Incisionless per vaginal bone anchor cystourethropexy for the treatment of female stress incontinence: experience with the first 50 patients

Long-Term Surgical Results of Pubovaginal Sling Procedure Using Polypropylene Mesh in the Treatment of Stress Urinary Incontinence

INTRODUCTION

Surgery for stress urinary incontinence (SUI) in women might cure incontinence symptom but develop new problems. This study assessed the long-term outcome of pubovaginal sling procedure using polypropylene mesh in patients with SUI.

MATERIALS AND METHODS

A total of 108 patients with various types of SUI received pubovaginal sling procedure using polypropylene mesh. A surgical technique that did not create bladder outlet obstruction after operation was used in all the patients. Video urodynamic study was performed at baseline, 2 weeks and 3 months after operation. The long-term surgical results and patients' satisfaction were assessed.

RESULTS

The age of patients ranged from 33 to 94 years (mean 62.6 +/- 12.0 years). The follow-up period ranged from 24 to 72 months (median 46 months). Among the 108 patients, a successful result was noted in 92 (85.2%), including a continence rate of 65.7% and mild SUI in 19.4% of patients. Treatment failure was noted in 16 patients (14.8%), including 13 (12%) with urge incontinence and 3 (2.8%) with severe SUI that was cured by a second sling. There were 104 patients (96.3%) who could void volitionally with little residual urine, whereas 4 (3.7%) needed transvaginal urethrolysis. Urodynamic study revealed no significant changes in the mean values of parameters at 3 months after operation. However, 22 (20%) patients had an increase in voiding pressure by 50% at 3 months postoperatively. The reported satisfactory rate was 89.8%.

CONCLUSIONS

Pubovaginal sling procedure using polypropylene mesh had a high success rate in all types of SUI. The continence rate was suboptimal, indicating that the absence of bladder outlet obstruction might result in inadequate urethral compression after pubovaginal sling procedure.

Osseous complications after transvaginal bone anchor fixation in female pelvic reconstructive surgery: Report from single largest prospective series and literature review

OBJECTIVES

To report, from our prospective database and review of published studies (including primary reported patient series and case reports for osseous complications after transvaginal bone anchor fixation in female pelvic reconstructive surgery), our results and those from previously reported patient series to determine the incidence of osteitis pubis and osteomyelitis.

METHODS

A total of 440 patients from our database of cadaveric transvaginal sling (n = 127) and cadaveric prolapse repair with sling (n = 313) procedures had at least 3 months of examination follow-up and were included in this report. We found 15 primary reported patient series involving transvaginal bone anchor fixation in published studies, for a total of 788 patients. The combined patient population of 1228 was assessed for the incidence of osteitis pubis and osteomyelitis.

RESULTS

Of our 440 patients included in this study, 2 developed osteitis pubis (0.45%), and none had osteomyelitis (0%). In the published studies we reviewed, no case of osteitis pubis and 1 case of osteomyelitis (1 of 788, 0.13%) were reported. One additional case of osteomyelitis with transvaginal bone anchor fixation was reported. The combined incidence of osteitis pubis was 2 (0.16%) of 1228, and the combined incidence of osteomyelitis was 1 (0.08%) of 1228.

CONCLUSIONS

In procedures using transvaginal bone anchor fixation in female pelvic reconstructive surgery, the combined incidence, from our experience and that reported in published studies, of osteitis pubis and osteomyelitis was 2 (0.16%) and 1 (0.08%) of 1228, respectively. The infectious osseous complication rate associated with transvaginal pubic bone anchor fixation appears to be less than that previously reported for suprapubic bone anchor placement. In our experience, when using careful surgical technique and proper prophylactic precautions, infectious osseous complications have not been encountered.

