The evolution of midurethral slings

A modified Altis® mid-urethral sling that allows immediate post-operative adjustment: experience in 197 patients

OBJECTIVES

The transobturator mid-urethral Altis^® "mini-sling" uses a static and a dynamic anchor on either end of a pulley suture for intraoperative tension adjustment. Given the potential for incorrect tensioning with sling placement, we adopted a modification for post-operative adjustment should stress urinary incontinence (SUI) persist. The objective is to describe technique, rate of postoperative adjustment driven by patient symptoms, and impact of preoperative/intraoperative variables.

METHODS

In this single-surgeon experience, retrospective chart review, demographic and clinical data were collected on patients who received the Altis^® sling for SUI between 2014 and 2019. We used descriptive statistics and three-group comparison tests to assess difference in variables among tightening, loosening, or no adjustment.

RESULTS

Altis^® sling placement was performed on 197 female patients with an average age of 58.7 years. Eighty-four percent (165/197) did not receive post-operative adjustment. Of the 32 patients with post-operative adjustment, 8 (4.1%) had loosening and 24 (12.2%) had tightening at an average of 10.5 days post-operatively. All tightening procedures were done in the clinic. Of the 8 patients with post-operative loosening, 6 were performed in clinic and 2 in the operating room. Preoperative and intraoperative variables were not significantly different among tightening, loosening, and no adjustment cohorts.

CONCLUSIONS

This modification of the Altis^® sling provides surgeons with the ability to tighten and loosen the sling for persistent SUI. All tightening and most loosening procedures were able to be performed in the clinic. The ability to easily tighten a sling in the early post-operative period may be a critical advantage.

Pelvic floor ultrasound: when, why, and how?

Pelvic floor disorders are a significant medical issue, reportedly affecting nearly one in four women in the United States. Nonetheless, until the last decade, there has been relatively limited imaging research into this highly prevalent disorder. The three major imaging modalities utilized to assess pelvic floor function are ultrasound, MRI and fluoroscopy. Pelvic floor ultrasound is a rapidly emerging technique which takes advantage of the widespread availability of ultrasound, the non-invasive and relatively inexpensive approach and the incorporation of real-time imaging and software advances which permit 3-D volume imaging. Pelvic floor ultrasound provides the opportunity to optimize patient counseling and enhance pre-operative planning by providing an anatomic and functional roadmap for the referring clinician. We recommend the consideration of pelvic floor ultrasound, as described here, as an addition to the imaging armamentarium available to physicians and surgeons serving this patient population.

Laparoscopic TOT-like Burch Colposuspension: Back to the Future?

OBJECTIVE

To demonstrate a modification of the classic Burch procedure, called "laparoscopic transobturator tape (TOT)-like Burch colposuspension." The technique does not involve any type of prosthesis placement, and it is an alternative for patients with stress urinary incontinence in a future without meshes. Describing and standardizing the procedure in different steps makes the surgery reproducible for gynecologists and safe for the patients.

DESIGN

Step-by-step educational video, underlining and focusing on the main anatomical landmarks.

SETTING

A university tertiary care hospital.

INTERVENTIONS

The patient is set under general anesthesia and in lithotomy position. The distinct steps of the procedure are performed as followed: Step 1: Installation. Two 10-mm trocars are positioned in the midline and 2 5-mm trocars in the suprapubic region. The recommended intra-abdominal pressure is 6 to 8 mm Hg, and excessive Trendelenburg is not needed. Step 2: Entry in the Retzius space. The median umbilical ligament and the vesicoumbilical fascia are transected. Step 3: Exposure of the Retzius space and the anatomical structures. The dissection is continued consecutively toward the pubic bone and the Cooper's ligament, laterally toward the external iliac vessels and the corona mortis and medially toward the bladder neck. Step 4: Vaginal dissection. The pubocervical is dissected at the level of the pubourethral ligaments. Step 5: Suspension of the vagina to the Cooper's ligament. In contrast to the standard technique, with the TOT-like Burch, the sutures on the pubocervical fascia are placed at the level of the attachment of the arcus tendinous fascia pelvis and the pubourethral ligament. This way of suspension ensures a lateral traction on the bladder neck, resembling the effect of the TOT, which leads to lower incidence of dysuric symptoms. Step 6: Peritoneal closure.

