Midurethral minimally invasive sling procedures for stress urinary incontinence

Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder

INTRODUCTION

The mid-urethral sling (MUS) procedure is the gold-standard for the surgical treatment of stress urinary incontinence (SUI). Urethro-vesical sling exposure is one of the most serious complications of this procedure. We describe the treatment and follow-up of 18 patients with bladder or urethral sling exposure.

PATIENTS AND METHODS

This single-center, retrospective study assessed the diagnosis and management of MUS penetrating the lower urinary tract in 18 women. The lesions included were classed as 4B, T3-4, S3 according to the international classification of complications related to the insertion of prostheses. Diagnosis was confirmed by flexible urethro-cystoscopy. The patients were treated surgically. In all cases, the aim was to remove all synthetic materials eroding the bladder or urethra. The patients were reassessed 6 weeks after the procedure, and functional urologic sequelae were treated. Urologic symptoms were evaluated using the USP questionnaire and urologic comfort was assessed using the Contilife questionnaire.

RESULTS

Seven MUSs were retro-pubic and 11 were trans-obturators. The material was 11 polypropylene macroporous monofilament, four polypropylene silicone coated and three non-available. There were six cases of urethral sling exposure, nine cases of bladder sling exposure, and three cases of urethral and bladder sling exposure, including five complicated cases of lithiasis and one urethra-vaginal fistula. Thirteen patients underwent one surgical procedure, four underwent two, and one underwent five procedures. Seven patients received a Martius flap. Three surgical approaches were necessary: (i) vaginal approach; (ii) urologic (urethral and suprapubic) cystoscopy approach; and (iii) laparoscopy approach. Median follow-up time was 34.5 months. At the end of follow-up, 17/18 patients had no sling exposure from the MUS, and 12/13 patients were considered comfortable from a functional urologic viewpoint.

CONCLUSION

Our study showed that surgery could treat urethro-vesical sling exposure. Three surgical approaches may be necessary. Controlled cystoscopy is vital to confirm healing due to the recurrences of sling exposure in our study.

On the Stiffness of the Mesh and Urethral Mobility: A Finite Element Analysis

Midurethral slings are used to correct urethral hypermobility in female stress urinary incontinence (SUI), defined as the complaint of involuntary urine leakage when the intra-abdominal pressure (IAP) is increased. Structural and thermal features influence their mechanical properties, which may explain postoperative complications, e.g., erosion and urethral obstruction. We studied the effect of the mesh stiffness on urethral mobility at Valsalva maneuver, under impairment of the supporting structures (levator ani and/or ligaments), by using a numerical model. For that purpose, we modeled a sling with “lower” versus “higher” stiffness and evaluated the mobility of the bladder and urethra, that of the urethrovesical junction (the α-angle), and the force exerted at the fixation of the sling. The effect of impaired levator ani or pubourethral ligaments (PUL) alone on the organs displacement and α-angle opening was similar, showing their important role together on urethral stabilization. When the levator ani and all the ligaments were simulated as impaired, the descent of the bladder and urethra went up to 25.02 mm, that of the bladder neck was 14.57 mm, and the α-angle was 129.7 deg, in the range of what was found in women with SUI. Both meshes allowed returning to normal positioning, although at the cost of higher force exerted by the mesh with higher stiffness (3.4 N against 2.3 N), which can relate to tissue erosion. This finite element analysis allowed mimicking the biomechanical response of the pelvic structures in response to changing a material property of the midurethral synthetic mesh.

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.

The first Iraqi experience with the rectus fascia sling and transobturator tape for female stress incontinence: A randomised trial

Objectives

To present the first experience in Iraq of autologous rectus fascia sling (RFS) procedures and transobturator tape (TOT) for treating female stress urinary incontinence (SUI), and to review the validity of the RFS in the era of synthetic tapes.

Patients and methods

From December 2004 to July 2012, 80 female patients with SUI were enrolled in the study, and randomly assigned into two types of surgery, with 40 treated by RFS (retropubic route) and 40 by TOT. The surgical results were compared between the groups and with those from previous studies.

Results

The mean operative duration was 80 min for RFS vs. 20 min for TOT. The early cure rate was 98% for RFS (with one failure due to prolonged urinary retention) and 95% for TOT (with two failures due to persistent incontinence). The early complications were mainly abdominal wound problems (20%) for RFS, and groin and upper thigh pain (13%) for TOT. The late complications were the development of postvoid residual urine (8% in RFS vs. 5% in TOT) and de novo detrusor overactivity (5% in each group). There were no vaginal or urethral erosions up to the end of the study.

Conclusions

RFS and TOT have comparable efficacy and safety in treating SUI. Nevertheless RFS, with its more invasive nature and long operative duration, should only be used when synthetic tapes are not available or not preferable.

[The Martius flap in stress urinary incontinence treated by suburethral sling]

OBJECTIVE

Study of a series of patients treated with suburethral tapes using the Martius flap technique, for complications or in a preventive way, in order to determine its interest and morbidity.

PATIENTS

Eleven female patients treated by suburethral tapes for stress urinary incontinence, for which we described the type of tapes used, their complications, the procedure including Martius flap and the outcomes.

RESULTS

Indications of the Martius flap were: three tapes through bladder neck, one through urethra, one uro-vaginal fistula, four loss of substance of the vaginal wall, one peri-urethral fibrosis and one preventive use on irradiated pelvis. Complications were transient postoperative pain and one abscess of the greater lip. In our series, the Martius flap never cured stress urinary incontinence. The placement of a suburethral tape on a Martius flap is feasible but the adjustment is more difficult.

CONCLUSION

The Martius flap is efficient in the treatment or prevention of suburethral tapes complications with low morbidity. It allows secondary placement of a suburethral tape with difficult adjustment.