The tensile strength of Cooper's ligament suturing: comparison of abdominal and transvaginal techniques

This study was designed to compare the strength and position of sutures anchored into Cooper's ligament utilizing a minimally invasive transvaginal suturing technique, versus the 'open' abdominal approach. In 12 fresh cadavers, Cooper's ligament was accessed via abdominal and vaginal incisions. After randomization, polytetrafluoroethylene (00) sutures were spaced along one ligament with the transvaginal device (n=36). Contralaterally, sutures were placed abdominally (n=36). Progressive load was applied until suture breakage or dislodgement, and tensile strength was measured using a digital tensiometer. Peak tension averaged 14.5 psi for abdominal and 12.96 psi for vaginal (p=0.28). Suture breakage rather than ligament 'pullout' was more likely for abdominal (95 vs. 56%, p=0.0001). Vaginal and abdominal sutures demonstrated nearly identical mean distances from mid-symphysis (4.62 vs. 4.24 cm, p=0.56). Peak tension was not correlated with suture location (r2=0.17, p=0.28). We conclude that transvaginal suturing, using the minimally invasive device, achieved similar tensile strength and position to the open technique. Transvaginal sutures were associated with greater likelihood of ligament 'pullout' before suture breakage under maximal load; however, the clinical implications of this finding are uncertain.

Incidence of pubic osteomyelitis after bladder neck suspension using bone anchors

OBJECTIVES

To determine the incidence of pubic osteomyelitis after bladder neck suspension using suprapubic bone anchors.

METHODS

The target population consisted of 290 consecutive women who underwent bladder neck suspension using suprapubic bone anchors between June 1994 and November 1999 at two referral centers. A structured telephone questionnaire was designed to elicit any history of clinical symptoms suspicious for pubic osteomyelitis. Positive responses were followed up by a detailed review of the medical records. Nonresponders were evaluated by chart review, with negative cases included only if the documented follow-up reached 1 year.

RESULTS

The sample consisted of 225 women, representing 77.6% of the study population, with a mean age of 69.7 years (range 40 to 88) and a mean follow-up of 31.8 months (range 13.4 to 42.2). Of the 225 women, 179 (80%) completed the telephone survey; 46 patients (20%) were evaluated by long-term chart review. Three patients (1.3%) reported positive responses to the screening questionnaire and were confirmed to have developed pubic osteomyelitis. Each had undergone exploratory laparotomy, anchor removal, bony debridement, and prolonged parenteral antibiosis. The most common noninfectious complaints were irritative voiding symptoms and pubic or groin pain responding to "conservative" therapy (3.5%), including 1 case of osteitis pubis. One subject underwent repeated operation because of erosion of the sling sutures into the bladder.

CONCLUSIONS

The estimated incidence of osteomyelitis after bone-anchored bladder neck suspension was 1.3%. Although postoperative osteomyelitis is rare, each case incurs substantial morbidity and a complicated postoperative course.

Bone anchor 4-corner cystourethropexy: long-term results

PURPOSE

We evaluate the long-term results of incision less transvaginal bone anchor cystourethropexy to treat genuine urinary stress incontinence.

MATERIALS AND METHODS

Between August 1995 and January 1997, 31 women 36 to 81 years old (mean age 58) with types I and II genuine urinary stress incontinence were treated. Four miniature bone anchors (2 on each side of the urethra) attached to a suture were fired transvaginally into the retropubic bone using a bone anchor stapler. The ipsilateral sutures were tied, thus creating a Marshall-Marchetti colposuspension.

RESULTS

Of the patients 3 were lost to followup and the remaining 28 were followed for at least 60 months. Only 6 patients (21.4%) are continent. In 5 patients 11 sutures passed through the bladder 5 of which were removed intraoperatively and the other 6 were detected and removed during followup. Incontinence recurred in 1 patient because the sutures cut through the vaginal tissue and were found loose in the retropubic space. In 8 patients 12 anchors had become detached from the bone of which 7 were detected on x-ray in the retropubic area, 2 were removed cystoscopically 1 year later and 3 were spontaneously expulsed through the vagina 10 months to 5 years postoperatively. In 1 patient with intravesical sutures a vesicovaginal fistula developed which was successfully repaired, and in another pubic osteomyelitis developed.

