Randomized Clinical Trial Comparing Suprapubic Arch Sling (SPARC) and Tension-Free Vaginal Tape (TVT): One-Year Results

Innovative decision making tools using discrete mathematics for stress urinary incontinence treatment

In this study, we applied graph theory to clinical decision-making for Stress Urinary Incontinence (SUI) treatment. Utilizing discrete mathematics, we developed a system to visually understand the shortest path to the desired treatment outcomes by considering various patient variables. Focusing on women aged 35-50, we examined the effectiveness of Tension-free Vaginal Tape (TVT) surgery and Vaginal Erbium Laser (VEL) treatment for over 15 years. The TVT group consisted of 102 patients who underwent surgery using either the Advantage Fit mid-urethral sling system (Boston Scientific Co., MA, USA) or the GYNECARE TVT retropubic system (Ethicon Inc., NJ, USA). The VEL group included 113 patients treated with a non-ablative Erbium: YAG laser (FotonaSmooth™ XS; Fotona d.o.o., Ljubljana, Slovenia), and there were 112 patients in the control group. We constructed a network diagram analyzing the correlations between health, demographic factors, treatment methods, and patient outcomes. By calculating the shortest path using heuristic functions, we identified significant correlations and treatment effects. This approach supports patient decision making by choosing between TVT and VEL treatments based on individual objectives. Our findings provide new insights into SUI treatment, highlighting the value of a data-driven personalized approach for clinical decision-making. This interdisciplinary study bridges the gap between mathematics and medicine, demonstrating the importance of a data-centric approach in clinical decisions.

Evaluation of Outcomes Between the Top-down Versus the Bottom-up Approach for Retropubic Midurethral Sling

INTRODUCTION AND HYPOTHESIS

Retropubic midurethral sling (MUS) placement is the gold standard for the treatment of stress urinary incontinence in the USA. The procedure can be approached from either a top-down or a bottom-up direction, but there is a paucity of contemporary data regarding outcomes between these approaches. The aim of this study was to provide updated clinical outcomes data.

METHODS

This was a retrospective cohort study of women undergoing the retropubic MUS procedure alone or at the time of pelvic organ prolapse repair between 2010 and 2020 at a single academic medical center. The electronic medical record was used to extract demographic data, operative approach, and perioperative complications. The primary outcome was a composite incidence of any perioperative complication.

RESULTS

Of the 309 patients analyzed, 140 (45.3%) underwent top-down and 169 (54.7%) underwent bottom-up retropubic MUS placement. Patients undergoing top-down MUS placement were more likely to be older (mean age 58 vs 54, p=0.02), have a history of diabetes mellitus (20% vs 8.9%, p=0.004), and have had a prior hysterectomy (27% vs 16%, p=0.02). They were less likely to have a concurrent anterior (p<0.001) or posterior repair (p<0.001). Patients undergoing the top-down procedure were less likely to experience sling exposure (p=0.02); complications in the two groups were otherwise similar.

CONCLUSIONS

The top-down approach to retropubic MUS placement was associated with lower rates of mesh erosion in this population of patients. Neither approach is associated with an increased overall risk of complications or de novo overactive bladder symptoms.

Bladder filling test, cystoscopy, or both for checking bladder perforation in tension-free-vaginal tape operations

Background/Aim: Tension-free-vaginal tape (TVT) has been widely used for treatment of stress urinary incontinence as a mid-urethral sling operation. Cystoscopy is routinely performed during tension-free-vaginal tape operations to check for bladder perforation or injury. This study aims to check the applicability and accuracy of the bladder filling test for predicting bladder perforation in tension-free-vaginal tape operations. Methods: Between 2015 and 2020, 285 women who had TVT operations were subject to evaluation. Out of 285 cases, 23 cases were suspected subjectively by the operating surgeons to have visible or occult bladder perforation during the TVT procedure. A routine cystoscopy was performed at the end of all operations. Additionally, before the routine cystoscopy, in cases suspected of a visible or occult bladder perforation, the bladder was filled with 500 ml saline or diluted methylene blue dye through a urinary catheter (bladder filling test) to check for occult bladder perforation that might not be visualized by cystoscopy. Any fluid leakage through the paraurethral dissected canals or from the abdominal incisions was observed for the possibility of bladder perforation. The accuracy of the bladder filling test was compared to cystoscopy to diagnose bladder perforation in suspected cases. In addition, all cases were followed up for three months to record any cases with late or occult bladder perforations missed in the diagnosis using cystoscopy or the bladder filling test perioperatively. Results: Out of 23 cases suspected subjectively by the operating surgeons to have visible or occult bladder perforation, 11 had visible bladder perforations (3.9%) confirmed by both cystoscopy and the bladder filling test. After the filling test, leakage at the abdominal incision site and/or para-urethral dissected canal was observed in all cases with bladder perforation. No leakage was observed in the remaining patients (n = 12) suspected of, but not diagnosed with bladder perforation by cystoscopy. The bladder filling test did confirm the same diagnosis revealed by cystoscopy in all suspected cases. Conclusion: The bladder filling test was found to be very sensitive in predicting bladder perforation at tension-free-vaginal tape operations compared to cystoscopy. This test can decrease the need for routine cystoscopy at tension-free-vaginal tape insertion, and cystoscopy can be limited to cases with leakage in the bladder filling test.

[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]

INTRODUCTION

Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term.

OBJECTIVES

In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected.

RESULTS

Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women.

