract
The multifactorial pathophysiology of pelvic floor disorder accounts for the coexistence of several pelvic floor disorders in many women. Up to 54% of women with pelvic organ prolapse (POP) report concurrent stress urinary incontinence (SUI). While POP is a risk factor for coexistent SUI, apical and anterior prolapse can also conceal SUI symptoms that are unmasked by POP repair, resulting in de novo SUI postoperatively. It is important for pelvic reconstructive surgeons to consider the relationship between POP and urinary incontinence in presurgical planning and to discuss with patients the risks and advantages of concurrent versus staged anti-incontinence procedures.
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Moskowitz D, Gioia KT, Wolff EM, Massman JD, Lucioni A, Kobashi KC, Lee UJ. Analysis of the Completely Dry Rate Over Time After Mid-urethral Sling in a Real-world Clinical Setting. Urology 2019; 126:65-69. [PMID: 30634028 DOI: 10.1016/j.urology.2018.12.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/23/2018] [Accepted: 12/29/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To improve patient counseling regarding mid-urethral slings (MUS), we performed an analysis of MUS patients dry at initial follow-up to evaluate probability of remaining dry over time, and analyzed clinical factors potentially influencing the probability of remaining dry. METHODS A retrospective review of our prospectively-collected institutional database identified patients who underwent retropubic MUS (RMUS) or transobturator MUS (TMUS) between January 2001 and March 2016 and were completely dry, defined as an answer of "not at all" to UDI-6 question 3, at first follow-up within 1.5 years of surgery. Proportion remaining dry over time was estimated by Kaplan-Meier. Associated factors were evaluated using Cox proportional hazards modeling. Proportion with urge urinary incontinence at time of sling failure was assessed. RESULTS Of 1102 patients undergoing MUS, 38.4% returned questionnaires and 47.5% of these were completely dry at initial follow-up (139 RMUS, 62 TMUS). Probability (95% CI, n = total patients) of remaining dry after RMUS at 3, 5, and 10 years was 72% (64%-81%, n = 70), 60% (51%-70%, n = 51), and 26% (18%-43%, n = 17). Probability estimates for TMUS at 3 and 5 years were 74% (62%-88%, n = 27) and 50% (35%-70%, n = 14). Obesity (Hazard ratio 2.22, P = .003) and age (Hazard ratio 1.043, P < .001) were associated with lower probability of remaining dry after RMUS. Of patients no longer completely dry at last follow-up, 72% RMUS and 75% TMUS had urge urinary incontinence. CONCLUSION In our real-world cohort, patients who are dry within the first 1.5 years following MUS have ≥50% chance of remaining dry for 4 more years.
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Affiliation(s)
- Dena Moskowitz
- Department of Urology, University of California, Irvine, CA
| | - Kevin T Gioia
- Hackensack Meridian Medical Group, Urology, Hackensack, NJ
| | - Erika M Wolff
- University of Washington, Department of Surgery, Seattle, WA
| | | | - Alvaro Lucioni
- Virginia Mason Medical Center, Section of Urology and Renal Transplantation, Seattle, WA
| | - Kathleen C Kobashi
- Virginia Mason Medical Center, Section of Urology and Renal Transplantation, Seattle, WA
| | - Una J Lee
- Virginia Mason Medical Center, Section of Urology and Renal Transplantation, Seattle, WA
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Veit-Rubin N, Dubuisson J, Ford A, Dubuisson JB, Mourad S, Digesu A. Burch colposuspension. Neurourol Urodyn 2019; 38:553-562. [PMID: 30620096 PMCID: PMC6850136 DOI: 10.1002/nau.23905] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/20/2018] [Indexed: 01/23/2023]
Abstract
Aims To evaluate the historic and pathophysiologic issues which led to the development of Burch colposuspension, to describe anatomic and technical aspects of the operation and to provide an update on current evidence. Methods We have performed a focused literature review and have searched the current available literature about historic dimension, technical descriptions, and efficacy of Burch colposuspension. Results Burch colposuspension, performed either by an open or a laparoscopic approach, is an effective surgical treatment for stress urinary incontinence. Conclusions In current recommendations, Burch colposuspension remains an option for secondary treatment. Because midurethral slings have recently become under scrutiny, it may return as a first‐line treatment procedure. Both open and laparoscopic Burch colposuspension should therefore nowadays be provided in fellowship programs worldwide.
