Complications of mid-urethral slings for treatment of stress urinary incontinence

Suburethral Synthetic Adjustment-controlled Tape Compared with Conventional Treatment for Female Stress Urinary Incontinence: A Randomized Controlled Trial

BACKGROUND

Urinary incontinence (UI) is a urological problem in women. Currently, suburethral slings are the standard of surgical treatment for stress UI in the female population.

OBJECTIVE

To prove the feasibility of an operating technique using suburethral adjustment-controlled tape (SACT) placement.

DESIGN, SETTING, AND PARTICIPANTS

A single-center comparative randomized controlled trial included patients randomized according to the CONSORT checklist from April to October 2018 and from November 2018 to April 2019. The inclusion criteria were women from 21 to 81 yr, stress and mixed UI forms, and positive cough test. The exclusion criteria were pregnancy, lactation, neurogenic bladder dysfunction, recurrent forms of UI, radiation therapy and pelvic surgery in anamnesis, genital prolapse (Pelvic Organ Prolapse Quantification system >2), urinary infection, and obstructive urination.

INTERVENTION

The first group (50 patients) was using synthetic SACT and the second group (75 patients) a transobturator tape (TOT) midurethral sling (MUS).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Subjective efficacy of 96% was established in group 1 and 86% in group 2, with a median follow-up of 12 mo. According to gynecological examination results, the objective surgical treatment efficiency was 96% in group 1 and 90.7% in group 2. This statistically significant indicator was evaluated in each group. However, when comparing both groups, no statistical difference was revealed. According to urodynamic studies, 1 mo after surgery in group 1, terminal and phase detrusor overactivity signs were 18% (n = 9) and 12% (n = 6), respectively. In group 2, these were 14.7% (n = 11) and 12% (n = 9), respectively.

RESULTS AND LIMITATIONS

The block approach was used to randomize patients into groups. A total of 125 patients (50 in the main group and 75 in the control group) were analyzed.

CONCLUSIONS

Our results prove the efficacy and safety of SACT in treating UI in women. The subjective and objective effectiveness results of treating patients in the study group show the possibility of using SACT in the same row with TOT MUS.

PATIENT SUMMARY

Our purpose was to standardize the surgery stage for urinary incontinence, and evaluate the effectiveness and safety of suburethral adjustment-controlled tape placement. We analyzed women with urinary incontinence and used two different surgical methods. Our results prove the efficacy and safety of suburethral adjustment-controlled tape in treating urinary incontinence in women.

A retrospective analysis of perioperative complications associated with retropubic tension-free vaginal tape in 960 women

Purpose

The purpose is to analyse perioperative complications associated with the retropubic tension-free vaginal tape (TVT) procedure and their management.

Methods

This retrospective, monocentric cohort study included 960 women after retropubic TVT procedure performed by one surgeon from 2011 to 2016. Complications were identified up to 6 weeks after the procedure, divided into specific and general complications and classified based on the Clavien–Dindo (CD) Classification. A visit 6 weeks after the surgical procedure was attended by all patients.

Results

77 complications, of which 74 occurred postoperatively and 3 intraoperatively, affecting 72 (7.5%) out of 960 women. Urinary retention and voiding problems were the most common complication. The mean age of women suffering complications was 3.4 years higher in comparison to the mean age of women without complications (p = 0.036). The Body Mass Index (BMI) of the group of women with perioperative complications had an average BMI which was 0.5 kg/m² lower than the average BMI of the women without complications. 22 (12.8%) out of 172 women with recurrent stress incontinence had postoperative complications, of which 21 were related to the TVT.

Conclusion

The retropubic TVT is a surgical procedure associated with a low number of perioperative complications, even in the group of elderly and overweight women, as well as in cases of recurrent stress incontinence.

Retropubic mid-urethral slings and de novo urinary urgency and frequency: The role of retropubic hematomas

AIMS

This is a prospective cohort study comparing de novo lower urinary tract symptoms (LUTS) in subjects undergoing a retropubic mid-urethral sling who either did or did not develop a postoperative retropubic hematoma within 6 weeks of surgery. The secondary objective was to measure the incidence and prevalence of retropubic hematomas, and subject characteristics associated with retropubic hematomas.

METHODS

Eligible subjects were recruited before undergoing a retropubic mid-urethral sling with or without concurrent pelvic reconstructive surgery. Validated urinary symptom questionnaires were completed before surgery and at 6 weeks postoperatively. An abdominal ultrasound was used to establish baseline lower urinary tract imaging. Ultrasound was repeated immediately after surgery and 6 weeks later to assess for the presence of retropubic hematomas.

RESULTS

Ninety-four subjects were enrolled. Baseline urgency and frequency were measured in 35% (33/93) of subjects. At 6 weeks postoperatively, 2% (1/52) had de novo LUTS which were not associated with a retropubic hematoma at any time. Immediately after surgery, the incidence of retropubic hematomas was 17% (16/94) while the prevalence of retropubic hematomas 6 weeks after surgery was 4% (3/75). There was no significant difference in the change in hemoglobin before and after surgery between those with and without postoperative retropubic hematomas.

