Burch Retropubic Urethropexy Compared With Midurethral Sling With Concurrent Sacrocolpopexy: A Randomized Controlled Trial

Defining success after surgical treatment of stress urinary incontinence

BACKGROUND

A consensus standardized definition of success after stress urinary incontinence surgical treatment is lacking, which precludes comparisons between studies and affects patient counseling.

OBJECTIVE

This study aimed to identify optimal patient-centric definition(s) of success after stress urinary incontinence surgical treatment and to compare the identified "more accurate" treatment success definitions with a commonly used composite definition of success (ie, no reported urine leakage, negative cough stress test result, and no retreatment).

STUDY DESIGN

We evaluated 51 distinct treatment success definitions for participants enrolled in a previously conducted randomized trial of stress urinary incontinence treatments concomitantly performed with sacrocolpopexy (NCT00934999). For each treatment success definition, we calculated the mean (SD) of participant-assessed symptom improvement and participant-assessed surgical success scores with an 11-point Likert scale among those achieving success and failure. The "more accurate" treatment success definition(s) were identified by measuring the magnitude of the mean difference of participant assessments with Hedges g values. The treatment success definitions with the highest Hedges g values were considered "more accurate" treatment success definitions and were then compared with the composite definition of success.

RESULTS

The percentage of participants who had treatment success (6.4% to 97.3%) and Hedges g values (-4.85 to 1.25) varied greatly according to each treatment success definition. An International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score ≤5, Urogenital Distress Inventory-6 score ≤33.3, and a no/mild stress urinary incontinence response on Urogenital Distress Inventory-6 question 3 had the highest Hedges g values and were considered the top 3 "more accurate" treatment success definitions. Paradoxically, treatment success definitions that required a negative cough stress test result or no persistent urinary leakage greatly reduced the ability to differentiate between participant-assessed symptom improvement and surgical success. When the "more accurate" treatment success definitions were compared with the composite definition, patients with failed treatment according to the composite definition had lower Urinary Impact Questionnaire-7 scores and a higher proportion of survey responses indicating complete satisfaction or some level of satisfaction and very good/perfect bladder condition. In addition, the composite definition had considerably fewer favorable outcomes for participants than did the top 3 "more accurate" treatment success definitions.

CONCLUSION

Successful outcomes of stress urinary incontinence surgical treatments for women undergoing concurrent sacrocolpopexy varied greatly depending on the definition used. However, stringent definitions (requiring complete dryness) and objective testing (negative cough stress test result) had decreased, rather than increased, participant-assessed symptom improvement and surgical success scores. The "more accurate" treatment success definitions better differentiated between participant-assessed symptom improvement and surgical success than the composite definition. The composite definition disproportionately misidentified participants who reported minor symptoms or complete/partial satisfaction with their outcome as having treatment failures and yielded a considerably lower proportion of women who reported favorable outcomes than did the top 3 "more accurate" treatment success definitions.

Racial and ethnic disparity in national practice patterns for stress urinary incontinence surgery

INTRODUCTION AND HYPOTHESIS

There is a paucity of information assessing whether race/ethnicity is associated with differences in surgical treatment of stress urinary incontinence (SUI). The primary objective was to assess for racial/ethnic disparities in SUI surgeries. Secondary objectives were to assess for surgical complication differences and trends over time.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we conducted a retrospective cohort analysis of patients undergoing SUI surgery from 2010 to 2019. Chi-squared or Fisher's exact test and ANOVA were used for categorical and continuous variables respectively. Breslow day score and multinomial and multiple logistic regression models were used.

