The long-term effects of bariatric surgery on female urinary incontinence

The transit of oral premedication beyond the stomach in patients undergoing laparoscopic sleeve gastrectomy: a retrospective observational multicentre study

BACKGROUND

Antiemetic and analgesic oral premedications are frequently prescribed preoperatively to enhance recovery after laparoscopic sleeve gastrectomy. However, it is unknown whether these medications transit beyond the stomach or if they remain in the sleeve resection specimen, thereby negating their pharmacological effects.

METHODS

A retrospective cohort study was performed on patients undergoing laparoscopic sleeve gastrectomy and receiving oral premedication (slow-release tapentadol and netupitant/palonosetron) as part of enhanced recovery after bariatric surgery program. Patients were stratified into the Transit group (premedication absent in the resection specimen) and Failure-to-Transit group (premedication present in the resection specimen). Age, sex, body mass index, and presence of diabetes were compared amongst the groups. The premedication lead time (time between premedications' administration and gastric specimen resection), and the premedication presence or absence in the specimen was evaluated.

RESULTS

One hundred consecutive patients were included in the analysis. Ninety-nine patients (99%) were morbidly obese, and 17 patients (17%) had Type 2 diabetes mellitus. One hundred patients (100%) received tapentadol and 89 patients (89%) received netupitant/palonosetron. One or more tablets were discovered in the resected specimens of 38 patients (38%). No statistically significant differences were observed between the groups regarding age, sex, diabetes, or body mass index. The median (Q1‒Q3) premedication lead time was 80 min (57.8‒140.0) in the Failure-to-Transit group and 119.5 min (85.0‒171.3) in the Transit group; P = 0.006. The lead time required to expect complete absorption in 80% of patients was 232 min (95%CI:180‒310).

CONCLUSIONS

Preoperative oral analgesia and antiemetics did not transit beyond the stomach in 38% of patients undergoing laparoscopic sleeve gastrectomy. When given orally in combination, tapentadol and netupitant/palonosetron should be administered at least 4 h before surgery to ensure transition beyond the stomach. Future enhanced recovery after bariatric surgery guidelines may benefit from the standardization of premedication lead times to facilitate increased absorption.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry; number ACTRN12623000187640; retrospective registered on 22/02/2023.

Effects of Sleeve Gastrectomy on Pelvic Floor Disorders in Female Patients with Severe Obesity: a Prospective Study

INTRODUCTION

Obesity is associated with pelvic floor disorders (PFD). Sleeve gastrectomy (SG) is one of the most effective weight loss methods. Although SG has been found to improve urinary incontinence (UI) and overactive bladder (OAB), its impact on fecal incontinence (FI) remains controversial.

MATERIALS AND METHODS

This prospective, randomized study involved 60 female patients with severe obesity who were randomly assigned to two groups: the SG group and the diet group. The SG group underwent SG, while the diet group received a low-calorie, low-lipid diet for 6 months. The patients' condition was assessed before and after the study using three questionnaires: the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), the Overactive Bladder 8-Question Awareness Tool (OAB-V8), and the Wexner Score (CCIS).

RESULTS

After 6 months, the SG group had a significantly higher percentage of total weight loss (%TWL) compared to the diet group (p<0.01). Both groups showed a decrease in the ICIQ-FLUTS, OAB-V8, and CCIS scores (p<0.05). UI, OAB, and FI improved significantly in the SG group (p<0.05), but no improvement was observed in the diet group (p>0.05). The correlation between %TWL and PFD was statistically significant but weak, with the strongest correlation between %TWL and ICIQ-FLUTS score and the weakest correlation between %TWL and CCIS score (p<0.05).

CONCLUSIONS

We recommend bariatric surgery for the treatment of PFD. However, given the weak correlation between %TWL and PFD after SG, further research should explore factors other than %TWL that are effective in recovery, particularly in relation to FI.

The efficacy and complications of retropubic tension‐free vaginal tapes after twenty years: a prospective observational study

OBJECTIVE

Long-term data regarding risks associated with tension-free vaginal tapes (TVT) are sparse, and where available are limited to small numbers. We analyse patient-reported outcomes of TVT after 16-24 years.

