THE TENSION-FREE VAGINAL TAPE PROCEDURE IN WOMEN WITH PREVIOUS FAILED STRESS INCONTINENCE SURGERY

Endopelvic free anchor minisling technique for stress urinary incontinence treatment: 10 years of experience

INTRODUCTION AND HYPOTHESIS

We present our 10-year experience in treating stress urinary incontinence (SUI) using a new minisling technique based on a tension-free vaginal tape band designed by our group. The major advantage of this tape is the use of minibelt polypropylene inserted through a single retropubic incision without the use of needles-the Endopelvic Free Anchor (EFA)-based on its location at the midurethra with a U shape. For insertion, each branch is placed using a simple Pean clamp from the vagina with perforation of the endopelvic fascia to achieve a retropubic insertion.

METHODS

From May 2001 to May 2011, we surgically treated 166 women with primary first- or second-degree SUI due to urethral hypermobility without genital prolapse. All were evaluated according to our study protocol, which included clinical and urodynamic evaluation before and 12 months after surgery.

RESULTS

With a median follow-up of 5 (1-11) years, 152 patients (91.6 %) were fully cured both from urodynamic and subjective points of view. Six patients (3.6 %) had significant improvement, and eight (4.8 %) were identified as technique failure. Complications included one bladder perforation (0.6 %), two cases of postoperative urinary retention (1.24 %), two of retropubic hematoma (1.24 %), and one of de novo urgency (0.6 %). No reinterventions were necessary, and there were no major bleeding complications, no chronic pain or de novo dyspareunia, and no voiding difficulty.

CONCLUSIONS

EFA is a viable, safe, and effective technique for treating UI due to urethral hypermobility.

Effectiveness of midurethral slings in recurrent stress urinary incontinence: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Midurethral slings (MUS) are the gold standard primary procedure for the surgical treatment of stress urinary incontinence (SUI). There is no robust evidence on the success with MUS in the treatment of recurrent SUI. Our objective was to evaluate the effectiveness and complications of MUS in women with recurrent SUI by systematic review and meta-analysis of the literature.

METHODS

A systematic literature search was carried out (up to August 2011) using relevant search terms in MEDLINE, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis of cure stated in prospective cohort studies was performed with a random effects model using Stata 8.

RESULTS

There was 1 randomised trial and 11 good quality prospective studies included in this systematic review. The overall subjective cure rate per meta-analysis of prospective cohort studies following MUS for recurrent SUI after any previous surgery was found to be 78.5 % [95 % confidence interval (CI) 69-88] at the follow-up of 29.72 ± 29.49 months. The subjective cure rate following MUS after previous failed MUS was 73.3 % (95 % CI 55-97) at the follow-up of 15.7 ± 7.7 months.

CONCLUSIONS

The studies report good cure rates of SUI after MUS surgery following previous incontinence surgery (62-100 %). There seems to be a lower cure rate with transobturator compared to the retropubic tape for recurrent SUI after previous surgery.

Tape Shortening for Recurrent Stress Urinary Incontinence After Transobturator Tape Sling: 3-Year Follow-up Results

PURPOSE

Recently, as the number of transobturator tape (TOT) procedures has increased, recurrence after this procedure has been frequently reported. However, there are no standard guidelines for treatment. We describe our experience with shortening the previously implanted tape in patients with recurrent stress urinary incontinence after the TOT procedure.

MATERIALS AND METHODS

We enrolled 10 women who underwent shortening of the previously implanted tape and were followed up for 3 years. Shortening of the previously implanted tape was done by a figure-eight suture with 1-0 Prolene. One year after TOT shortening, we investigated continence status, patient satisfaction by means of a questionnaire, maximal flow rate (Qmax), and postvoid residual urine volume. Three years after TOT shortening, we evaluated continence status and patient satisfaction.

