The Virtue quadratic male sling for postradical prostatectomy urinary incontinence: 3-Year outcome measurements and a predictive model of surgical outcome from a European prospective observational study

AIMS

This prospective multicenter observational study evaluated postprostatectomy incontinence treatment outcomes with Virtue male sling at 12 and 36 months.

METHODS

Objective assessment was based on a 24-h pad weight test with improvement defined by a decrease >50% and cure by less than 1.3 g. Subjective assessment was based on the patient global impression of improvement and International Consultation on Incontinence Questionnaire-urinary incontinence-short form (ICIQ-UI-SF) questionnaires. Subgroups were analyzed by baseline severity of incontinence on a 24-h-pad test, body mass index (BMI), and pads usage. Factors associated with treatment response were assessed using logistic regression at Months 36. Complications were reported.

RESULTS

We analyzed data from 117 men. Objective and subjective improvement were achieved in 54% and 35% and 51% and 34% at 12 and 36 months, respectively. Twenty-one percent and 19% were considered cured, respectively, at 12 and 36 months. No differences per baseline incontinence severity, BMI and pads usage were found at 36 months. Mean ICIQ-UI-SF score decreased from 15 to 9. Predictive factors were BMI, postvoid residual urine, number of nighttime urination, and ICIQ total score. Seven Clavien-Dindo Grade III (5.1%) including four Virtue sling revisions were reported. The most frequent Grade II complications were overactive bladder symptoms and pain reported in 10.3% and 2.9%, respectively. No complications required explantation.

CONCLUSIONS

Virtue male sling is safe and effective in males with mild to severe postprostatectomy urinary incontinence over 36 months. Virtue could be considered an interesting option for postradical prostatectomy urinary incontinence with positive results over time even in patients with high BMI. The predictive model should be validated by further studies.

Normative noninvasive bladder function measurements in healthy women: A systematic review and meta-analysis

AIM

To conduct an evidence synthesis of normative reference values for bladder function parameters in women.

METHODS

We conducted a systematic review and meta-analysis of studies reporting bladder function parameters obtained from noninvasive tests in healthy women. Seven databases were searched for relevant studies from inception through December 2018, with manual searching of reference lists. We included English language articles that provided quantitative data on urination frequency, voided and postvoid residual volumes, and uroflowmetry results in women without lower urinary tract symptoms. Study selection, data extraction, and quality assessment were undertaken by at least two independent reviewers. Random-effects meta-analytic models were used to derive study-level pooled mean estimates and 95% confidence intervals.

RESULTS

A total of 24 studies (N = 3090 women, age range, 18-91 years) met eligibility criteria. Pooled mean estimates of bladder function parameters were: 6.6 daytime voids (95% confidence interval (95% CI), 6.2, 7.0), 0.4 nighttime voids (95% CI, 0.0, 0.8), 1577 mL for 24-hour voided volume (95% CI 1428,1725); 12 mL for postvoid residual volume (95% CI, 4, 20); and 28 mL/sec for maximum flow rate (95% CI, 27,30). Between-study heterogeneity was high for all outcomes (I²  = 61.1-99.6%), but insufficient data were available to explore reasons for this high heterogeneity (eg, differences by age).

CONCLUSION

Although summary mean estimates of bladder function parameters were calculated, the wide heterogeneity across studies precludes generalization of these estimates to all healthy women. Further research is needed to determine normative reference values within specific groups, such as those defined by age.

Objective efficacy of the tension-free vaginal tape in obese/morbidly obese women versus non-obese women, at median five year follow up

BACKGROUND

One subjective long-term evaluation of the tension-free vaginal tape (TVT) success rate in obese women showed a worse prognosis in the obese, but objective studies have been limited to short-term follow-up (less than two years).

AIM

To determine whether the long-term objective cure rate in obese/morbidly obese women who underwent TVT was reduced, compared to non-obese women (at five or more years).