CONCLUSION

Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

Imaging and Treatment of Complications of Abdominal and Pelvic Mesh Repair

Surgical mesh is used most frequently for tension-free repair of abdominal wall hernias in adults, because the rate of hernia recurrence is lower with mesh than with primary soft-tissue repair. Since the introduction of polypropylene mesh in the middle of the 20th century, many mesh materials and configurations for specific surgical procedures have been developed. In addition to abdominal wall hernia repair, mesh may be used for repair of diaphragmatic hernias, urinary incontinence in women (female slings), genitourinary prolapse (vaginal mesh and sacrocolpopexy), rectal prolapse (rectopexy), and postprostatectomy male urinary incontinence (male slings). General mesh repair complications include chronic pain; fluid collections such as seromas, hematomas, and abscesses; adhesions that may lead to intestinal blockage; erosion into solid or hollow viscera including enterocutaneous fistulizing disease; and mesh failure characterized by mesh shrinkage, detachment, and migration with repair malfunction. Several mesh complications are often diagnosed with imaging, primarily with CT and less frequently with MRI and US, despite variable mesh visibility at imaging. This article reviews the common surgical mesh applications in the abdomen and pelvis, discusses imaging of mesh repair complications, and provides complication treatment highlights.^©RSNA, 2020.

Stress Urinary Incontinence and Pelvic Organ Prolapse: Biologic Graft Materials Revisited

Symptomatic stress urinary incontinence (SUI) and pelvic organ prolapse (POP) refractory to conservative management with pelvic floor muscle training or vaginal pessaries may warrant surgical intervention with different forms of biologic or synthetic material. However, in recent years, several global regulatory agencies have issued health warnings and recalled several mesh products due to an increase in complications such as mesh erosion, infection, chronic pain, and perioperative bleeding. At present, current surgical treatment strategies for SUI and POP are aimed at developing biological graft materials with similar mechanical properties to established synthetic meshes, but with improved tissue integration and minimal host response. This narrative review aims to highlight recent studies related to the development of biomimetic and biologic graft materials as alternatives to traditional synthetic materials for SUI/POP repair in female patients. We also investigate complications and technical limitations associated with synthetic mesh and biological biomaterials in conventional SUI and POP surgery. Our findings demonstrate that newly developed biologic grafts have a lower incidence of adverse events compared to synthetic biomaterials. However there remains a significant disparity between success in preclinical trials and long-term clinical translation. Further characterization on the optimal structural, integrative, and mechanical properties of biological grafts is required before they can be reliably introduced into clinical practice for SUI and POP surgery. Impact statement Our review article aims to outline the clinical history of developments and controversies associated with the use of synthetic mesh materials in the surgical treatment of stress urinary incontinence and pelvic organ prolapse, as well as highlighting recent advancements in the area of biological graft materials and their potential importance in an area that remains an enduring issue for patients and clinicians alike. This article aims to provide a concise summary of previous controversies in the field of urinary incontinence, while evaluating the future of potential biomaterials in this field.

Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures

INTRODUCTION AND HYPOTHESIS

Urethral injury resulting from transvaginal mesh slings is a rare complication with an estimated incidence of <1%. Our objective was to review the surgical management and functional outcomes of women presenting with urethral mesh perforation following midurethral sling (MUS) placement.

METHODS

This was a retrospective multicenter review of women who from January 2011 to March 2016 at two institutions underwent mesh sling excision for urethral perforation with Female Pelvic Medicine and Reconstructive Surgery fellowship-trained surgeons. Data comprising preoperative symptoms, operative details, and postoperative outcomes were collected by telephone (n 13) or based on their last follow-up appointment.

RESULTS OBTAINED

Nineteen women underwent transvaginal sling excision for urethral mesh perforation. Eight (42%) patients had undergone previous sling revision surgery. Sixty percent of women had resolution of their pelvic pain postoperatively. At follow-up, 92% reported urinary incontinence (UI), and three had undergone five additional procedures for vaginal prolapse mesh exposure (n 1), incontinence (onabotulinum toxin injection n 1, rectus fascia autologous sling n 1), prolapse (colpopexy n 1), and pain (trigger-point injection n 1). Patient global impression of improvement data was available for 13 patients, of whom seven (54%) rated their postoperative condition as Very much better or Much better.

CONCLUSIONS

The management of urethral mesh perforation is complex. Most women reported resolution of their pelvic pain and a high rate of satisfaction with their postoperative condition despite high rates of incontinence.

Update on complications of synthetic suburethral slings

Synthetic suburethral slings have become the most widely used technique for the surgical treatment of stress urinary incontinence. Despite its high success rates, significant complications have been reported including bleeding, urethral or bladder injury, urethral or bladder mesh erosion, intestinal perforation, vaginal extrusion of mesh, urinary tract infection, pain, urinary urgency and bladder outlet obstruction. Recent warnings from important regulatory agencies worldwide concerning safety issues of the use of mesh for urogynecological reconstruction have had a strong impact on patients as well as surgeons and manufacturers. In this paper, we reviewed the literature regarding surgical morbidity associated with synthetic suburethral slings.

Mid-urethral sling operations for stress urinary incontinence in women

BACKGROUND

Urinary incontinence is a very common and debilitating problem affecting about 50% of women at some point in their lives. Stress urinary incontinence (SUI) is a predominant cause in 30% to 80% of these women imposing significant health and economic burden on society and the women affected. Mid-urethral sling (MUS) operations are a recognised minimally invasive surgical treatment for SUI. MUS involves the passage of a small strip of tape through either the retropubic or obturator space, with entry or exit points at the lower abdomen or groin, respectively. This review does not include single-incision slings.

OBJECTIVES

To assess the clinical effects of mid-urethral sling (MUS) operations for the treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH METHODS

We searched: Cochrane Incontinence Specialised Register (including: CENTRAL, MEDLINE, MEDLINE In-Process, ClinicalTrials.gov) (searched 26 June 2014); Embase Classic (January 1947 to Week 25 2014); WHO ICTRP (searched 30 June 2014); reference lists.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or MUI, in which both trial arms involve a MUS operation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of potentially eligible studies and extracted data from included trials.