RESULTS

The mean period of TOT shortening was 4.2 months (range, 1-12 months) after the TOT procedure. One year after TOT shortening, 7 patients showed complete dryness, 2 patients showed improvement, and 1 patient reported failure. Eight patients were very satisfied or satisfied with the 1-year result after TOT shortening. The mean preoperative and postoperative Qmax were 23.8 and 26.7ml/s, respectively, and there was no significant difference. Three years after TOT shortening, 6 patients showed complete dryness, 2 patients showed improvement, and 2 patients reported failure. Among them,1 had failed from 1 year after TOT shortening and the other had shown 1 year of complete dryness. Eight patients were very satisfied or satisfied and 2 patients were dissatisfied with the 3-year result after TOT shortening.

CONCLUSION

Most of the patients who underwent TOT shortening reported satisfaction as well as improvement of incontinence after a 3-year follow up. Therefore, we suggest that TOT shortening may be recommended primarily in patients with recurrent stress urinary incontinence after the TOT sling procedure.

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.

The management of recurrent cases after the Burch colposuspension: 7 years experience

PURPOSE

We aimed to discuss our approach to the failure cases whose primary surgery was Burch colposuspension.

METHODS

Total cases who underwent Burch colposuspension was 298, however, 36 cases lost follow-up therefore the study population was 262 cases. Forty-two patients having recurrent stress urinary incontinence (16.0%) after Burch procedure enrolled for the study. Twenty-nine of the recurrent cases were treated with mid-urethral slings tension-free vaginal tape or transobturator tape (TOT) as a secondary procedure, whereas thirteen of the recurrent cases preferred to take medical therapy. Seven of the failed patients after the repeat surgery accepted TOT as a tertiary procedure.

RESULTS

The cumulative cure rates after the secondary and tertiary interventions were 62.1 and 57.1%, respectively. No complications were noticed during the secondary and tertiary surgical interventions.

CONCLUSION

Our study showed that suburethral sling surgery can be an effective choice for the treatment of recurrent cases after Burch colposuspension.

Midurethral minimally invasive sling procedures for stress urinary incontinence

OBJECTIVE

To provide an update on currently used minimally invasive surgical treatments for stress urinary incontinence in women: tension-free vaginal tape (TVT) procedure, transobturator tape (TOT) procedure, and other midurethral sling devices.

OPTIONS

The discussion is limited to minimally invasive surgical management of stress urinary incontinence in women.

EVIDENCE

A search of PubMed and Cochrane library for articles published in English before the end of February 2008 identified the most relevant literature. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

VALUES

This update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada.

BENEFITS, HARMS, AND COSTS

Counselling for the surgical management of urinary incontinence should consider all benefits, harms, and costs of the surgical options.

Long-term follow-up of a transvaginal Burch urethropexy for stress urinary incontinence

OBJECTIVE

The objective of the study was to describe long-term objective and subjective success rates and complications following transvaginal Burch urethropexy for stress urinary incontinence.

STUDY DESIGN

A case series of 66 women who underwent vaginal Burch urethropexy for urodynamic stress urinary incontinence with urethral hypermobility using a suture carrier device is presented. Concurrent prolapse repairs were performed as indicated.

RESULTS

Sixty-six women (mean age 49.4 +/- 12.1 years) underwent vaginal Burch urethropexy. Mean follow-up time was 20.9 +/- 18.9 months. Objective failure was observed in 16 patients (24.2%). Subjective failure was reported by 21.2% of patients, with 50% and 28.8% reporting success and improvement, respectively. Six patients (9%) experienced febrile illness, 4 (6%) experienced intraoperative hemorrhage, 1 (1.5%) received transfusion, and 1 (1.5%) experienced pelvic abscess. Twelve patients (18.2%) experienced suture erosion; half required surgical revision or excision.

CONCLUSION

Vaginal Burch urethropexy is generally well tolerated but is associated with poor long-term success and high suture erosion rates.

External iliac artery injury during insertion of tension-free vaginal tape: a case report and literature review

Although rare, serious vascular injuries after tension-free vaginal tape (TVT) insertion have been well known. We present a case of external iliac artery injury after TVT insertion, managed successfully by surgical intervention. This article also reviews the literature regarding major vascular injuries and their management. We conclude that clinicians should be able to suspect rare but serious vascular injuries, and patients have to be fully counselled regarding their potential consequences.