CONCLUSIONS

There is no significant association with de novo LUTS and retropubic hematomas. Though there is a 17% incidence of retropubic hematomas detected immediately after surgery, those with hematomas who were not lost to follow-up resolved by the 6-week postoperative visit and is of unclear clinical significance.

Focusing on long-term complications of mid-urethral slings among women with stress urinary incontinence as a patient safety improvement measure: A protocol for systematic review and meta-analysis

BACKGROUND

There are 3 different types of mid-urethral sling, retropubic, transobturator and single incision performed for women with stress urinary incontinence. Prior studies comparing these three surgeries merely focused on the successful rate or efficacy. But nevertheless, what is more clinically important dwells upon investigating postoperative complications as a safety improvement measure.

METHODS

A systematic review via PubMed, Ovid, and the Cochrane Database of Systematic Review and studies were applied based on the contents with clearly identified complications. Selected articles were reviewed in scrutiny by 2 individuals to ascertain whether they fulfilled the inclusion criteria: complications measures were clearly defined; data were extracted on study design, perioperative complications, postoperative lower urinary tract symptoms, postoperative pain, dyspareunia, and other specified late complications.

RESULTS

A total of 55 studies were included in the systemic review. Perioperative complications encompassed bladder perforation, vaginal injury, hemorrhage, hematoma, urinary tract infection. There were postoperative lower urinary tract symptoms including urine retention and de novo urgency. Furthermore, postoperative pain, tape erosion/ extrusion, further stress urinary incontinence surgery, and rarely, deep vein thrombosis and injury of inferior epigastric vessels were also reported.

CONCLUSIONS

Complications of mid-urethral sling are higher than previously thought and it is important to follow up on their long-term outcomes; future research should not neglect to address this issue as a means to improve patient safety.

Intraoperative Vaginal Perforation During Various Mid-Urethral Sling Procedures Treating Female Stress Urinary Incontinence

BACKGROUND

Incidence of intraoperative vaginal perforation is generally considered to be low but varies among different procedures. Vaginal perforation could not only prolong the surgeries and aggravate surgical trauma but also result in postoperative discomfort or even a second surgery.

METHOD

Vaginal perforation, vaginal epithelial perforation, vaginal wall perforation, vaginal penetration, urinary incontinence were searched in PubMed, Cochrane, Embase database to identify the qualified clinical trial and relevant literature sources were also searched.

RESULTS

A total of 9223 cases of from 33 trials from literatures and 387 cases from our own trail were analyzed, which provided detailed data on intraoperative vaginal perforation. Incidence of intraoperative vaginal perforation during mid-urethral sling surgery treating stress urinary incontinence was generally low, which was 1.56%. Incidence of intraoperative vaginal perforation during transobturator (TOR) procedure was higher than that during retropubic (RPR) procedure, which were 2.11% and 0.89% respectively. Incidence of intraoperative vaginal perforation during outside-to-inside TOR procedure like TOT and MONARC was higher than that during inside-to-outside TOR procedure like TVT-O, which were 2.74% and 1.52%, respectively. Incidence of intraoperative vaginal perforation during single-incision surgery like H-type TVT-SECUR reached 1.97%, while no report on U-type TVT-SECUR surgeries.

CONCLUSION

The incidence of intraoperative vaginal during mid-urethral sling procedures for female stress urinary incontinence is fairly high. Vaginal perforation was more common in trans-obturator route (TOR) than retropubic route (RPR). In TOR route, it was less frequent in inside-to-outside procedure than outside-to-inside procedure. Surgery proficiency could also have an impact on this complication.

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.

Safety of synthetic mesh in pelvic surgery

Mesh in the form of a midurethral sling is an acceptable and generally safe treatment option for stress urinary incontinence in patients who have failed conservative treatment options such as weight loss and pelvic floor muscle training. In patients with pelvic organ prolapse, when outcomes are measured in terms of improvement in postoperative physical exam (anatomic success), many studies have demonstrated that mesh augmented repairs are superior to prolapse repairs not using mesh (native tissue). However, from a symptomatic standpoint, the outcomes of mesh and native tissue repairs are equivalent. This means that even though the physician may see more prolapse on physical exam after native tissue repair, most patients do not perceive this as a problem because their sensation of a vaginal bulge is gone. The vaginal bulge is one of the most common complaints of a patient prior to pelvic organ prolapse repair. Based on interpretation of the available literature, it does not appear that mesh is superior to native tissue repair for anterior (cystocele) and posterior (rectocele) compartment pelvic organ prolapse repair. However, for apical repairs the native tissue repairs are more technically challenging and it appears that suspension of the apex of the vagina with mesh to the sacrum (sacrocolpopexy) may yield better outcomes. Unfortunately, like all mesh surgeries there is a significant risk of mesh complications with sacrocolpopexy. Surgeons should thoroughly counsel their patients about the permanent nature of synthetic mesh and the potential serious complications related to its use. Mesh augmented pelvic organ prolapse repairs carry unique complications that are not present with native tissue repairs and may not provide better outcomes.

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.