MAIN RESULTS

We included 81 trials that evaluated 12,113 women. We assessed the quality of evidence for outcomes using the GRADE assessment tool; the quality of most outcomes was moderate, mainly due to risk of bias or imprecision.Fifty-five trials with data contributed by 8652 women compared the use of the transobturator route (TOR) and retropubic route (RPR). There is moderate quality evidence that in the short term (up to one year) the rate of subjective cure of TOR and RPR are similar (RR 0.98, 95% CI 0.96 to 1.00; 36 trials, 5514 women; moderate quality evidence) ranging from 62% to 98% in the TOR group, and from 71% to 97% in the RPR group. Short-term objective cure was similar in the TOR and RPR groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97, 95% CI 0.87 to 1.09; 5 trials, 683 women; low quality evidence; and RR 0.95, 95% CI 0.80 to 1.12; 4 trials, 714 women; moderate quality evidence, respectively). In the long term, subjective cure rates ranged from 43% to 92% in the TOR group, and from 51% to 88% in the RPR group.MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR (0.6% versus 4.5%; RR 0.13, 95% CI 0.08 to 0.20; 40 trials, 6372 women; moderate quality evidence). Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR.Postoperative voiding dysfunction was less frequent following TOR (RR 0.53, 95% CI 0.43 to 0.65; 37 trials, 6200 women; moderate quality evidence). Overall rates of groin pain were higher in the TOR group (6.4% versus 1.3%; RR 4.12, 95% CI 2.71 to 6.27; 18 trials, 3221 women; moderate quality evidence) whereas suprapubic pain was lower in the TOR group (0.8% versus 2.9%; RR 0.29, 95% CI 0.11 to 0.78); both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 1.65; 31 trials, 4743 women; moderate quality evidence). There were only limited data to inform the need for repeat incontinence surgery in the long term, but it was more likely in the TOR group than in the RPR group (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women; low quality evidence).A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure (RR 1.10, 95% CI 1.01 to 1.19; 3 trials, 477 women; moderate quality evidence). It incurred significantly less voiding dysfunction, and led to fewer bladder perforations and vaginal tape erosions.Short-and medium-term subjective cure rates between transobturator tapes passed using a medial-to-lateral as opposed to a lateral-to-medial approach were similar (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate quality evidence). There was moderate quality evidence that voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, 1121 women; moderate quality evidence), but vaginal perforation was less frequent in the medial-to-lateral route (RR 0.25, 95% CI 0.12 to 0.53; 3 trials, 541 women). Due to the very low quality of the evidence, it is unclear whether the lower rates of vaginal epithelial perforation affected vaginal tape erosion (RR 0.42, 95% CI 0.16 to 1.09; 7 trials, 1087 women; very low quality evidence).

AUTHORS' CONCLUSIONS

Mid-urethral sling operations have been the most extensively researched surgical treatment for stress urinary incontinence (SUI) in women and have a good safety profile. Irrespective of the routes traversed, they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term. This review illustrates their positive impact on improving the quality of life of women with SUI. However, a brief economic commentary (BEC) identified three studies suggesting that transobturator may be more cost-effective compared with retropubic. Fewer adverse events occur with employment of a transobturator approach with the exception of groin pain. When comparing transobturator techniques of a medial-to-lateral versus a lateral-to-medial insertion, there is no evidence to support the use of one approach over the other. However, a bottom-to-top route was more effective than top-to-bottom route for retropubic tapes.A salient point illustrated throughout this review is the need for reporting of longer-term outcome data from the numerous existing trials. This would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.

Midurethral slings in the mesh litigation era

Stress urinary incontinence (SUI) has always been a major health issue for women. With the progression of technology and surgical techniques, mid urethral slings (MUS) used in both transvaginal and transobturator routes have become the gold standard in the treatment of SUI. There is ample short to mid-term data confirming the efficacy and safety in using MUS in treating SUI in women. However, long-term data supporting the use of MUS in women to treat SUI is scarce. There has been much controversy surrounding the US Food and Drug Administrations' (FDA) public notification of potential complications surrounding the use of transvaginal mesh, which has been magnified and generalised by the media; but despite this there has still been substantial growth and uptake of MUS for treating SUI. In this review, we aim to explore some of the issues with MUS, the factors around litigation with mesh use, the impact of FDA's notification on the uptake of MUS and ultimately, the results and efficacy of MUS for the treatment of SUI.

Cost utility analysis of urethral bulking agents versus midurethral sling in stress urinary incontinence

OBJECTIVE

The aim of this study was to determine the cost utility of urethral bulking agents (BA) compared with midurethral slings (MUS) in the treatment of stress urinary incontinence (SUI) in patients without urethral hypermobility.

METHODS

A decision tree was constructed to compare the cost utility of urethral BA versus MUS in the setting of SUI without urethral hypermobility. Probability estimates for success, failure, and complications were obtained from the published literature. Immediate-term, short-term, and longer-term complications were accounted for over a 1-year time horizon in the model. One-way and 2-way sensitivity analyses and Monte Carlo simulations were performed to assess the robustness of our results.

RESULTS

Our model demonstrated that MUS cost $436,465 more than BA for every 100 women treated in 1 year. Using MUS compared with BA leads to an incremental cost-effectiveness ratio of $70,400 per utility gained. Assuming a willingness to pay of $50,000, this makes MUS not cost-effective as a first-line treatment in many situations. When MUS costs less than $5132, it becomes a cost-effective first-line treatment, and when it costs less than $2035, it is cost saving.

CONCLUSIONS

Bulking agents are more cost-effective than MUS over a 1-year time horizon in the treatment of SUI in patients without urethral hypermobility. In women who lack urethral hypermobility, BA remain a cost-effective option in this patient population.

Mid-urethral sling operations for stress urinary incontinence in women

BACKGROUND

Urinary incontinence is a very common and debilitating problem affecting about 50% of women at some point in their lives. Stress urinary incontinence (SUI) is a contributory or predominant cause in 30% to 80% of these women. Mid-urethral sling (MUS) operations are a recognised minimally invasive surgical treatment for SUI. MUS involves the passage of a small strip of tape through either the retropubic or obturator space, with entry or exit points at the lower abdomen or groin, respectively. This review does not include single incision slings.