RESULTS

A total of 53,333 patients were analyzed. Using White race/ethnicity and sling surgery as references, Hispanic patients underwent more laparoscopic surgeries (OR1.17 [CI 1.03, 1.33]) and anterior vesico-urethropexy/urethropexies (OR 1.97 [CI 1.66, 2.34]); Black patients underwent more anterior vesico-urethropexy/urethropexies (OR 1.49 [CI 1.07, 2.07]), abdomino-vaginal vesical neck suspensions (OR 2.19 [CI 1.05-4.55]), and inflatable urethral slings (OR 4.28 [CI 1.23-14.90]). White patients had lower rates of inpatient stay (p < 0.0001) and blood transfusion (p < 0.0001) compared with patients who were Black, indigenous, people of color (BIPOC). Over time, Hispanic and Black patients were more likely to undergo anterior vesico-urethropexy/urethropexies than White patients (RR 2.03:1 [CI 1.72-2.40]) and (RR 1.59 CI [1.15-2.20]) respectively. Adjusting for possible confounders, Hispanic and Black patients had a greater chance of having a nonsling surgery, 37% (p < 0.0001) and 44% (p = 0.0001) greater chances respectively.

CONCLUSION

We observed racial/ethnic differences in SUI surgeries. Although causality cannot be proven here, our results confirm previous findings suggesting inequities in care.

Abdominal and robotic sacrocolpopexy costs following implementation of enhanced recovery after surgery

OBJECTIVE

To compare perioperative costs and morbidity between open and robotic sacrocolpopexy after implementation of enhanced recovery after surgery (ERAS) pathway.

METHODS

The present retrospective cohort study of patients undergoing open or robotic sacrocolpopexy (January 1, 2014, through November 30, 2017) used an ERAS protocol with liposomal bupivacaine infiltration of laparotomy incisions. Primary outcomes were costs associated with index surgery and hospitalization, determined with Medicare cost-to-charge ratios and reimbursement rates and adjusted for variables expected to impact costs. Secondary outcomes included narcotic use, length of stay (LOS), and complications from index hospitalization to postoperative day 30.

RESULTS

For the total of 231 patients (open cohort, 90; robotic cohort, 141), the adjusted mean cost of robotic surgery was $3239 higher compared with open sacrocolpopexy (95% confidence interval [CI] $1331-$5147; P < 0.001). Rates were not significantly different for intraoperative complications (robotic, 4.3% [6/141]; open, 5.6% [5/90]; P = 0.754), 30-day postoperative complications (robotic, 11.4% [16/141]; open, 16.7% [15/90]; P = 0.322), or readmissions (robotic, 5.7% [8/141]; open, 3.3% [3/90]; P = 0.535). The percentage of patients dismissed on postoperative day 1 was greater in the robotic group (89.4% [126/141] vs. 48.9% [44/90], P < 0.001).

CONCLUSIONS

Decreased LOS associated with ERAS provided significant cost savings with open sacrocolpopexy versus robotic sacrocolpopexy without adverse impacts on perioperative complications or readmissions.

Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition)

The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.

Surgical management of stress urinary incontinence following traumatic pelvic injury

INTRODUCTION AND HYPOTHESIS

The objective was to discuss the evaluation and management of stress urinary incontinence (SUI) following traumatic pelvic injury by use of a video case.

METHODS

We present a patient with severe SUI following pelvic trauma and our surgical approach to her case. Her injuries included two sacral compression fractures and four un-united bilateral pubic rami fractures, with her right-upper pubic rami impinging on the bladder.

RESULTS

Preoperative assessment included detailed review of her pelvic imaging, multichannel urodynamic testing, cystoscopy, and examination of periurethral and bony pelvis anatomy. We proceeded with a synthetic retropubic mid-urethral sling, which required medial deviation of the trocar passage owing to her distorted anatomy. Rigid cystoscopy provided an inadequate bladder survey following sling placement, thus flexible cystoscopy was used to confirm the absence of bladder perforation. Postoperatively, our patient experienced resolution of SUI.

CONCLUSIONS

In patients who sustain pelvic fractures, imaging to evaluate bony trauma and genitourinary tract injury is essential. Urodynamic testing provides clarity of the nature and severity of incontinence symptoms. Rigid and/or flexible cystoscopy should be performed for diagnostic purposes pre-operatively and after operative intervention. Typical anti-incontinence procedures can be offered to these patients, but since bony anatomy can be unreliable, an individualized approach to their specific injury should be utilized.