CONCLUSIONS

We regard 4-corner bone anchor cystourethropexy as unsuitable for genuine urinary stress incontinence based on the unfavorable outcome of incontinence and high rate of complications, including a relatively high incidence of confirmed anchor detachment.

Compliance with recommendations of the urodynamic society for standards of efficacy for evaluation of treatment outcomes in urinary incontinence

The Urodynamic Society (US) published (1997) minimal standards to assess the efficacy of therapy for urinary incontinence (UI). The standards were developed by a US committee and were approved by the American Urological Society. The objective of our study was to evaluate compliance with these standards in recent UI research studies. A MEDLINE search was conducted for all articles in which outcomes of treatment for UI were reported (November, 1997-October, 1999). Reported data were compared with the recommended minimum standards including pre- and posttreatment data. Compliance rates for each data field were calculated by percentages for (1) the individual article and (2) overall compliance rate among all articles. A total of 39 articles that reported treatment for UI were selected. The treatments included various surgical procedures, injectables, pharmacologic treatments, and mechanical valves. Overall compliance for each article varied between 0% and 100%. Only one article met all 100% of the recommendations and one met none. The overall mean compliance rate for each article was 29%. We conclude that there is far less than optimal reporting of outcomes for treatment of UI per the recommendations of the Urodynamic Society. This low compliance makes standardized evaluation of treatment outcomes of UI difficult if not impossible. We suggest that initiation of funded cooperative clinical trials may improve the standardization in UI.

[Urethrocystopexy with bone anchors: technical modification]

OBJECTIVE

To communicate a technical modification of urethrocystopexy which consist in the suspension of the urethropelvic ligaments to the posterior pubic bone with using bone fixations inserted with the In-Fast system.

MATERIAL AND METHODS

Between August 2000 and January 2001, thirteen patients with an mean age of 56.1 years were operated with this technic. Using a transvaginal approach and after great opening of the endopelvic fascia we insert one fixation screw in each side of the symphisis pubic bone, later we give two or three stitches to the urethropelvic ligament with the polypropylene no. 1 suture that each screw have joined to their end.

RESULTS

The mean stay has been 5.1 days. The cystostomy has been remained for a mean of the 10.1 days. We didn't observe any complication neither intra nor postoperatives. With a mean follow-up of 5.3 months all the patients present a disappearance of their stress incontinence.

CONCLUSIONS

Lack of confirm with a larger following and more cases, the suspension of the urethropelvisc ligaments with screw fixations directly situated into the pubic bone per vaginal approach, has been a simple method, safe and highly comfortable for the patients.

Pubovaginal slings: a review of the technical variables

The pubovaginal sling, reintroduced in the late 1970s by Maguire and Blaivas, has become the gold standard for managing anatomic incontinence. Newer technology, materials, surgical techniques and even new theories on the mechanism of action are evolving to further reduce the morbidity of these procedures and improve patient satisfaction. In the following review, we will highlight some of the exciting advances we have witnessed over the last year and try to put them into perspective for the reader.

Bone anchor infections in female pelvic reconstructive procedures: a literature review of series and case reports

PURPOSE

We determined the reported prevalence of infectious osseous complications due to the use of bone anchors for suture fixation in female pelvic reconstructive procedures. In addition, the type and method of bone anchors as well as the reported pathogens associated with osseous infections were reviewed.

MATERIALS AND METHODS

Primary reported series of female pelvic reconstructive procedures involving bone anchor suture fixation referenced in Index Medicus from January 1990 to July 2000 were extracted using the MEDLINE bibliographic database on English language articles involving humans. All case reports of infectious osseous complications due to bone anchor use in female reconstructive procedures were also reviewed during this period.