DESIGN

Prospective observational study.

SETTING

Single-centre study in a tertiary referral urogynaecology unit.

POPULATION

A cohort of 350 women who had a TVT inserted between 1999 and 2004, in which 96% had urodynamically proven stress incontinence.

METHODS

Postal questionnaire survey using the International Consultation on Incontinence Questionnaire, a visual analogue scale and a yes/no question as to whether they would have the procedure again.

MAIN OUTCOME MEASURES

The primary outcome was cure of stress urinary incontinence, which was assessed using the ICIQ-FLUTS questionnaire. Secondary outcomes included overactive bladder symptoms, pain, sexual dysfunction, and patient satisfaction with the procedure.

RESULTS

A total of 183/350 (52%) responses were received. The median age of women at follow up was 67 years (range 53-93 years) and the median follow up was 20 years (17-24 years). Stress urinary incontinence was denied by 39.3% of women. Urgency was reported by 42.1%. Bladder pain was reported either 'never' or 'occasionally' by 92.3% of women. The median satisfaction rate was 98/100 and 92.4% said they would have the TVT procedure again.

CONCLUSIONS

Tension-free vaginal tape has high levels of satisfaction and cure up to 24 years after placement. Pain was uncommon and its impact on quality of life was low. Symptoms of urgency were prevalent but may be related to age. TVT is an effective treatment for SUI more than 20 years after initial placement.

Weight loss with bariatric surgery or behaviour modification and the impact on female obesity-related urine incontinence: A comprehensive systematic review and meta-analysis

Women with obesity are at risk of pelvic floor dysfunction with a 3-fold increased incidence of urge urinary incontinence (UUI) and double the risk of stress urinary incontinence (SUI). The National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) recommend that women with a body mass index ≥30 kg/m² should consider weight loss prior to consideration for incontinence surgery. This systematic review and meta-analysis will assess this recommendation to aid in the counselling of women with obesity-related urinary incontinence (UI). Medical Literature Analysis and Retrieval System online (MEDLINE), EMBASE, Cochrane, ClinicalTrials.gov, and SCOPUS were systematically and critically appraised for all peer reviewed manuscripts that suitably fulfilled the inclusion criteria established a priori and presented original, empirical data relevant to weight loss intervention in the management of urinary incontinence. Thirty-three studies and their outcomes were meta-analysed. Weight loss interventions were associated in a decreased prevalence in UI (OR 0.222, 95% CI [0.147, 0.336]), SUI (OR 0.354, 95% CI [0.256, 0.489]), UUI (OR 0.437, 95% CI [0.295, 0.649]) and improved quality of life (PFDI-20, SMD -0.774 (95% CI [-1.236, -0.312]). This systematic review and meta-analysis provide evidence that weight loss interventions are effective in reducing the prevalence of obesity-related UI symptoms in women. Bariatric surgery in particular shows greater sustained weight loss and improvements in UI prevalence. Further large scale, randomized control trials assessing the effect of bariatric surgery on women with obesity-related UI are needed to confirm this study's findings.

Review: Sex-Specific Aspects in the Bariatric Treatment of Severely Obese Women

This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. A systematic literature search was carried out according to Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. After the literature selection, the following categories were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined. A summary that includes key messages is given for each subsection. An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks.

Effect of an exercise programme for reducing abdominal fat on overactive bladder symptoms in young overweight women

INTRODUCTION AND HYPOTHESIS

The effect of exercise in relation to overweight and overactive bladder (OAB) in young women has not been sufficiently supported by studies. The objective of our study was to reduce symptoms of OAB through a 3-month exercise programme in young overweight women with OAB. The sample consisted of 70 women (mean age 26.7 ± 4.8 years), 36 being treated and 34 in the control group.

METHODS

We used a body composition analyser with the assessment of skeletal muscle mass (SMM) (kg), body fat mass (BFM) (kg), body fat percentage (BFP) (%), visceral fat area (VFA) (cm²/level) and the waist/hip circumference index (WHR). OAB symptoms were evaluated using a voiding diary, the overactive bladder questionnaire (OAB-q) and the Patient Perception of Intensity of Urgency Scale (PPIUS). The intervention was a programme for the reduction of abdominal fat (PRAF), with elements of aerobic training, strengthening of the abdominal muscles and stretching.