The effectiveness of tension-free vaginal tape (TVT) and quality of life measured in women with previous urogynecologic surgery: analysis from The Netherlands TVT database

OBJECTIVE

Long-term outcome of tension-free vaginal tape (TVT) in women with a history of surgery for urinary incontinence and/or prolapse.

STUDY DESIGN

Prospective cohort study of 809 women. Twenty-eight teaching and 13 local hospitals, 54 gynecologists and urologists performed the TVTs. The Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) were used to measure the results of the TVT procedure (preoperative at 2, 6, 12, 24, and 36 months postoperative). According the recommendation of the International Continence Society, the question "Do you experience urinary leakage during physical activity, coughing or sneezing?" was selected from the UDI to assess stress urinary incontinence.

RESULTS

The decrease in IIQ/UDI mean scores was statistically significant. The UDI scores of women with a history of previous prolapse and/or incontinence surgery were not statistically different to the scores for primary cases after 3 years follow-up (P = .193).

CONCLUSION

TVT is effective for women with recurrent stress urinary incontinence and/or previous prolapse surgery.

Tension-free vaginal tape surgery for stress urinary incontinencne: A prospective multicentered study in Japan

AIM

To report the prospective multicentered study of the tension-free vaginal tape (TVT) procedure for stress urinary incontinence.

METHODS

One hundred and fifty-one women with stress urinary incontinence were operated on by the TVT procedure and were followed up at 3, 12, and 24 months after surgery. Patients' age and body mass index (BMI) averaged 57 years and 23.9, respectively. Forty-nine women were classified as type I, 46 women type II and 56 women type III (McGuire's classification). Local anesthesia was used in the operations on 137 women (91%) and epidural or general anesthesia was used in 14 (9%). Surgical outcomes were analyzed with Kaplan-Meier survival curves.

RESULTS

The subjective and objective cumulative cure rates 24 months later were 92% and 77%, respectively (P > 0.05). The TVT operation for women with type III (62%) resulted in a significantly lower cure rate compared to those with type I or with type II (83%) (P < 0.001). Post-operatively a urethral catheter was indwelt one day in 77 women (51%), two days in 14 (9%) and 3-7 days in 60 (40%). Surgical complications were encountered in 43 women (28%). The most frequent was bladder perforation in 24 women followed by postoperative difficulty in urination and de novo urgency.

CONCLUSIONS

The TVT surgery was promising for the treatment of stress incontinence because of minimal surgical invasiveness and satisfactory surgical results. Women with type III incontinence resulted in fewer satisfactory outcomes than those with type I or II incontinence.

Significance of tension in tension-free mid-urethral sling procedures: a preliminary study

We report the results of the release and tape-shortening techniques in polypropylene pubovaginal slings. Of female patients who had undergone mid-urethral sling procedures [tension-free vaginal tape procedure and suburethral polypropylene (SPARC)], in cases in which postoperative retention occurred, the patients were offered release or tape cutting. Women reporting postoperative urinary incontinence underwent a tape-shortening procedure. In these patients, the tape was shortened by the use of clips. Mean follow-up time after the release and/or the shortening operations was 9.9 months (range 6-18). A total of 15 women, ranging from 41 to 75 years old (mean 58.3) were included in this study. Upon the latest follow-up, six women exhibited prolonged urinary retention and subsequently underwent a release procedure (n=5) or a tape-cutting procedure (n=1). After the release procedure, all patients remained continent, but one patient's urinary retention issues were not resolved, and she subsequently underwent a tape-cutting. Both of the patients who underwent the cutting procedure then developed recurrent stress urinary incontinence. The tape-shortening technique was conducted with nine patients. Seven of these patients recovered their continence, and no one patient experienced any urinary retention or other voiding difficulties. Two patients reported only minimal stress leakage and elected to undergo no further interventions. Our findings suggest that tension plays a substantial role in tension-free mid-urethral sling procedures.

Is there still a place for the pubovaginal sling at the bladder neck in the era of the midurethral sling?