RESULTS

Since the inception of bone anchor suture fixation for female pelvic reconstructive procedures 10 years ago, the overall prevalence of related infectious complications has been 6 cases in 1,018 procedures (0.6%). This type of adverse event developed between followup weeks 1 and 24. The prevalence of suprapubic bone anchors has been 6 cases in 698 procedures (0.86%). For transvaginal bone anchor procedures no infectious cases have been reported in the combined series of 314 procedures and the same is true for 1 reported case of sacral bone anchor placement in 6 procedures. No statistical difference was noted in regard to the prevalence of infection in procedures involving suprapubic bone anchors and transvaginal bone anchor combined with sacral bone anchor placement (Fisher's exact test p = 0.19). The organisms reported in case reports suggest a coliform, skin or hematogenous source for contamination of the bone anchor site.

CONCLUSIONS

An infectious bone anchor complication in female pelvic reconstructive procedures is an uncommon event with a reported prevalence of 0.6%. Currently there is no evidence of differences in the prevalence of osseous complications after transvaginal versus suprapubic bone anchor fixation. Preoperative broad-spectrum antibiotics are recommended to decrease the potential of infectious bone anchor complications.

Use of bone anchors in female urology

Stress urinary incontinence remains one of the most prevalent conditions encountered by urologists. In many cases, surgical correction of this condition is carried out using a pubovaginal sling procedure. Bone anchors were initially used in transvaginal needle suspension procedures to improve stabilization of the bladder neck. This technology has been extended to sling procedures, allowing completion of these procedures by an entirely transvaginal approach. Early results of these procedures are encouraging, and overall morbidity appears much less when compared with conventional pubovaginal sling procedures. In this article, the application of bone anchors in female urology is reviewed. Techniques of pubovaginal sling and abdominal sacrocolpopexy using bone anchors and potential complications of bone anchor implantation are discussed. Surgeons performing procedures for the treatment of stress incontinence should be aware of the benefits and potential risks of bone anchor implantation.

Cadaveric fascia lata sling: analysis of five recent adverse outcomes

OBJECTIVES

To report a series of adverse outcomes of urethral sling procedures that used allograft fascia lata and to review the literature regarding the use of this material in genitourinary reconstruction.

METHODS

Five neurologically normal patients presented to our center between August 1999 and October 1999 with complaints of recurrent incontinence or voiding dysfunction after undergoing urethral sling procedures at outside institutions that used fascia lata allografts. All patients underwent a thorough evaluation, including history and physical examination, voiding cystourethrography, and urodynamic studies. Sections of fascia were removed for histology in 2 patients at the time of operation.

RESULTS

Three patients were diagnosed with de novo bladder outlet obstruction, 1 with recurrent urethral hypermobility, and 1 with intrinsic sphincteric deficiency. Histology of cadaveric fascia demonstrated collagen with almost complete absence of cellularity. There was no evidence of capillary or fibroblast ingrowth. All patients underwent reoperation and have had clinical improvement with short-term follow-up.

CONCLUSIONS

Although distressing, the present series of adverse outcomes may simply reflect an overall increase in the number of sling procedures being performed nationally. Although decreased operative time and morbidity have been attributed to the use of fascia lata in urethral sling procedures, it is essential to ensure that long-term safety and efficacy will not be jeopardized before accepting it as a new standard of care.

Metastatic osteomyelitis after pubovaginal sling using bone anchors

We report a case of osteomyelitis with metastasis to the T10 vertebra related to bone anchor use with pubovaginal sling. The morbidity was significant: long-term intravenous antibiotics, multiple surgeries to correct the problem, and subsequent chronic pelvic pain. Given that this complication is unheard of after standard fascia or allograft sling, consideration should be given before bone anchor use in women at risk for wound infection (diabetes, obesity, or reoperation). Minimally, patients should be told of the possibility of this severe complication in the informed consent with bone anchor use.

Transvaginal bone anchored sling

INTRODUCTION

To describe a new technique for the treatment of stress urinary incontinence by the transvaginal creation of a sling anchored to the pubic bone. This technique is minimally invasive and easy to learn, with minimal morbidity and complications.