MATERIALS AND METHODS

Body mass index (BMI) was collected on patients undergoing TVT procedure. Recruited patients were asked to perform a 24 h pad test and complete an International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) at five years postoperatively. Data was analyzed according to pre-operative urodynamic diagnoses and BMI, using 'routine' and 'strict' objective definitions of objective cure.

RESULTS

At median follow-up of 64 months (interquartile range 58-80 months), 136 patients returned a pad test and ICIQ-SF. Using a routine definition of cure (pad test of ≤10 g in a 24 h period), 96% of patients were cured overall. The BMI results (n = 119 patients) were stratified into ≤25, 25.1-35 and ≥35.1 kg/m² , which represented 41, 53 and 6% of patients, respectively. The routine cure rates for these three groups were 98, 97 and 71%, respectively (P = 0.004).

CONCLUSION

Long-term objective outcomes of the TVT in morbidly obese women are significantly poorer than in women with a normal BMI.

A pilot randomized trial of conventional versus advanced pelvic floor exercises to treat urinary incontinence after radical prostatectomy: a study protocol

Background

Radical prostatectomy is the most common and effective treatment for localized prostate cancer. Unfortunately, radical prostatectomy is associated with urinary incontinence and has a significant negative impact on quality of life. Pelvic floor exercises are the most common non-invasive management strategy for urinary incontinence following radical prostatectomy; however, studies provide inconsistent findings regarding their efficacy. One potential reason for sub-optimal efficacy of these interventions is the under-utilization of regional muscles that normally co-activate with the pelvic floor, such as the transverse abdominis, rectus abdominis, and the diaphragm. Two novel approaches to improve urinary continence recovery are ‘Pfilates’ and ‘Hypopressives’ that combine traditional pelvic floor exercises with the activation of additional supportive muscles. Our study will compare an advanced pelvic floor exercise training program that includes Pfilates and Hypopressives, to a conventional pelvic floor exercises regimen for the treatment of post-radical prostatectomy urinary incontinence.

Methods/Design

This is a pilot, randomized controlled trial of advanced pelvic floor muscle training versus conventional pelvic floor exercises for men with localized prostate cancer undergoing radical prostatectomy. Eighty-eight men who will be undergoing radical prostatectomy at hospitals in Toronto, Canada will be recruited. Eligible participants must not have undergone androgen deprivation therapy and/or radiation therapy. Participants will be randomized 1:1 to receive 26 weeks of the advanced or conventional pelvic floor exercise programs. Each program will be progressive and have comparable exercise volume. The primary outcomes are related to feasibility for a large, adequately powered randomized controlled trial to determine efficacy for the treatment of urinary incontinence. Feasibility will be assessed via recruitment success, participant retention, outcome capture, intervention adherence, and prevalence of adverse events. Secondary outcomes of intervention efficacy include measures of pelvic floor strength, urinary incontinence, erectile function, and quality of life. Secondary outcome measures will be collected prior to surgery (baseline), and at 2, 6, 12, 26-weeks post-operatively.

Discussion

Pfilates and Hypopressives are novel approaches to optimizing urinary function after radical prostatectomy. This trial will provide the foundation of data for future, large-scale trials to definitively describe the effect of these advanced pelvic floor exercise modalities compared to conventional pelvic floor exercise regimes for men with prostate cancer undergoing radical prostatectomy

Trial registration

Clinicalstrials.gov Identifier: NCT02233608.

The results of a 24-h pad test in Brazilian women

INTRODUCTION AND HYPOTHESIS

The International Continence Society (ICS) adopted 1.3 g as the normative value for the 24-h pad test. We hypothesized that this cutoff value may not be valid for women who live in countries with high temperatures.

METHODS

We documented the 24-h pad test values of continent women in Brazil and investigated the factors that can influence in vaginal humidity.