CONCLUSION

The classic colposuspension was created in 1961 for the treatment of stress urinary incontinence prolapse [1]. In the following years, vaginal meshes gained popularity as a treatment option for prolapse and for incontinence owing to their ease of use and satisfying results, which led to a decreased use of the Burch procedure [2,3]. In 2019, the Food and Drug Administration forbid the production of the transvaginal meshes for prolapse [4], an interdiction that could influence the use of synthetic meshes for incontinence in the future [5]. Owing to these recent events, searching for an effective way of management for patients with stress urinary incontinence without any synthetic prostheses, gynecologists have turned back to the 60-year-old Burch colposuspension. One of the drawbacks of the original technique is the high incidence of voiding difficulties-up to 22% [6]. Owing to the knowledge of the exact course of traction with the TOT, in our modified technique, the lateral direction of the suspension provides a tension-free support on the urethra and the bladder neck. The laparoscopic TOT-like Burch colposuspension is a safe and effective treatment for patients with stress urinary incontinence with low rates of dysuric symptoms and represents a valuable alternative for gynecologists in a future without meshes.

Managing female pelvic floor disorders: a medical device review and appraisal

Pelvic floor disorders (PFDs) will affect most women during their lifetime. Sequelae such as pelvic organ prolapse, stress urinary incontinence, chronic pain and dyspareunia significantly impact overall quality of life. Interventions to manage or eliminate symptoms from PFDs aim to restore support of the pelvic floor. Pessaries have been used to mechanically counteract PFDs for thousands of years, but do not offer a cure. By contrast, surgically implanted grafts or mesh offer patients a more permanent resolution but have been in wide use within the pelvis for less than 30 years. In this perspective review, we provide an overview of the main theories underpinning PFD pathogenesis and the animal models used to investigate it. We highlight the clinical outcomes of mesh and grafts before exploring studies performed to elucidate tissue level effects and bioengineering considerations. Considering recent turmoil surrounding transvaginal mesh, the role of pessaries, an impermanent method, is examined as a means to address patients with PFDs.

Midurethral slings for treatment of stress urinary incontinence review

PURPOSE

The midurethral sling (MUS) has largely been regarded as the "gold standard" in treatment of stress urinary incontinence (SUI). Recently the safety and use of the MUS has come under scrutiny following concerns about the use of mesh implants. The aim of this review was to detail the background to SUI which has led to the development of MUS, to highlight the issues surrounding the use of mesh under the current climate of mesh controversies and to provide an update on current evidence on the use of MUS.

MATERIALS AND METHODS

We conducted a review of the literature looking at the efficacy and safety of MUS.

RESULTS

MUS has good rates of subjective cure in the short and into the longer term. The overall rates of complications are low including those associated with the use of mesh implants. When compared to other continence procedures, MUS is equally effective in regard to cure but has lower rates of complications and more favorable operative outcomes. The use of mesh has been supported by major Urogynaecological Societies along with the reports from government driven enquiries into the use of mesh.

CONCLUSIONS

Overall, MUS have been shown to be an effective and safe surgical treatment for management of stress urinary incontinence.

Repeat Surgical Intervention for Stress Urinary Incontinence after a Failed Mid Urethral Sling

INTRODUCTION

We determined the incidence of stress urinary incontinence surgery performed after mid urethral sling procedures and the impact of physician volume on mid urethral sling failure.

METHODS

Administrative data were used to identify all women who underwent a mid urethral sling procedure in Ontario, Canada between 2002 and 2013. The primary outcome was subsequent stress urinary incontinence surgery. The primary exposure was surgeon mid urethral sling case volume with high volume defined as greater than the 75th percentile.

RESULTS

A total of 59,556 women with a median age of 52 years (IQR 45-63) received a mid urethral sling, of whom 3.3% underwent additional stress urinary incontinence operations. The most common secondary surgery was a repeat mid urethral sling in 78.3% of cases and a pubovaginal sling in 5.8%. The cumulative incidence of repeat stress urinary incontinence surgery at 10 years of followup was 5.2% (95% CI 4.9-5.5). On multivariable survival analysis the effect of surgeon mid urethral sling volume on subsequent stress urinary incontinence surgery was nonsignificant (HR 0.89, 95% CI 0.76-1.03). Younger patient age, lower comorbidity and simultaneous hysterectomy decreased the hazard of future stress urinary incontinence surgery. In this cohort 1,425 women (2.4%) required surgical revision or removal of the initial mid urethral sling, of whom 215 (15%) underwent a simultaneous or subsequent incontinence procedure. The most common procedure was still a mesh sling, which was placed in 159 women (74.0%).

