New Treatments for Recurrent Stress Incontinence

Minimum 1-year results of mesh spiral-sling procedure in managing refractory and primary disabling stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We present our minimum 1-year results with a mesh spiral-sling procedure (MSSP) for managing refractory and disabling stress urinary incontinence (SUI) in women.

METHODS

Thirty-four women were treated with MSSP between 2007 and 2011. Six had incomplete data and were excluded from analysis. Study cohort comprised 21 women with refractory (mean number of previous surgeries 2.2; range 1-6) and seen with primary disabling SUI. All patients had marked intrinsic sphincter deficiency (ISD) with a Valsalva leak-point pressure (VLPP) <60 cm H2O. Preoperative workup included assessing the impact of voiding symptoms using the International Consultation on Incontinence Questionnaire--Short Form (ICIQ-SF), estimating the daily number of pads, and urodynamic studies. Preoperative and postoperative findings were compared using the Wilcoxon signed-rank test.

RESULTS

Intraoperative unilateral bladder-neck perforation occurred in two women during dorsal urethrolysis. With a mean follow-up of 26 months (range 12-48), SUI was cured in 71.4% of patients. Distal urethral reconstruction with vaginal mucosal flaps was performed in two patients with short urethral length (<2.5 cm) due to recurrence of SUI 10 months after MSSP. Mean ICIQ-SF score decreased from 19.4 ± 3.6 preoperatively to 7.3 ± 2.8 postoperatively (p = 0.001). Mean daily pad number decreased from 5.2 preoperatively to 1.2 postoperatively (p = 0.02). Urethral or vaginal erosion was not observed in any case during follow-up.

CONCLUSION

Using spiral slings may be a viable option in managing refractory and disabling SUI.

Outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape insertion, and transobturator tape insertion in women with recurrent stress urinary incontinence

OBJECTIVE

Although the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures.

METHODS

This retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications.

RESULTS

Forty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction.

CONCLUSION

The laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.

Recurrent stress urinary incontinence after synthetic mid-urethral sling procedures

PURPOSE OF REVIEW

Synthetic mid-urethral slings (MUSs) have been widely adopted for female stress urinary incontinence (SUI). Practitioners are encountering increasing numbers of women with recurrent SUI after a failed MUS. Several studies over the past 18 months have reported outcomes for secondary continence procedures in this context and form the basis of this review.

RECENT FINDINGS

Expert consensus supports a trial of conservative therapy for recurrent SUI, although a sound evidence base is lacking. As regards repeat surgical intervention, retrospective studies on repeat synthetic MUSs have demonstrated medium-term cure rates of 60-70%, which is lower than that achieved with primary surgery. Secondary transobturator tape appears inferior to secondary retropubic tape in women with intrinsic sphincteric deficiency. Promising early results have been reported with spiral slings and the adjustable continence procedures, although these interventions are technically more challenging and longer-term follow-up is warranted. Artificial urinary sphincters show high efficacy rates for severe, refractory SUI, although complication rates are higher in women with prior failed MUS.

SUMMARY

Repeat synthetic MUSs are likely to form the mainstay of secondary continence procedures presently. Longer-term follow-up of promising newer modalities, including adjustable continence therapies, is required. Above all, there is an urgent need for good quality, prospective data to guide practitioners in this growing clinical challenge.

Salvage spiral sling techniques: alternatives to manage disabling recurrent urinary incontinence in females

PURPOSE

Females with recurrent stress urinary incontinence after anti-incontinence surgery represent a therapeutic challenge. In our experience and that of others standard sling procedures have occasionally failed to correct these problems. We determined the effectiveness of various spiral sling techniques used in these cases to manage pipe stem urethras in which conventional slings had failed.

MATERIALS AND METHODS

Between January 2007 and July 2008 we evaluated 30 female patients with persistent stress urinary incontinence after multiple failed anti-incontinence procedures. Preoperative and postoperative evaluation consisted of history, physical examination, number of pads, Stamey score and quality of life questionnaires.

RESULTS

We followed 28 patients a minimum of 15 months (range 15 to 18). Mean patient age was 60 years (range 36 to 84). At presentation patients had undergone a mean of 3.5 prior vaginal procedures (range 1 to 6) and used a mean of 7 pads daily (range 3 to 12). Of the patients 21 received a synthetic spiral sling, 5 received an autologous spiral sling (rectus fascia in 3 and fascia lata in 2) and 3 received a lateral spiral sling. Mean pad use decreased to 0.9 daily (range 0 to 2, p<0.05). Postoperative mean Stamey score decreased from 2.6 to 0.3 (p<0.05). Complications included unilateral vesical perforation in 3 patients with a contralateral lateral spiral sling. The overall success rate was 72%.

CONCLUSIONS

Salvage spiral sling techniques are a satisfactory alternative treatment for refractory stress urinary incontinence. When synthetic material cannot be used, autologous tissue can provide similar results. When the bladder is perforated unilaterally, a lateral spiral sling can be used on the contralateral side.