Perhaps the most significant advance in the modern-day surgical management of stress urinary incontinence is the introduction of the tension-free midurethral sling procedures. Based on a theory of anatomy and function, which emphasizes the importance of the midurethra in maintaining continence during stress, these minimally invasive procedures are being used widely in the surgical treatment of stress urinary incontinence. As surgeons continue to experience excellent early results, a major concern is defining the role of the traditional pubovaginal sling placed at the bladder neck. In addition to the obvious indications to consider a more traditional sling procedure (markedly atrophic vaginal wall or situations that may promote sling erosion), are there other clinical scenarios in which there still is a role for the traditional pubovaginal sling? Several clinical conditions that warrant consideration of a traditional sling procedure are presented in this review. Based on the mechanism of action and clinical data demonstrating decreased efficacy of midurethral sling procedures, we propose that a traditional pubovaginal sling be considered in the following clinical conditions: lack of urethral mobility, mixed urinary incontinence, concomitant urethral reconstruction, and after a failed sling procedure. In the absence of randomized control trials, we present evidence that makes a case for consideration of the traditional sling procedure in these complex clinical conditions.

[Usefulness of abdominal leak point pressure determination in the diagnosis of female urinary incontinence in the TVT era]

OBJECTIVE

To analyse our results about continence in the treatment of female urinary incontinence with the tension-free vaginal tape (TVT) procedure based on abdominal leak point pressure(ALPP).

PATIENTS AND METHODS

Retrospective study of the fifty two patients who had urodynamic study and abdominal leak point pressure determination and were operated on between 1999 and 2002 for stress urinary incontinence. We reviewed the data of clinical history, physical examination and urodynamic report, surgery, complications, and objective and subjective results. Those patients having ALPP > 100 are included in group 1, between 61 and 100 in group 2 and less than 60 in group 3.

RESULTS

There were 19 patients in group 1, 17 in group 2 and 16 in group 3. We found no difference between the three groups regarding age, delivery, menopause, hysterectomy, evolution, previous surgery, grade of cystocele, association of anterior colporraphy to TVT and type of anaesthesia. The Obrink clinical grade increased as the ALPP decreased (grade 3 in 26.32% of group 1, 31.58% in group 2 and 68.71% in group 3). 100% of patients in groups 1 and 2 were continent with effort and 93.75% in group 3. Complications, especially de novo instability or urgency-frequency episodes or persistence of instability in patients having mixed incontinence, caused a decrease in the satisfaction degree to 79% in group 1, 76.5% in 2 and 62.5% in 3.

CONCLUSIONS

Abdominal leak point pressure determination does not change our decision of perform a TVT procedure but permits us to differentiate one group in which results could be worse.

Quality of life assessments in women operated on by tension-free vaginal tape (TVT)

The aim of the study was to evaluate quality of life (QOL) prospectively in women who undergo tension-free vaginal tape (TVT) operation for stress urinary incontinence. Sixty-six women who completed QOL questionnaires and a 2-year follow-up examination were included. Improvement of health-related QOL was assessed by the Incontinence Impact Questionnaire-7 (IIQ-7), the Urogenital Distress Inventory-6 (UDI-6), and two questions regarding patient satisfaction and de novo urge incontinence. Prior to surgery, patients complained most of stress symptoms followed by physical activities and emotional health. Postoperatively IIQ-7 and UDI-6 as a whole and all seven domains improved significantly (p<0.001). Scores of IIQ-7, UDI-6, and seven domains did not differ between the adult and the elderly groups. Of the patients 88% were much satisfied or satisfied with surgical outcomes. Incidence of de novo urge incontinence was 12%. It is concluded that the TVT procedure significantly improved health-related quality of life.

Sling failures: What’s next?

The pubovaginal sling has been used to treat anatomic, functional, and recurrent stress urinary incontinence for decades with excellent results. Nevertheless, enthusiasm for the pubovaginal sling is tempered by the surgical morbidity and postoperative voiding dysfunction associated with it. New modifications such as alternative sling materials, bone anchor suspension, and midurethral slings have been developed to reduce operating time and surgical morbidity. The less invasive approaches are now well recognized and midurethral slings have become the most common procedure performed for stress urinary incontinence. Despite the ubiquity of sling procedures in all of their forms, there is no consensus on the management of sling failures. Recent literature suggests that similar to primary genuine stress incontinence, recurrent stress urinary incontinence as a result of sling failure is being successfully managed with less invasive techniques.