OBJECTIVES

To assess the clinical effects of mid-urethral sling (MUS) operations for the treatment of stress urinary incontinence (SUI), urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE in process, ClinicalTrials.gov and handsearching of journals and conference proceedings (searched 26 June 2014), Embase and Embase Classic (January 1947 to Week 25 2014), WHO ICTRP (searched on 30 June 2014) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or MUI, in which both trial arms involve a MUS operation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of potentially eligible studies and extracted data from the included trials.

MAIN RESULTS

We included 81 trials that evaluated 12,113 women. We assessed the quality of evidence for outcomes using the GRADE assessment tool; the quality of most outcomes was moderate, mainly due to risk of bias or imprecision.Fifty-five trials with data contributed by 8652 women compared the use of the transobturator route (TOR) and retropubic route (RPR). There is moderate quality evidence that in the short term (up to one year) the rate of subjective cure of TOR and RPR are similar (RR 0.98, 95% CI 0.96 to 1.00; 36 trials, 5514 women; moderate quality evidence) ranging from 62% to 98% in the TOR group, and from 71% to 97% in the RPR group. Short-term objective cure was similar in the TOR and RPR groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97, 95% CI 0.87 to 1.09; 5 trials, 683 women; low quality evidence; and RR 0.95, 95% CI 0.80 to 1.12; 4 trials, 714 women; moderate quality evidence, respectively). In the long term, subjective cure rates ranged from 43% to 92% in the TOR group, and from 51% to 88% in the RPR group.MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR (0.6% versus 4.5%; RR 0.13, 95% CI 0.08 to 0.20; 40 trials, 6372 women; moderate quality evidence). Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR.Postoperative voiding dysfunction was less frequent following TOR (RR 0.53, 95% CI 0.43 to 0.65; 37 trials, 6200 women; moderate quality evidence). Overall rates of groin pain were higher in the TOR group (6.4% versus 1.3%; RR 4.12, 95% CI 2.71 to 6.27; 18 trials, 3221 women; moderate quality evidence) whereas suprapubic pain was lower in the TOR group (0.8% versus 2.9%; RR 0.29, 95% CI 0.11 to 0.78); both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 1.65; 31 trials, 4743 women; moderate quality evidence). There were only limited data to inform the need for repeat incontinence surgery in the long term, but it was more likely in the TOR group than in the RPR group (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women; low quality evidence).A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure (RR 1.10, 95% CI 1.01 to 1.19; 3 trials, 477 women; moderate quality evidence). It incurred significantly less voiding dysfunction, and led to fewer bladder perforations and vaginal tape erosions.Short-and medium-term subjective cure rates between transobturator tapes passed using a medial-to-lateral as opposed to a lateral-to-medial approach were similar (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate quality evidence). There was moderate quality evidence that voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, 1121 women; moderate quality evidence), but vaginal perforation was less frequent in the medial-to-lateral route (RR 0.25, 95% CI 0.12 to 0.53; 3 trials, 541 women). Due to the very low quality of the evidence, it is unclear whether the lower rates of vaginal epithelial perforation affected vaginal tape erosion (RR 0.42, 95% CI 0.16 to 1.09; 7 trials, 1087 women; very low quality evidence).

AUTHORS' CONCLUSIONS

Mid-urethral sling operations have been the most extensively researched surgical treatment for stress urinary incontinence (SUI) in women and have a good safety profile. Irrespective of the routes traversed, they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term. This review illustrates their positive impact on improving the quality of life of women with SUI. With the exception of groin pain, fewer adverse events occur with employment of a transobturator approach. When comparing transobturator techniques of a medial-to-lateral versus a lateral-to-medial insertion, there is no evidence to support the use of one approach over the other. However, a bottom-to-top route was more effective than top-to-bottom route for retropubic tapes.A salient point illustrated throughout this review is the need for reporting of longer-term outcome data from the numerous existing trials. This would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.

TVT-Exact and midurethral sling (SLING-IUFT) operative procedures: a randomized study

OBJECTIVES

The aim of the study is to compare results, effectiveness and complications of TVT exact and midurethral sling (SLING-IUFT) operations in the treatment of female stress urinary incontinence (SUI).

METHODS

A single center nonblind, randomized study of women with SUI who were randomized to TVT-Exact and SLING-IUFT was performed by one surgeon from April 2009 to April 2011. SUI was diagnosed on coughing and Valsalva test and urodynamics (cystometry and uroflowmetry) were assessed before operation and 1 year after surgery. This was a prospective randomized study. The follow up period was 12 months. 76 patients were operated using the TVT-Exact operation and 78 patients - using the SLING-IUFT operation. There was no statistically significant differences between groups for BMI, parity, menopausal status and prolapsed stage (no patients had cystocele greater than stage II).

RESULTS

Mean operative time was significantly shorter in the SLING-IUFT group (19 ± 5.6 min.) compared with the TVT-Exact group (27 ± 7.1 min.). There were statistically significant differences in the effectiveness of both procedures: TVT-Exact - at 94.5% and SLING-IUFT - at 61.2% after one year. Hospital stay was statistically significantly shorter in the SLING-IUFT group (1. 2 ± 0.5 days) compared with the TVT-Exact group (3.5 ± 1.5 days). Statistically significantly fewer complications occurred in the SLING-IUFT group.

CONCLUSION

the TVT-Exact and SLING-IUFT operations are both effective for surgical treatment of female stress urinary incontinence. The SLING-IUFT involved a shorter operation time and lower complications rate., the TVT-Exact procedure had statistically significantly more complications than the SLING-IUFT operation, but a higher effectiveness.