RESULTS

The sample consisted of 257 participants. The temperatures ranged from 19°C to 27.8°C. The median increase in the weight of the pad was 1.9 g (1.4-3.0 g, 95th percentile 4.4 g). Pad test results differed significantly between pre- and postmenopausal women (p = 0.026). There was a significant difference in the pad weights of women who use hormone therapy (p = 0.003).

CONCLUSIONS

The value of the 24-h pad test established by the ICS was not valid for the investigated sample. Environmental conditions, menopausal status, and use of hormone therapy can interfere with the values of the pad test.

Update: the "Contiform" intravaginal device in four sizes for the treatment of stress incontinence

The aim of this study was to evaluate the efficacy of the Contiform intravaginal device for stress incontinence after the addition of a fourth size. We offered the device to a cohort of 73 women with a main complaint of stress incontinence but no prolapse. Of the 73 women invited to participate, 65 enrolled, of whom 52 were fitted. Of these 52 women, 37 (71%) completed the study protocol. Outcome measures were the 24-h pad test, St George score, and quality of life tests. Urine loss on pad test was significantly reduced from a median 6.6 g (interquartile range [IQR] = 4.3-22.6) to 2.2 g (IQR = 0.5-8.2; P = 0.0016) after 4 weeks with significant benefit seen on the Incontinence Impact Questionnaire and Urinary Distress Inventory. The insertion technique was quickly learnt, and the device was well tolerated. The recently developed medium/large size of Contiform was used by 6/37 (16%) women.

The diagnostic strength of the 24-h pad test for self-reported symptoms of urinary incontinence in pregnancy and after childbirth

The clinical impact of incontinence in pregnancy and after childbirth is growing because some studies report the efficacy of physiotherapy in pregnancy and because obstetric choices are supposed to have significant impact on post-reproductive urinary function (Goldberg et al. in Am J Obstet Gynecol 188:1447–1450, 2003). Thus, the need for objective measurement of urinary incontinence in pregnancy is growing. Data on pad testing in pregnancy are lacking. We assessed the clinical relevance of the 24-h pad test during pregnancy and after childbirth, compared with data on self-reported symptoms of urinary incontinence and visual analogue score. According to the receiver operating characteristic curve, the diagnostic value of pad testing for measuring (severity of) self-reported incontinence during pregnancy is not of clinical relevance. However, for the purposes of research, pad tests, combined with subjective/qualitative considerations, play a critical role in allowing comparisons across studies, quantifying the amount of urine loss and establishing a measure of severity.

Extracorporeal Magnetic Stimulation is of Limited Clinical Benefit to Women with Idiopathic Detrusor Overactivity: A Randomized Sham Controlled Trial

OBJECTIVES

To observe the effect of both acute and medium-term magnetic stimulation of the pelvic floor on detrusor function amongst women with idiopathic detrusor overactivity (IDO).

METHODS

Two separate studies were undertaken amongst women with a sole diagnosis of IDO. The first study assessed the acute effect of magnetic stimulation (provided by Neocontrol ) on detrusor function during the filling phase of standard cystometry. Multiple filling cycles were performed with stimulation at a different key moment in each. This was done to establish that the device could influence the detrusor. Subsequently, a randomized sham control trial was performed to assess clinical efficacy. A total of 20 treatments, each of 20 minutes duration, were administered over six weeks with follow-up six weeks thereafter. Half the patients received therapy from a genuine device, the others receiving fake treatment on an identical looking/sounding sham device. The sham device contained a deflector plate to degrade the magnetic field and was located in a separate room. Outcome measures included changes in a 24 hour fluid volume chart, urine loss (24 hour pad test) and quality of life instruments.