Bladder injury during transobturator sling

The new minimally invasive transobturator sling for surgical treatment of female genuine stress urinary incontinence is designed to reproduce the natural suspension of the urethral fascia while eliminating the need for retropubic needle passage. We report 3 cases of bladder perforation during the transobturator sling procedure. All injuries were identified intraoperatively by cystoscopy, and successful reinsertion of the mesh was accomplished. Transurethral bladder drainage with a Foley catheter was maintained for 5 to 7 days postoperatively. All 3 patients recovered uneventfully. Routine intraoperative cystoscopy is, therefore, recommended for the identification of bladder injuries during the transobturator sling procedure.

THE ROSTI SLING: A NEW, MINIMALLY INVASIVE, TENSION-FREE TECHNIQUE FOR THE SURGICAL TREATMENT OF FEMALE URINARY INCONTINENCE—THE FIRST 217 PATIENTS

PURPOSE

We evaluated the outcome of a new, innovative, inexpensive tension-free technique, the Rosti sling (RS), for female urinary incontinence.

MATERIALS AND METHODS

RS was performed in 217 patients under local (45%), spinal (52%) or general (3%) anesthesia. A 1.5 x 33 cm strip of polypropylene mesh was inserted under the mid urethra from above through small suprapubic stabs down and out through a 1.5 cm midline vaginal incision using the Stamey needle. Of the women 76% had stress urinary incontinence and 24% had mixed incontinence. Patient age was 24 to 90 years (mean 56) and parity was 0 to 6 (mean 2). The diagnosis of incontinence was based on history and physical examinations with a cough stress test. Mean followup was 23 months.

RESULTS

Mean operative time was 25 minutes (range 15 to 45) and mean hospital stay was 3 days (range 1 to 12). Perioperative complications were bladder and urethral perforations in 2 and 1 cases, respectively (1.4%), and hematoma in 3 (1.4%). There was postoperative retention with a variable duration in 49 patients (23%), of whom 41 underwent Hegar dilation. Altogether 186 of 215 patients (86.5%) were cured of incontinence. Two patients were lost to followup and 14 (16.3%) had de novo urge incontinence. The cure rates were 87% for stress urinary incontinence and 91% for mixed incontinence. The cure rate in patients treated under local and spinal anesthesia were 82% and 91%, respectively (p = 0.1084). The rates for RS with recurrent vs primary incontinence were 84% vs 87% (p = 0.5800) and for RS with vs without Hegar dilation 80% vs 88% (p = 0.2094).

CONCLUSIONS

The technique described is simple, safe and inexpensive. The cure rates are comparable to those of tension-free vaginal tape. However, because of the relatively high rate of postoperative voiding difficulties compared to tension-free vaginal tape, this technique can be criticized. To avoid these problems special attention should be focused on applying the mesh without tension and with precision.

[TVT: three years of experience]

INTRODUCTION

Since the description of the TVT technique as a therapy to stress urinary incontinence, in 1996, about 150000 subjects have undergone it. This technique was first used in our centre in november 1998. This article is aimed to contain our view of its evolution in the past three years.

MATERIALS AND METHODS

142 patients of an average of 59 years old have been operated on. In 57% of the cases, we also focused on the solutions to anatomic pelvis disorders.

RESULTS

After a follow-up of 17 months and a mean of 14 months, 93% of the cases succeeded. Failures arose during the first six months of therapy. We found the following complications: 4.8% of bladder perforations, 17% of postoperative retentions of no longer than 30 days, 2% of long-term retentions, 2.7% of postsurgical hematomas, and 9% of urge incontinence. Surgery was performed on 10 patients who had undergone surgery against bladder incontinence before, and all the cases proved success.

CONCLUSIONS

This technique is simple and only requires a short surgical time, and it can be applied for major ambulatory surgery. Although it is possible to encounter complications, they rarely occur and results are still encouraging. However, it is now necessary to verify that our long-term studies match with the success rates of 84.7%.