CONCLUSIONS

Secondary stress urinary incontinence surgery after mid urethral sling placement was observed in 3.3% of women. The majority of women with recurrent incontinence were treated with a repeat mid urethral sling. There is a nonsignificant trend toward higher mid urethral sling provider volume being correlated with a reduced risk of future stress urinary incontinence surgery.

Use of symptom-relieving drugs before and after surgery for urinary incontinence in women: a cohort study

OBJECTIVE

To describe the use of symptom-relieving drugs (antimuscarinic drugs or duloxetine) before and after surgery for urinary incontinence (UI); and for those with use of antimuscarinic drugs or duloxetine before surgery, to estimate the risk of being a postoperative user, relative to those without use before surgery.

DESIGN

A historical population-based cohort study.

SETTING

Denmark.

PARTICIPANTS

Women ≥18 years with a first-time surgical procedure for UI from the county of Funen, Denmark between 1 January 1996 and 31 December 2006, extended to the Region of Southern Denmark from 1 January 2007 to the end of 2010. For these women, data on redeemed prescriptions ±365 days of date of surgery were extracted.

MAIN OUTCOME MEASURES

Effect of preoperative use of antimuscarinic drugs or duloxetine on the risk of being a postoperative user of these drugs.

RESULTS

Of 2151 women with a first-time surgical procedure for UI, 358 (16.6%) were preoperative users of antimuscarinic drugs or duloxetine and 1793 were not (83.4%). A total of 110 (30.7%) of the preoperative users also redeemed prescriptions for these drugs within 0-60 days after surgery, and 152 (42.5%) of the preoperative users redeemed prescriptions for these drugs within 61-365 days after surgery. Among preoperative non-users, 25 (1.4%) and 145 (8.1%) redeemed prescriptions within 0-60 and 61-365 days after surgery, respectively. Presurgery exposure to antimuscarinic drugs or duloxetine was a strong risk factor of postoperative drug use, both within 0-60 days (adjusted OR=33.0, 95% CI 20.0 to 54.7) and 61-365 days (OR=7.2, 95% CI 5.4 to 9.6).

CONCLUSIONS

A substantial number of women will continue to be prescribed symptom-relieving drugs after surgery for UI within a year of follow-up. Only a minority of preoperative non-users initiated usage of symptom-relieving drugs after surgery. Compared with other factors included in the regression model, preoperative use of antimuscarinic drugs or duloxetine was the strongest risk factor for postoperative use.

The autologous fascia pubovaginal sling for complicated female stress incontinence

INTRODUCTION

The purpose of this study is to review our contemporary experience with autologous fascia pubovaginal slings (AF-PVS) in the era of the midurethral sling.

METHODS

A retrospective review was completed to identify all patients who underwent an AF-PVS between 2002 and 2009. A cross-sectional questionnaire was used to assess postoperative urinary-specific quality of life (consisting of the Urogenital Distress Inventory [UDI-6] and the Incontinence Impact Questionnaires [IIQ-7]).

RESULTS

We identified 33 patients. They had failed a median of two previous incontinence treatments. Of these patients, 16 (48%) had failed a previous midurethral sling, and of these half had experienced a significant mesh erosion necessitating mesh removal. Preoperative median incontinence pad usage was 5/day. After a median follow-up of 16 months from the time of AF-PVS, the median pad usage had decreased to 1/day (p = 0.003). A third of the patients had postoperative urgency, and only 1 patient continues to use intermittent catheterization. The median IIQ-7 score was 19/100, and the median UDI-6 score was 44/100. Overall quality of life was mixed-to-delighted in 62% of patients.

CONCLUSIONS

The AF-PVS has reasonable outcomes in a diverse population of patients, despite failure of other treatment modalities.

A systematic review and meta-analysis of Macroplastique for treating female stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Macroplastique® (polydimethylsiloxane injection) is a minimally invasive urethral bulking agent with global clinical literature describing its use over 20 years. This study critically assessed the safety and effectiveness outcomes for adult women treated with Macroplastique for stress urinary incontinence (SUI) through a systematic review and meta-analysis.

METHODS

A systematic review of the scientific literature from 1990 to 2010 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to quantitatively summarize the safety and effectiveness of Macroplastique for female SUI. A total of 958 patients from 23 cohorts were eligible for inclusion and were analyzed. Random-effects models were used to estimate the improvement and cure rates following treatment at three time periods: short-term (<6 months), mid-term (6-18 months), and long-term (>18 months). Expanded models assessed the effect of reinjection rate on successful treatment outcomes. Adverse event rates were aggregated and reported.