RESULTS

Amongst 10 patients receiving stimulation during cystometry, volume at first involuntary detrusor contraction during filling rose from a median value of 240ml (Inter-quartile range (IQR) 210-300) to 285ml (IQR 231-320), p = 0.03 and maximum detrusor pressure decreased from 40cm water (IQR 34-45) to 33cm water (IQR 25-41), p<0.01. The RCT was completed by 29 of 44 (66%) recruits. Of these, 15 of 29 (52%) received active treatment and 14 of 29 (48%) sham therapy. Active therapy significantly reduced the number of urge episodes per day, p<0.01. With respect to baseline, actively treated patients experienced significant reduction in voids per day and quality of life but this trend did not reach significance when compared to the sham group, partly due to unexpected difficulty in recruitment which yielded an underpowered sample size for these outcome measures.

CONCLUSIONS

Magnetic stimulation reduces detrusor contractility in the acute phase of administration. Although the treatment was well tolerated and urge episodes reduced following prolonged therapy, no statistically significant improvement was observed in quality of life indices or measured 24 hour urinary loss. The treatment cannot be recommended for women with IDO.

A statistical comparison of pad numbers versus pad weights in the quantification of urinary incontinence

AIMS

Pad per day (PPD) usage is a frequently utilized measure of urinary incontinence. The 24-hour pad weight test (24PWT) is a reproducible test for quantifying incontinence volumes. We investigated whether PPD validly reports the magnitude of urinary incontinence.

METHODS

This was a retrospective review of patients undergoing stress incontinence surgery from July 2002 to 2005. Inclusion criteria were a documented 24PWT and patient-reported PPD usage. Grams of urine loss per pad (GPP) provided a third measure of incontinence. Descriptive statistics and correlations between all variables and significance were noted. Factor analysis was performed on the three measures of leakage and age for all patients over age 50.

RESULTS

One hundred forty-five male and 116 female patients met inclusion criteria. Correlated against 24PWT, GPP has the strongest association with a correlation of 0.80 for males and 0.88 for females. PPD has a weaker correlation of 0.64 for males and 0.61 for females (R2 = 0.38 overall). Factor analysis identified two components associated with incontinence. A "leakage" component correlated best with 24PWT and GPP. Additionally, an "age" component implies that despite stable 24PWT values, older patients increase GPP while PPD decreases.

CONCLUSIONS

Self-reported PPD is an unreliable measure of incontinence as this variable only measures 38% of the variation of urinary incontinence volume. Patients at a given PPD level present with a wide range of 24PWT values. Older patients have higher per-pad leakage. Future incontinence studies should report 24PWT to ensure the most reliable and uniform data.

The standard 1-hour pad test: does it have any value in clinical practice?

OBJECTIVES

The aim of this study was to determine whether self subjective assessment of urinary incontinence as perceived by female patients could replace the standard 1-hour pad test in clinical practice.

DESIGN

Prospective cohort study.

SETTING

District General Hospital, South West of England.

METHODS

Ninety women awaiting surgical treatment for urodynamic stress incontinence were recruited. They underwent 160 pad tests; on each test women were asked to classify themselves on a four point scale into one category (0: totally continent to urine, 1: mild/occasional urinary incontinence (UI), 2: moderate UI, 3: severe UI), to complete the King's Health Questionnaire (KHQ) and carry out the standard International Continence Society 1-hour pad test. A pad gain >1 gm was considered a positive result.

MAIN OUTCOME MEASURES

Women perception for severity of UI, 1-hour pad gain, KHQ scores.

RESULTS

Self subjective assessment of UI (continent vs. incontinent) had good correlation (r = 0.88) with the pad test result (negative vs. positive), and correlated well with the KHQ scores (r = 0.79). Poor correlation was seen between the pad gain and the KHQ scores (r = 0.48) and between the pad gain and the self subjective assessment of UI scale (r = 0.48). The self subjective assessment of UI (incontinent vs. continent) had sensitivity 95.65% and specificity 93.33% to detect the pad test results (positive vs. negative).

CONCLUSION

This study suggest that, in either the pre- or postoperative phase, simply asking a woman if she is continent for urine or not was as good as doing the pad test and correlated better with the patient quality of life.