The techniques of trocar insertion and intraoperative urethrocystoscopy in tension-free vaginal taping: an experience of 600 cases

BACKGROUND

To determine the frequency of lower urinary tract (LUT) injury for stress incontinent women undergoing the tension-free vaginal tape (TVT) procedure with or without concomitant procedures.

METHODS

Over a period of 5 years, 600 women who had stress urinary incontinence (SUI), with or without pelvic prolapse, consecutively underwent the TVT procedure either with or without concomitant surgery. All study subjects underwent intraoperative transurethral urethrocystoscopy. During the examination 34 (6%) women at high risk of ureteral injury also received intravenous injection of 6 mL of diluted methylene blue to observe the patency and function of the ureter as well as the integrity of the bladder.

RESULTS

The mean patient age was 52.75 years (range 32-76) and mean parity was 2.54 (range 0-6). Of the 600 women, 188 (31.4%) had had previous surgery, 169 (28.2%) had concomitant surgery, and 9 (1.5%) had abnormal urethrocystoscopic findings. These findings included one case each of previously placed suspension sutures, granuloma-like tissue in the bladder, a delayed dye emission from the ureteric orifice, an adhesive band in the urethra, three cases of perforation of the bladder by the trocar and two cases of an area of thin bladder mucosa. The bladder perforation rate related to the TVT device was 0.8% (5/600).

CONCLUSIONS

Based on the data of this 5-year review, and a high rate of bladder injury (0-25%) reported in the literature, intraoperative urethrocystoscopy is imperative in the TVT procedure, although the rate of bladder injury was only 0.8% in the present study.

The tension-free vaginal tape procedure for female urinary incontinence without preoperative urodynamic evaluation

BACKGROUND

We evaluated the short-term outcomes of the tension-free vaginal tape (TVT) technique for female urinary incontinence, when the diagnosis was based on incontinence symptoms and pelvic examination including cough stress test or transperineal ultrasonography or both, but without preoperative urodynamic verification.

STUDY DESIGN

Tension-free vaginal tape was performed on 191 patients under local (82%) or spinal (18%) anesthesia. One hundred twenty-seven women (66%) had stress urinary incontinence and 64 (34%) had mixed incontinence. Fifty-eight percent had undergone previous surgery; 21% for incontinence. Thirty-four women underwent concomitant surgery. The age range was from 32 to 84 years (mean 60) and parity from 0 to 8 (mean 2). Seventy-four (39%) had concomitant chronic illnesses. The diagnosis of incontinence was based on specific questionnaires and physical examinations. Urogynecological ultrasonography was performed on patients with mixed incontinence. The mean followup was 17 months.

RESULTS

The mean operative time was 27 min (16 to 63), the mean hospital stay was 2 days (1 to 10). Intraoperative complications were: bladder perforation in five patients (2.6%), hematoma in five patients (2.6%), heavy bleeding (400 mL) in one patient, and persistent retention in four patients (2.2%). Altogether, 164 of 187 patients (87.7%) were completely cured, and 23 patients experienced no improvement. Six patients (4.8%) developed de novo urge incontinence, 60% had less urge incontinence. The cure rates were: 97% among stress urinary incontinence patients versus 69% among mixed incontinence patients (p = 0.001); TVT alone, 88% versus in combination with other surgery 85% (p = 0.576); TVT under local anesthesia, 88% versus under spinal anesthesia 88%; TVT with recurrent incontinence, 85% versus primary incontinence 89% (p = 0.583); and in patients with concomitant illnesses, 82% versus healthy 91% (p = 0.076).

CONCLUSIONS

Tension-free vaginal tape can be used to treat patients with primary or recurrent stress or mixed incontinence with or without concomitant surgery under local or spinal anesthesia. But the success rate is considerably lower in patients in whom TVT is performed for mixed incontinence.

Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders

STUDY DESIGN

Retrospective.

OBJECTIVE

To evaluate the safety and efficacy of the tension-free vaginal tape (TVT) for the treatment of stress incontinence in females with neuropathic bladders.

SETTING

London Spinal Injuries Unit, Stanmore & Institute of Urology, London, UK.