RESULTS

Improvement rates were 75 % [95 % confidence interval (CI), 69-81] in the short-term, 73 % (95 % CI, 62-83) in the mid-term, and 64 % (95 % CI, 57-71) long-term. Cure/dry rates were 43 % (95 % CI, 33-54), 37 % (95 % CI, 28-46), and 36 % (95 % CI, 27-46) over the same respective follow-up periods. Higher study reinjection rates were associated with improved long-term SUI outcomes. No serious adverse events were reported.

CONCLUSIONS

This quantitative review supports Macroplastique as an effective, durable, and safe treatment option for female SUI. Meta-analytic evidence suggests that long-term therapeutic benefit is frequently maintained, with some patients requiring reinjection.

Mid-urethral slings in female incontinence: Current status

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring one's choice of MUS to the individual patient and her unique clinical parameters remains the best option.

Animal models of stress urinary incontinence

Stress urinary incontinence (SUI) is a common health problem significantly affecting the quality of life of women worldwide. Animal models that simulate SUI enable the assessment of the mechanism of risk factors for SUI in a controlled fashion, including childbirth injuries, and enable preclinical testing of new treatments and therapies for SUI. Animal models that simulate childbirth are presently being utilized to determine the mechanisms of the maternal injuries of childbirth that lead to SUI with the goal of developing prophylactic treatments. Methods of assessing SUI in animals that mimic diagnostic methods used clinically have been developed to evaluate the animal models. Use of these animal models to test innovative treatment strategies has the potential to improve clinical management of SUI. This chapter provides a review of the available animal models of SUI, as well as a review of the methods of assessing SUI in animal models, and potential treatments that have been tested on these models.

Is modified Raz technique of midurethral sling a reliable and cost-effective method of treating stress urinary incontinence?

OBJECTIVES

We report our experience of pure stress urinary incontinence (SUI) treated by midurethral synthetic sling placement by modified Raz technique.

MATERIALS AND METHODS

Fifty-three patients with pure SUI operated at our institute between June 2003 and December 2008 were included in this study. Midurethral sling tape, fashioned from commercially available large pore synthetic mesh, was placed using the modified Raz technique. The technique consisted of placing the tape within retropubic space using double-pronged needle, which is passed under finger control through the fascia and retropubic space. Outcomes were assessed on the basis of patient's interview in follow-up OPD.

RESULTS

Mean age was 57.68 (28-69) years. Forty-five (85%) patients were totally dry and eight (15%) socially dry at the end of the follow-up. Mean operative time was 46.5 + 11.3 minutes (35-80 minutes). None of the patients required blood transfusion or had bladder/bowel injury. Mean duration of hospital stay was 2.17 days (2-4 days). Mean duration of follow-up was 46.1 months (12-78 months).

CONCLUSIONS

Modified Raz technique is safe and cost-effective for placing midurethral sling for genuine stress incontinence.

Review article: Mid-urethral synthetic slings for female stress urinary incontinence

• Mid-urethral synthetic slings (MUSS) have grown in acceptance and popularity to gain a foremost position in stress urinary incontinence (SUI) surgery. • There are numerous studies that provide a large amount of Level 1 and 2 evidence that support the concept of a sling placed at the level of the mid-urethra. • Long-term follow-up has been published for the original tension-free vaginal tape (TVT) procedure with the most recent publication providing Level 2 evidence with mean follow-up of 11.5 years of 69/91 (77%) of patients from the original series. There was objective cure was in 90% of women and 77% considered themselves subjectively cured, based on the Patient Global Impression of Improvement. • Level 1 evidence with long-term follow-up has been provided comparing colposuspension to TVT at 2 and 5 years. At 5 years for the primary efficacy variable of a negative 1 h stress pad test, there was no difference in success (81% vs 90%). • Two recent meta-analyses provide Level 1 evidence comparing outcomes for retropubic vs transobturator MUSS. One included 18 studies, randomized and cohort: cohort studies had a 12.3% failure rate for transobturator and 13.7% failure for the retropubic approach, randomized studies showed 5.7% failure in the transobturator vs 7.8% in the retropubic group. The other meta-analysis included 11 studies published 2008-2009, which found that the short-term cure rate was borderline inferior for the transobturator tape group (odds ratio 0.62; 95% confidence interval 0.37-1.00), nearly reaching statistical significance (P= 0.05). • This review details further comparator evidence and evidence for use in specific patient groups (elderly, obese, intrinsic sphincter deficiency, mixed UI).