Transvaginal retropubic sling systems: efficacy and patient acceptability

Stress urinary incontinence is a common, disabling, and costly medical problem that affects approximately 50% of women with urinary incontinence. Suburethral retropubic slings have been developed as a minimally invasive and effective surgical option, and they have been used as a first-line treatment for stress urinary incontinence since 1995. However, complications including vaginal extrusion, erosion, pain, bleeding, infections, lower urinary tract symptoms, urinary retention, and incontinence have been reported with use of the slings. Several companies manufacture sling kits, and the sling kits vary with regard to the composition of the mesh and introducer needle. The aim of this review was to determine which sling kit was most effective for patients, had minimal reported side effects, and was best accepted by patients and surgeons. In a review of the literature, it was found that a total of 38 studies were published between 1995 and 2014 that reported on eight tension-free retropubic sling kits: SPARC, RetroArc, Align, Advantage, Lynx, Desara, Supris, and Gynecare TVT. The Gynecare TVT was the most cited sling kit; the second most cited was the SPARC. This review provides a summary of the studies that have examined positive and negative outcomes of the retropubic tension-free suburethral sling procedure using various sling kits. Overall, the results of the literature review indicated that data from comparisons of the available sling kits are insufficient to make an evidenced-based recommendation. Therefore, the decision regarding which sling kit is appropriate to use in surgery is determined by the medical provider’s preference, training, and past experience, and not by the patient.

Analysis of patient and technical factors associated with midurethral sling mesh exposure and perforation

OBJECTIVES

To evaluate the technical and patient characteristics associated with the development of mesh perforation and exposure in patients after midurethral sling surgeries.

METHODS

After a retrospective review of referred patients, the risk of mesh perforation of the urinary tract over exposure in the vagina was analyzed with multivariate logistic regression, adjusting for the possible predictors of age, body mass index, smoking status at the time of mesh placement, presence of diabetes, type of sling placed, type of surgeon and trocar injury at the time of mesh placement.

RESULTS

A total of 77 women were identified, 27 with mesh perforation and 50 with mesh exposure. The patients' average body mass index was 29.2, and 13% were diabetic. Nine (33%) patients in the perforation group and two (4%) patients in the exposure group had evidence of trocar injury to the bladder or urethra at the time of mesh placement (P < 0.001). After multivariate logistic regression analysis, trocar injury (odds ratio 25.90, 95% confidence interval 2.84-236.58, P = 0.004) and diabetes (odds ratio 9.90, 95% confidence interval 1.1.25-78.64, P = 0.03) were associated with an increased risk of mesh perforation. Increased body mass index (odds ratio 0.88, 95% confidence interval 0.77-0.99, P = 0.05) was associated with a decreased risk of mesh perforation. Finally, postoperative hematomas and blood transfusions occurred more commonly in the mesh perforation group (15% vs 0%, P = 0.01).

CONCLUSIONS

Trocar injury, diabetes and bleeding complications at the time of surgery are associated with higher risk of mesh perforation in patients undergoing midurethral sling placement.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis

OBJECTIVE

Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery.

STUDY DESIGN

We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs).

RESULTS

For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS.

CONCLUSION

Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Novel endoscopic management of a late complication following TVT insertion for stress urinary incontinence

Patient: Female, 57 Final

Diagnosis: Bladder erosion

Symptoms: Haematuria • irritative bladder symptoms • recurrent UTI

Medication: —

Clinical Procedure: Endoscopic tape resection

Specialty: Urology

Management of complications after tension-free midurethral slings

Since their introduction in 1996, tension-free midurethral slings (MUS) have been proven to have long-term efficacy and safety. They are considered the gold standard treatment of female stress urinary incontinence, especially in cases that are associated with urethral hypermobility. However, they are not free of complications and, although rare, some of these complications can be challenging for both patients and physicians. Some complications occur intraoperatively, whereas others appear in the early or late postoperative period. There is less controversy in the diagnosis and treatment of complications such as vaginal extrusion or urinary system erosion, whereas de novo voiding problems are at best not completely understood. Voiding dysfunction after MUS placement may vary in a wide range from urinary frequency or urgency to retention and is usually attributed to the obstructive or irritative effect of the sling. However, present urodynamic criteria for the diagnosis of female infravesical obstruction are not satisfactory, and the best management policy for de novo voiding dysfunction remains controversial. In the majority of cases, the diagnosis of obstruction leading to a urethral release surgery depends on a combination of several clinical findings. The timing of urethral release surgery varies depending on the preferences of the surgeon, and the outcome of this surgery is not always predictable. The purpose of this review was to assess the diagnosis and management of the immediate, short-term, and long-term complications of MUS in light of the current literature in an attempt to determine the best management policy.

The fate of synthetic mid-urethral slings in 2013: A turning point

INTRODUCTION

Since the introduction of the first retropubic tension-free synthetic sling to treat stress urinary incontinence (SUI), newer approaches, different techniques and new devices have been created. Transobturator and single-incision sling (SIS) techniquespara-were developed with the goal of diminishing the rate of complications andspeeding the recovery phase.

METHODS

For this review we searched Medline for relevant papers, with an emphasis on meta-analysis and randomised controlled trials (RCTs). Specially selected reports were identified to address both 'index patients' (defined as those with genuine SUI and no previous anti-incontinence procedure or other genitourinary sign or symptom that might affect her SUI) and, briefly, non-index patients. Two authors independently reviewed papers for eligibility.

RESULTS

Level 1 evidence from a Cochrane review and two meta-analyses indicated that subjective outcomes with the mid-urethral sling (MUS) were similar to those from colposuspension. However, the MUS was better than colposuspension when assessing objective outcomes (Level 1). MUS are equally effective as autologous pubovaginal slings (Level1). Two meta-analyses suggest that retropubic MUS (RMUS) might be better than transobturator MUS when assessing objective outcomes. Five more recent RCTs with longer term outcomes showed high success rates and only one reported a significant advantage for the RMUS in women with intrinsic sphincteric deficiency. One meta-analysis addressing the SIS showed inferior outcomes to the MUS (Level 1). New and improved SIS techniques have been used, but long-term outcomes are limited and results are still controversial when compared to the MUS.