METHODS

Twelve women (mean age 53.3 years; range 41-80 years) with neuropathic bladder dysfunction and stress urinary incontinence were treated with tension-free vaginal tape (TVT) between November 1997 and December 2000. The group consisted of women with: (i) traumatic spinal cord injuries (n=3); (ii) post lumbar spinal surgery (n=6); (iii) spinal stenosis (n=3). Four of the 12 patients had previously failed surgery for stress incontinence. All patients underwent pre- and post-TVT evaluation with video-urodynamic studies.

RESULTS

Mean follow-up was 27.1 months (range 17-54 months). Three patients were voiding spontaneously (stress voiding) before surgery and continued to do so post-operatively. The remaining 9 were performing clean intermittent self-catheterisation before the insertion of TVT and continued to do so after the surgery. At follow up 10 patients (83.3%) were dry. The procedure failed in one patient and the other complained of mild leakage, but she reported a decrease in the number of pads used. One patient developed detrusor hyperreflexia on post-operative video-urodynamics but there was no evidence of stress incontinence. One patient had a bladder perforation on insertion of TVT, managed successfully with extended use of a urethral catheter post-operatively. Three patients developed post-operative urinary tract infection successfully treated with oral antibiotics.

CONCLUSIONS

Tension-free vaginal tape insertion is minimally invasive, safe and effective for the treatment of stress incontinence in females with bladder neuropathy with intrinsic sphincter deficiency. Previous surgery for incontinence did not affect post-operative complications or outcome.

Autologous and synthetic urethral slings for female incontinence

Over the past decade, urethral slings have emerged as the procedure of choice for the surgical correction of most types of female urinary stress incontinence. A variety of materials, autologous, alloplastic, and synthetic, have been used successfully as urethral slings. In the next decade, it is hoped that a better understanding of the factors that influence surgical success will translate into continued refinement of surgical technique.

Tension-free vaginal tape procedure after previous failure in incontinence surgery

OBJECTIVES

To study the efficacy of the tension-free vaginal tape (TVT) procedure for patients with recurrent genuine stress incontinence.

METHODS

Forty-one women, including 11 with urethral sphincter incompetence (mean age 49.6 years, range 37 to 66), were treated for recurrent genuine stress incontinence with TVT procedure under local or regional anesthesia. Urodynamic studies, a 1-hour pad test, introital ultrasonography on the urethra, a cotton swab test, and subjective symptom analysis were documented before the procedure and at 1 year postoperatively.

RESULTS

Of the 41 women, 34 (82.9%) were cured, 2 improved, and 5 (12.2%) had treatment failure. Among the women with failure, three had urethral sphincter incompetence with a fixed urethra. No major surgical complications occurred. Four bladder perforations were noted. The 1-hour pad test reduced from a mean of 27.3 to 1.7 g (P <0.001). The operating time was 22 minutes (range 15 to 44), and the postoperative hospital stay was 22.4 hours (range 12 to 72). Spontaneous voiding with adequate postvoid residual urine volume was noted for all patients by the fourth day postoperatively. The preoperative and postoperative cotton swab result was 40.0 degrees (range 10 degrees to 80 degrees ) and 38.7 degrees (range 10 degrees to 76 degrees ), respectively, without statistically significant changes. Of the 36 cured and improved patients, 31 (86.1%) had a cotton swab test result of 30 degrees or more before and after the TVT procedure. Urodynamic parameters related to the voiding dysfunction showed no significant difference before and after the surgery. Urodynamic assessment showed no significant difference in the filling, voiding, and urethral pressure profile (dynamic and static) variables, except for significant increases in the maximal flow rate, bladder volume at the first desire to void, and cystometric capacity, which were measured preoperatively and postoperatively. No de nova detrusor instability or micturition disturbances were found in the cystometric study.

CONCLUSIONS

The TVT procedure for the treatment of recurrent genuine stress incontinence is a safe, effective, and minimally invasive option requiring only a short hospital stay. However, the immobile urethra seems to be a risk factor for failure. Long-term follow-up is needed to determine whether this surgery achieves long-lasting results.