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Affiliation(s)
- Nikolaus Veit-Rubin
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean Dubuisson
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Abigail Ford
- Department of Urogynaecology, St. Mary's Hospital, Imperial College London, London, Unted Kingdom
| | | | | | - Alex Digesu
- Department of Urogynaecology, St. Mary's Hospital, Imperial College London, London, Unted Kingdom
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Surgical management of urinary stress incontinence – Where are we now? Best Pract Res Clin Obstet Gynaecol 2019; 54:31-40. [DOI: 10.1016/j.bpobgyn.2018.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 11/22/2022]
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A Danish national population-based cohort study of synthetic midurethral slings, 2007-2011. Int Urogynecol J 2018; 30:733-741. [PMID: 30073484 DOI: 10.1007/s00192-018-3719-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Synthetic midurethral slings (MUSs) have shown similar cure rates in several short- and medium-term follow-up studies. Recently, long-term follow-up studies have indicated that the cure rate is higher following the retropubic midurethral sling (RPMUS) compared with the transobturator midurethral sling (TOMUS) procedure. The aim was to evaluate the efficacy of synthetic MUSs and to examine the influence of department and surgeon volume and patient-related factors on the cure rate of synthetic MUSs. METHODS A retrospective cohort study based on a national population over a 5-year period (2007-2011) using data from the Danish Urogynaecological Database (DugaBase). RESULTS A total of 4519 women with first-time MUS were registered in the DugaBase. Cure was achieved in 1242/1639 (75.78%) at a 3-month follow-up. RPMUSs were more frequently in use in high-volume departments compared with the other departments and more often implanted by high- than low-volume surgeons. Women treated by a medium- (adjusted OR 1.82; 95% CI 1.01-3.28, "frequency") or high-volume surgeon (1.98; 1.18-3.32, "frequency") had an increased probability of cure compared with women treated by a low-volume surgeon. The difference was only significant for women who received a TOMUS. CONCLUSIONS This national population-based cohort study confirmed a high cure rate of synthetic MUSs at short-term follow-up. It is the largest study to indicate a learning curve for TOMUS. Patients were not actively involved in which synthetic MUS was to be performed as the choice of surgical option was made at the departmental level.
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Lose G, Klarskov N. Retropubic versus transobturator MUS: time to revisit? Int Urogynecol J 2017; 28:1113-1114. [PMID: 28676935 DOI: 10.1007/s00192-017-3403-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/14/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Gunnar Lose
- Department of Obstetrics and Gynecology, Herlev Gentofte Hospital, University of Copenhagen, Herlev Ringvej, DK-2730, Herlev, Denmark.
| | - Niels Klarskov
- Department of Obstetrics and Gynecology, Herlev Gentofte Hospital, University of Copenhagen, Herlev Ringvej, DK-2730, Herlev, Denmark
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Concurrent midurethral sling excision or lysis at the time of repeat sling for treatment of recurrent or persistent stress urinary incontinence. Int Urogynecol J 2017; 29:285-290. [DOI: 10.1007/s00192-017-3385-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/17/2017] [Indexed: 01/08/2023]
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Can pelvic floor dysfunction after vaginal birth be prevented? Int Urogynecol J 2016; 27:1811-1815. [DOI: 10.1007/s00192-016-3117-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/31/2016] [Indexed: 02/08/2023]
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Hansen MF, Lose G, Kesmodel US, Gradel KO. Repeat surgery after failed midurethral slings: a nationwide cohort study, 1998–2007. Int Urogynecol J 2015; 27:1013-9. [DOI: 10.1007/s00192-015-2925-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/02/2015] [Indexed: 12/30/2022]
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