CONCLUSION

MUS are still the standard to treat the index patient as previously stated by the American and European Associations of Urology. Currently data are lacking to define which sling and what approach works best. Complications are significantly different between sling types and are dependent on technique.

Bladder perforation during tension-free vaginal tape procedures: abdominal versus vaginal approach

OBJECTIVE

Bladder perforation rates for the tension-free vaginal tape (TVT) are higher with inexperienced surgeons. The purpose of this study was to examine if surgical approach affects this rate.

METHODS

We performed a retrospective cohort study of consecutive patients undergoing a TVT as the sole procedure. All cases were performed by senior residents using 2 different surgical approaches-vaginal or abdominal trocar passage. Power analysis indicated that 103 patients in each group (vaginal and abdominal approach) were required to demonstrate a 50% reduction in perforation rates.

RESULTS

The rate of perforation was 37.9% (95% confidence interval [CI], 28.5%-47.3%) for the vaginal compared with 6.8% (95% CI, 1.9%-11.7%) for the abdominal technique (P < 0.001). The relative risk that the abdominal technique results in bladder injury compared with the original transvaginal was 0.18 (95% CI, 0.08-0.38).

CONCLUSIONS

Bladder perforation occurs significantly less frequently with abdominal needle placement for the TVT procedure. We recommend this technique to less experienced surgeons.

One-year outcomes of mid-urethral sling procedures for stress urinary incontinence according to body mass index

Purpose

The purpose of our study was to investigate the safety and efficacy of the suprapubic arch (SPARC) sling operation and the transobturator tape (MONARC) sling operation according to body mass index (BMI).

Materials and Methods

Between January 1, 2004, and July 12, 2009, a retrospective clinical trial was performed with 284 patients treated by the SPARC sling procedure and 49 patients treated by the MONARC sling procedure. The women were classified into 3 groups by BMI according to the WHO Expert Consultation: normal weight (A, BMI 18.5 to 22.9 kg/m²), overweight (B, BMI 23 to 27.5 kg/m²), and obese (C, BMI>27.6 kg/m²). Patients' characteristics and clinical outcomes of the operation were analyzed according to BMI at 1 year after surgery via questionnaires and interviews with the patients about their voiding symptoms and medical records.

Results

There were 103 patients in group A, 186 in group B, and 34 in group C. The objective cure rates for groups A, B, and C after the SPARC procedure were 94.4%, 96.7%, and 96.8%, respectively (p=0.321), and the subjective cure rates were 94.4%, 96.1%, and 96.8%, respectively (p=0.222). The objective cure rates for groups A, B, and C after the MONARC procedure were 100.0%, 90.9%, and 66.7%, respectively (p=0.742), and the subjective cure rates were 92.3%, 93.9%, and 66.7%, respectively (p=0.779). The complication rates were similar among the three study groups.

Conclusions

Mid-urethral sling procedures for urinary incontinence result in similar objective and subjective cure rates and postoperative complications irrespective of BMI.

Female incontinence: long-term results of slings

PURPOSE OF REVIEW

Several different sling procedures are currently in use and most of them are newly developed. Despite the fact that they are widely in use, knowledge about their long-term efficacy, morbidity, and functional sequeal is scarce. The aim of the present review is to provide an update of several different procedures.

RECENT FINDINGS

The tension-free vaginal tape is the best studied and documented procedure with excellent long-term outcome data and low rates of complications. Tension-free vaginal tape appears to be followed by significantly higher objective cure rates than transobturator tape. Concerning comparison of different types of transobturator tape, no significant differences were found so far. Minislings still need to be evaluated concerning long-term safety and efficacy.

SUMMARY

Tension-free vaginal tape and transobturator tape are equally effective; for assessment of new approaches, surgical long-term data are mandatory.

Mid-urethral slings in female incontinence: Current status

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring one's choice of MUS to the individual patient and her unique clinical parameters remains the best option.

[Functional results following transobturator and retropubic mid-urethral sling]

OBJECTIVE

To compare functional results following retropubic and transobturator mid-urethral sling procedures.

METHODS

Multicenter randomized controlled trial. Power calculation was based on the rate of bladder injury. The current study concerns an analysis of secondary judgment criteria.

RESULTS

One hundred and forty-nine patients were randomly allocated to either TVT (n=75) or TVT-O (n=74). Among them, 132 women completed a 24-month follow-up. There was no significant difference between the two groups, concerning urodynamics data (excluding uroflowmetry) at 12 months follow-up, functional and sexual results at 6, 12 and 24 months follow-up. Concerning sexual results, an improvement in visual analogue scale scores was observed in both groups at 24 months follow-up with no difference between the two groups: median score increased from 70 (IQR: 50-80) pre-operatively to 90 (IQR: 70-100) at 24 months follow-up (P=0,0004) in TVT-O group and from 70 (IQR: 50-80) to 85 (IQR: 70-100) (P=0,0009) in TVT group.

CONCLUSION

TVT and TVT-O procedures are both associated with an increase in quality of life with no significant differences in functional results at 2 years follow-up.

The evolution of surgical treatment for female stress urinary incontinence: era of mid-urethral slings

Based on the integral theory, tension-free placement of a mid-urethral sling (MUS) for female stress urinary incontinence (SUI) has gained substantial popularity owing to the ease of the procedure and its effectiveness. Published series with long-term follow-up show continence rates after the MUS procedure ranging from 70% to 80%. Complication rates after MUS procedures are usually low. This review aimed to describe the historical change and the current use of the MUS. We discuss the efficacy and complications of various MUS procedures and the current strategies for managing failed slings.

Prospective Study Comparing the Suprapubic Arc (Sparc) Procedure and the Transobturator (Monarc) Procedure for Treating Female Stress Urinary Incontinence

OBJECTIVES

In a comparative trial we evaluated the efficacy and safety of the suprapubic arch (Sparc) and transobturator (Monarc) procedures for the treatment of female stress urinary incontinence (SUI).