Definition of mild, moderate and severe incontinence on the 24-hour pad test

The values for 'mild', 'moderate' and 'severe' urinary incontinence have not been determined for the 24-hour pad test. To define these values, a prospective observational study was performed on 110 women with the primary symptom of urinary incontinence. Consenting women performed two 1-hour pad tests one week apart, and seven 24-hour pad tests for seven consecutive days. The 1-hour pad test definitions for mild, moderate and severe were translated to centiles, and used to categorise the 24-hour test values. This revealed that the range for 'mild incontinence' was between 1.3 and 20 g, 'moderate incontinence' ranged from 21 to 74 g, and 'severe incontinence' was defined as 75 g or more in 24 hours. Severity of leakage was analysed in relation to urodynamic diagnosis, age, parity and pelvic floor muscle strength. Increasing severity was associated with increasing age and parity. Women with detrusor overactivity were most likely to have severe leakage. In conclusion, this study defines the three grades of severity for the 24-hour pad test, which may help to guide patients' choice between conservative and surgical treatment and is useful for stratified randomisation of controlled trial participants.

Pad test by mail for home evaluation of urinary incontinence

AIMS

To present a simple, cost-effective, and convenient method of home pad test using the mail system and evaluating change in pad weight over time.

MATERIALS AND METHODS

A series of nine kinds of commonly available commercial brands of urinary incontinence pads ranging from thin liners less than 10 g in dry weight to large diapers weighing over 100 g each were assembled. Two or three of each variety were individually weighed on an OHAUS LS2000 Portable Standard scale accurate to +/- 1 g. The pads were then wet uniformly with 20 cc of saline, placed individually in sealable plastic bags, sealed, and reweighed. Random groups of three pads were mailed by standard 1st class mail to the Urocenter of New York. The sealed pads were reweighed at 8 and 14 days from the original wetting. Concurrently, ten incontinence pads soiled with urine were similarly examined to confirm that there would be no detectable difference between urine and saline for the purpose of the study. In the second part of the study, 20 pads of the same type (13 inch-long pads with absorbent gel) were divided into 4 groups of 5 pads; each group was uniformly wet with 5, 10, 20, or 50 g of saline. These pads were mailed and reweighed at 7 and 14 days from the initial wetting.

RESULTS

Twenty-four pads were used in the first part of the study. The dry weights of 22/24 (92%) of the pads were within 2 g of the average weight for their brand. At the first reweighing, 22 pads (92%) weighed within 2 g of their initial wet weights (Fig. 1). Only two pads on day 8 differed substantially from their initial weights: one pad appeared to have lost 4 g and another one 9 g. On day 14, 23/24 pads remained within 1 g of their day 8 weight and 1 differed by 2 g, and the total weight of the 24 pads on day 14 was only 4 g different from their initial weight (P = 0.71, Fig. 1). The soiled pads exhibited weight changes that were indistinguishable from the saline pads. The average cost of mailing the pads by 1st class mail was $4 and the average length of time in the mail was 5 days +/- 1 day. In the second part of the study, 18/20 pads had lost less than 1 g at 1 week, and at 2 weeks, 19/20 had lost less than 2 g when compared to their initial weights (Fig. 2). One pad had lost 3 g. Pads in the low volume groups (5 and 10 g) lost an average of 1.4 and 1.2 g, respectively, while pads in the high volume groups (20, 50 g) lost an average of 1.8 and 2 g at 2 weeks.

CONCLUSIONS

Dry pads of any single brand have a relatively standard weight that varies insignificantly between pads. Up to 2 weeks of delay in the weighing of individually sealed pads does not significantly affect the clinical measurement of weight at a variety of low (5 g) or high (50 g) volumes of simulated incontinence. Home pad test using the mail system is a feasible, inexpensive, and clinically accurate method of evaluating incontinence. Patients can be instructed in techniques for home pad test, allowing for greater compliance, and convenience for both physicians and patients.