TECHNICAL CONSIDERATIONS

Miniature bone screws with No. 1 polypropylene sutures attached to them and a battery-operated screw inserter are used for the fixation of a biocompatible fabric sling to the pubic bone. The procedure is performed transvaginally with no abdominal or suprapubic incisions. One screw is inserted on each side of the urethra into the pubic bone below the bladder neck. A tunnel is made submucosally between these two holes just below the bladder neck, and the sling is passed through it. Using the sutures on each side of the urethra, the sling edges are tied and pulled toward the pubic bone. The openings made in the vaginal mucosa are closed with absorbable sutures.

CONCLUSIONS

This sling procedure is minimally invasive, safe, and effective. Further experience and longer follow-up are necessary to establish its role in the treatment of women with stress urinary incontinence.

Incisionless cystourethropexy--the Intac device--an initial experience

Our aim was to evaluate a new minimally invasive device for the treatment of genuine stress incontinence in women by both objective and subjective measures of outcome. Fifteen women with Type I or Type II urinary stress incontinence were treated with a new per vaginal bone anchor device designed to fix periurethral tissues to the pubic bone. No patients had significant operative morbidity. After 6-13 months a follow-up questionnaire and repeat urodynamic testing was performed for all the women. Subjectively 73% of patients had improvement in symptoms and on urodynamic testing 53% of patients were cured.

Assessment of a new bone anchor system for the treatment of female genuine stress incontinence

OBJECTIVE

To evaluate the efficacy of the In-Tac bone-anchor system (using shape-memory metal bone anchors, Influence Medical Technologies, Lancs, UK) as a vaginal procedure for the treatment of female genuine stress incontinence (GSI).

PATIENTS AND METHODS

Between January 1997 and April 1998, 30 patients with GSI were recruited into the study (age range 36-74 years); patients who had undergone previous failed continence surgery were not excluded. All patients underwent a urodynamic assessment before and 3 months after surgery. All In-Tac bone-anchor procedures were performed under general anaesthesia. Patients were reviewed after surgery at 6 weeks, 3, 6 and 12 months, and yearly thereafter.

RESULTS

The mean (range) operative duration was 42 (20-75) min and the blood loss 60 (10-200) mL (median 30). There were no intraoperative complications and minimal analgesia was required postoperatively. At 6 weeks, 27 patients (90%) were subjectively cured. The urodynamic assessment at 3 months revealed that 22 patients (73%) were objectively cured; at 6 months and one year the subjective cure rate was 80%.

CONCLUSION

The In-Tac bone-anchor system is simple and safe, the procedure easily learned and the operation brief. It offers promise as an incision-less vaginal procedure that may have wide application for the treatment of women with GSI. A longer follow-up is needed to fully confirm its durability and effectiveness.

A transvaginal sling procedure with bone anchor fixation

Urethral sling procedures have become increasingly popular in the treatment of female stress incontinence. Until recently, the use of this procedure in the urologic community has been limited by technical difficulties and complications (e.g., urinary retention, urethral injury, urge frequency). Many modifications of the original sling procedure recently have been described to decrease surgical morbidity. This article describes a minimally invasive sling procedure performed completely through the vagina, with the aid of bone anchor fixation. The potential advantages of this operation include a rapid return to full activity and normal voiding. It should be noted that neither the long-term safety nor the efficacy has been established.

Pubic bone anchoring in the treatment of women with stress urinary incontinence: new applications to an old concept

The concept of using the pubic bone as a support for the bladder neck and urethra in the treatment of women with genuine stress urinary incontinence is well established, and is applied in traditional procedures such as Marshall-Marchetti-Krantz and the Burch colposuspensions. Recently, minimally invasive techniques, including the use of laparoscopic surgery and pubic bone anchoring systems, have been introduced. These new techniques, attempt to combine the advantages of retropubic procedures while remaining minimally invasive. A search of the English literature was carried out, traditional and new procedures using the pubic bone as a support for the bladder neck and urethra are described, and their efficacy and complications are reviewed and discussed. Traditional procedures have proved to be highly effective and well tolerated, with good long-term outcomes. The early results of innovative minimally invasive techniques are promising, but further experience and longer follow-up is needed to establish their role in the treatment of female stress urinary incontinence.