METHODS

Between November 2003 and May 2004, 46 women with SUI who underwent the Sparc procedure and 42 women who underwent the Monarc procedure were analyzed. The preoperative evaluation included history taking, physical examination, voiding diary, stress and 1-h pad tests and a comprehensive urodynamic examination. Postoperative evaluation included a stress test, 1-h pad test, and uroflowmetry with postvoid residuals.

RESULTS

After 1 year of follow up, the rates of cure and satisfaction were 93.5 and 93.0%, respectively, in the Sparc group. The rates of cure and satisfaction were 95.2 and 85.7%, respectively, in the Monarc group. After 2 years of follow up, the rates of cure (93.5 vs 92.9%) and satisfaction (84.8 vs 83.3%) were similar between the two groups. No bladder injury occurred in the Monarc group. Bladder injury occurred in 6.5% (n = 3) of the patients in the Sparc group. Vaginal wall perforation occurred in 4.8% (n = 2) of the patients in the Monarc group (P > 0.05). Late complications included de novo urge symptoms (8.7 vs 11.9%) and voiding dysfunction (10.9 vs 9.5%).

CONCLUSIONS

The transobturator Monarc procedure appears to be as efficient and safe as the retropubic Sparc procedure for the treatment of SUI.

Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women

BACKGROUND

Stress urinary incontinence (SUI) is a common condition affecting up to 30% of women. Minimally invasive synthetic suburethral sling operations are among the latest forms of procedures introduced to treat SUI.

OBJECTIVES

To assess the effects of minimally invasive synthetic suburethral sling operations for treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 20 March 2008), MEDLINE (January 1950 to April 2008), EMBASE (January 1988 to April 2008), CINAHL (January 1982 to April 2008), AMED (January 1985 to April 2008), the UK National Research Register, ClinicalTrials.gov, and reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or symptoms of stress or mixed urinary incontinence, in which at least one trial arm involved a minimally invasive synthetic suburethral sling operations.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trials.

MAIN RESULTS

Sixty two trials involving 7101 women were included. The quality of evidence was moderate for most trials. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings ( trials, n = 599, Risk Ratio (RR) 1.03, 95% Confidence Interval (CI) 0.94 to 1.13) but with shorter operating time and less post-operative voiding dysfunction and de novo urgency symptoms.Minimally invasive synthetic suburethral sling operations appeared to be as effective as open retropubic colposuspension (subjective cure rate at 12 months RR 0.96, 95% CI 0.90 to 1.03; at 5 years RR 0.91, 95% CI 0.74 to 1.12) with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time and hospital stay but significantly more bladder perforations (6% versus 1%, RR 4.24, 95% CI 1.71 to 10.52).There was conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (objective cure, RR 1.15, 95% CI 1.06 to 1.24; subjective cure RR 1.11, 95% CI 0.99 to 1.24). Minimally invasive synthetic suburethral sling operations had significantly less de novo urgency and urgency incontinence, shorter operating time, hospital stay and time to return to daily activities.A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI 1.01 to 1.20; RR 1.06, 95% CI 1.01 to 1.11) and incurred significantly less voiding dysfunction, bladder perforations and tape erosions.Monofilament tapes had significantly higher objective cure rates (RR 1.15, 95% CI 1.02 to 1.30) compared to multifilament tapes and fewer tape erosions (1.3% versus 6% RR 0.25, 95% CI 0.06 to 1.00).The obturator route was less favourable than the retropubic route in objective cure (84% versus 88%; RR 0.96, 95% CI 0.93 to 0.99; 17 trials, n = 2434), although there was no difference in subjective cure rates. However, there was less voiding dysfunction, blood loss, bladder perforation (0.3% versus 5.5%, RR 0.14, 95% CI 0.07 to 0.26) and shorter operating time with the obturator route.

AUTHORS' CONCLUSIONS

The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short term but with less postoperative complications. Women were less likely to be continent after operations performed via the obturator (rather than retropubic) route, but they had fewer complications. Most of the trials had short term follow up and the quality of the evidence was variable.

Economic impact of tension-free vaginal tape surgery for urinary incontinence in an ambulatory regimen compared with hospital admission

OBJECTIVES

To determine the cost per patient of a tension-free vaginal tape procedure involving major ambulatory surgery (MAS) compared with inpatient surgery in 2002 and 2003, and to analyse the medical care given following each procedure in a public hospital in Spain.

MATERIAL AND METHODS

The method used was activity-based costing, which involves designing a protocol of processes of caring for the patient with the help of professionals and subsequently calculating the cost of each process; this system was applied retrospectively to patients cared for in 2002 and 2003. In addition, the clinical histories of these patients were reviewed in order to evaluate complementary care given by the emergency service and admissions to hospital immediately following surgery. The relation between these events and each sample group was analysed by means of a non-parametric test and CIs for a 95% level of significance were obtained in order to make the calculations more robust.

RESULTS

The mean cost for the patients in the ambulatory group was 42.43% lower than that for the hospitalized patients. Whereas 5.5% of the ambulatory patients subsequently required admission and a further 7.3% required complementary medical care, 19.2% of the patients who had been hospitalized for the surgery required complementary medical care and 1.4% were readmitted after intervention. In spite of these results, there was no dependence between these variables according to the chi(2) test.

CONCLUSION

MAS produced better results in terms of minimizing costs; under our conditions it was less costly but was of equal efficacy to the surgical intervention.

Body mass index as a risk factor for cystotomy during suprapubic placement of mid-urethral slings

INTRODUCTION AND HYPOTHESIS

This study aims to investigate whether body mass index (BMI) is a risk factor for cystotomy during sling placement via suprapubic approach for stress urinary incontinence.

METHODS

Retrospective chart review was performed for suprapubic mid-urethral sling placement between June 2005 and October 2007. Data collected included demographics, BMI, and history of prior and concomitant procedures. Primary outcome was cystotomy during sling placement.