RESULTS

In the OAB symptoms assessed through the voiding diary (number of voidings per 24 h, nocturia, mean voided volume) as well as in the OAB-q and PPIUS scales after training, significant differences were reported in favour of the treatment group [number of voidings per 24 h: treatment vs. control group, baseline 9.1 ± 0.3 vs. 8.6 ± 0.3, final 6.9 ± 0.2 vs. 8.1 ± 0.2, p < 0.0001; mean voided volume per 24 h (ml): treatment vs. control group, baseline 154.2 ± 9.1 vs. 162.2 ± 9.3, final 201.3 ± 9.3 vs. 164.1 ± 9.6, p < 0.0001] with a large effect size (ES). In the body composition analysis after training, significant differences were also reported in favour of the treatment group in the reduction of body mass index (BMI), BFP and VFA (p < 0.0001), with a large ES.

CONCLUSIONS

Body composition analysis confirmed a reduction of BMI, body weight, body fat percentage, visceral abdominal fat, the WHR index and waist circumference in favour of the treatment group after the 12-week PRAF exercise programme. A reduction in OAB symptoms was also objectively confirmed following the PRAF exercise programme.

What Is the Effect of Body Mass Index on Subjective Outcome Following Vaginal Hysterectomy for Prolapse?

PURPOSE

Obesity is a significant risk factor for pelvic organ prolapse (POP), but the effects of obesity on outcomes of surgery for POP are poorly understood. The aim of this study was to assess the relationship between POP symptomatology, subjective outcomes of surgery and body mass index (BMI) in women undergoing vaginal hysterectomy for POP.

METHODS

Pre- and postoperative data from a validated pelvic floor questionnaire (electronic Personal Assessment Questionnaire-Pelvic Floor) were collected prospectively from 60 women undergoing vaginal hysterectomy for POP. Of these, 20 were normal weight (BMI 18.5-24.9 kg/m2), 20 were overweight (BMI 25-29.9 kg/m2), and 20 were women with obesity (BMI 30-34.9 kg/m2). The relationship between BMI and symptom scores for prolapse, impact on vaginal symptoms on quality of life (VS-QoL) and 'overall change in condition' was assessed. Pre- and postoperative symptom scores were compared using repeated mixed analysis of variance test for BMI as a categorical variable (normal, overweight, and obese). Spearman rank order correlation test was carried out to evaluate BMI as a continuous variable. All women underwent vaginal hysterectomy using a standardized technique.

RESULTS

Overall, 93% of women reported improvement in their condition. The main finding was that 'overall change in condition' was negatively correlated with increasing BMI (rs=-0.324, P=0.028). Irrespective of BMI, significant improvements were observed in symptoms of prolapse and VS-QoL at 3-month postoperation.

CONCLUSION

With increasing BMI, women are likely to report lower levels of satisfaction following prolapse surgery, despite reporting equivalent improvements in symptoms. BMI is known to affect how individuals perceive their general health and well-being with obese individuals reporting poorer levels of subjective health status. Women with obesity may perceive change in their condition after prolapse surgery differently to women of normal weight. Reduction of weight prior to prolapse surgery could be considered in obese women to improve subjective outcomes of surgery.

Self-management in women with stress incontinence: strategies, outcomes and integration into clinical care

The objective of this review is to present and discuss up-to-date conservative treatment strategies for the management of stress urinary incontinence (SUI) in women. This review aims to provide an overview of the importance of initial self-management strategies and conservative management options for women with SUI and how these treatments can be integrated into clinical practice. The various treatment modalities available including pelvic floor physiotherapy, biofeedback, and neuromuscular electrical stimulation devices, in addition to lifestyle changes which can significantly affect symptoms, are discussed. The relevance and importance of individual assessment and training programs is highlighted in addition to additional adjuncts available to facilitate rehabilitation and symptom improvement. Expected outcomes for women with mild to moderate SUI who participate in targeted individualized conservative management programs are generally good, with a high likelihood of substantial improvement in symptoms.

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

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