RESULTS

Of 198 women identified, 129 had a BMI < 30 kg/m2 and 69 had a BMI > or = 30 kg/m2. There were 18 (14.0%) cystotomies in the BMI < 30 kg/m2 group and three (4.3%) in the BMI > or = 30 kg/m2 group (p = 0.04). BMI < 30 kg/m2 remained a risk factor for cystotomy after controlling for confounders (OR 4.63, 95% CI 1.20-17.86), as did prior anti-incontinence surgery (OR 3.55, 95% CI 1.01-12.50).

CONCLUSIONS

BMI < 30 kg/m2 may be a risk factor for cystotomy during sling placement utilizing the suprapubic approach.

Urethral injury associated with minimally invasive mid-urethral sling procedures for the treatment of stress urinary incontinence: a case series and systematic literature search

The introduction of the TVT has brought about dramatic changes in our practice as regards surgery for stress urinary incontinence, although the risk of bladder injury has caused concern. The subsequent development of tapes introduced through the obturator foramina may limit the rate of bladder injury, and some have suggested that cystoscopy is no longer required during stress incontinence surgery. Several cases of urethral injury referred to our unit have caused us concern about this approach. We present here brief details of these cases along with a systematic search of the literature on urethral injury following mid-urethral tape procedures.

TVT and TOT: a comparison between these two techniques based on our clinical experience

Aim of the Study

A retrospective evaluation and a comparison of results from two minimally invasive surgery techniques that we adopted for the treatment of SUI.

Materials and Methods.

In this study we evaluated 113 selected patients who underwent SUI minimally invasive surgery from 1–1-2000 to 31–12–2007. 87 patients underwent epidural anesthesia. 26 local anesthesia. In Group A (TVT) 61 patients were enrolled, mean age 57.6 (±22). 43 patients (70%) were on menopause. In Group B (TOT out-in) 52 patients were enrolled (for 34 of them we used the Obtape® sling while for 18 the Obtryx® one), their mean age was 58.5 (±20.5) and 39 patients (75%) were on menopause. Patients from both groups did not undergo any past previous urogynecological surgery and suffered from stress urinary incontinence with cervico-urethral hypermobility butno other associated pathology. The pre-operative work-up included an evaluation of patients based on ICS guidelines.

Results.

Group A (TVT) - mean follow-up 66.3 months, dry patients 53/61 (86.8%). Bladder perforations resolved by catheterization 3/61 (5%). Transient voiding dysfunction 14/61 (22.8%). “De novo” urgency 8/61 (13%). One patient on self-catheterization due to persistent urinary retention underwent a single-side section of the sling with spontaneous micturition and complete continence recovery. Group B (TOT out-in) - mean follow-up 35.5 months, dry patients 43/52 (82%). 4 patients (7.6%) complained oftransient voiding dysfunction, 5 patients (9.5%) for “de novo” urgency, 1 patient underwent a sling removal due to vaginal erosion 4 months after surgery (Obtape®).

Complications of mid urethral slings: important outcomes for future clinical trials

PURPOSE

Mid urethral slings are becoming the first line surgical treatment for stress urinary incontinence in women. We reviewed the complications of mid urethral sling placement and their potential pathophysiology.

MATERIALS AND METHODS

We conducted a literature search on MEDLINE from 1995 to 2007 using the key words sling, complications, mid-urethral slings, transvaginal tape, transobturator tape, trials, pathophysiology and complications. The Cochrane database was also searched. The results were summarized according to the type of mid urethral slings reported.

RESULTS

There were 928 MEDLINE citations for sling and complications, 279 for sling and complications and bladder, and 68 for sling and complications and voiding dysfunction. The reported complication rates ranged from 4.3% to 75.1% for retropubic and 10.5% to 31.3% for transobturator mid urethral slings. Complications included bladder perforation, hemorrhage, bowel injury, vaginal extrusion, de novo urgency and urge incontinence, urinary tract infections and voiding dysfunction. Retropubic mid urethral slings led to a higher occurrence of complications such as bladder perforation and hematoma. In addition, the retropubic approach resulted in serious complications such as bowel injury, major vascular injury and death. Groin pain was more common after the transobturator approach. Experimental studies indicated that the potential mechanisms for sling complications may include vaginal dissection, denervation injury and bladder remodeling.

CONCLUSIONS

Mid urethral slings result in bothersome complications which should not be minimized. Awareness of these complications should encourage improvements in patient counseling as well as further investigation of the underlying mechanisms. Decreasing complications should be considered an important outcome for future clinical studies of mid urethral slings.

Lynx midurethral sling system: a 1-year prospective study on efficacy and safety

The objective of this study is to determine the outcomes for the Lynx midurethral sling system in the treatment of urodynamic stress incontinence (USI). Prospective study of 118 subjects who underwent a Lynx midurethral sling procedure for USI. Subjects were considered cured if they were subjectively dry by history and objectively dry by standing stress test. Intraoperative and postoperative complications were documented. Complete information was available on 102 (86%) subjects at 1 year. Ninety-two patients were considered cured, and ten were failures. There were four intraoperative bladder perforations and five (4.2%) erosions. Two patients developed urinary retention with one resolving at 31 days and the other undergoing subsequent takedown at 6 months. Both remain dry at 12 months. The Lynx midurethral sling system shows high subjective and objective success rates for the treatment of USI at 1 year with low rates of intraoperative and postoperative complications.

Midurethral slings for stress urinary incontinence

Midurethral synthetic slings for female stress urinary incontinence are minimally invasive polypropylene mesh tapes, which are inserted under the midurethra with trocars. In the last decade this new technology has become the most commonly performed procedure for female stress urinary incontinence, replacing the traditional open procedures. Using only 3 small incisions, these outpatient procedures can be performed under local anesthesia with conscious sedation. Retropubic and transobturator approaches will be reviewed along with a review of efficacy, comparative studies, complications, and use in many different clinical situations.