Is There Outcome Reporting Heterogeneity in Trials That Aim to Assess the Effectiveness of Surgical Treatments for Stress Urinary Incontinence in Women?

CONTEXT

Inconsistent reporting of effectiveness outcomes in surgical trials of stress urinary incontinence (SUI) has hindered direct comparisons of various surgical treatments for SUI.

OBJECTIVE

To systematically review the verbatim outcome names, outcome definitions, and tools used to measure the outcomes in surgical trials of SUI in women.

EVIDENCE ACQUISITION

Trials of women with SUI who have undergone surgical interventions were included. We conducted a systematic review (SR) on outcomes reported in randomized controlled trials of surgical management published in 2014-2019, covering the following databases: MEDLINE, EMBASE, CENTRAL, and CDSR. Verbatim outcome names extracted from the included studies were categorized and then grouped into domains using the Williamson-Clarke (W/C) outcome taxonomy. A matrix was also created to visualize and quantify the dimensions of outcome reporting heterogeneity in SUI trials.

EVIDENCE SYNTHESIS

A total of 844 verbatim outcome names were extracted, of which, 514 varied terms were reduced to 71 standardized outcome names. They were further categorized into 11 domains from the W/C taxonomy. There were 7.24 different terms on average to describe each outcome, and the four outcomes with the most heterogeneity evident in terms used to describe them were "urinary retention", "reoperation", "subjective cure rate" and "quality of life". Each of them had ≥20 different terms. Only 28% of the outcome definitions were reported and a variety of measuring tools was noted, particularly in subjective outcomes. High heterogeneity was found in the outcome names, outcome definitions, choice and number of measuring instruments of the outcomes, and choice and number of outcomes reported across studies.

CONCLUSIONS

This SR provides objective evidence of heterogeneity in outcome reporting in SUI surgical trials. Our categorization of outcomes highlights the difficulties in summarizing the current evidence base. A core outcome set, developed using the methods advocated by the Core Outcome Measures in Effectiveness Trials (COMET) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) initiatives, is required.

PATIENT SUMMARY

In this research, we have highlighted the diversity in outcomes reporting in stress urinary incontinence (SUI) surgical trials and have categorized the outcomes. We support the development of a core outcome set for SUI, which will promote future clinical researchers to measure the same outcome in the same way in all trials. This will, in turn, help researchers summarize the evidence more effectively and aid decision making for patients and doctors.

A comprehensive look at risk factors for mid-urethral sling revision surgery

INTRODUCTION

The objective of this study was to identify risk factors and urodynamic parameters predictive of mid-urethral sling (MUS) revision surgery that can be used for counseling patients and individualizing risk prediction.

METHODS

Retrospective case-control analysis of 40 sling revisions performed during the 12-year study period were compared to 123 control cases that did not require revision to obtain a 1:3 case-to-control ratio. Demographic, perioperative, and urodynamic data were analyzed, with p < 0.05 as significant. Independent predictors of sling revision were assessed by binary logistic regression models, with risk expressed as adjusted odds ratios.

RESULTS

After multiple regression analysis, younger age at time of index MUS placement (aOR 0.93, 95% CI 0.88-0.97), increasing number of cesarean deliveries (CD) (aOR 2.00, 95% CI 1.01-3.96), and concomitant apical prolapse repair during index MUS procedure (aOR 4.63, 95% CI 1.34-15.93) were significant predictors of sling revision.

CONCLUSIONS

Young age at the time of placement, multiple CD, and concomitant apical prolapse repair were independent factors predictive of sling revision. Giving consideration to risk factors could improve patient counseling and surgical candidate selection.

Revisiting current treatment options for stress urinary incontinence and pelvic organ prolapse: a contemporary literature review

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) affect many women in their lifetime. In this review, we describe and evaluate the latest treatment options for SUI and POP, including the controversy around transvaginal mesh (TVM) use. Growing evidence supports the utilization of pelvic floor muscle training as first-line treatment for both SUI and POP. Vaginal pessaries continue to be an effective and reversible option to manage SUI and POP symptoms. The midurethral sling remains the gold standard for surgical treatment of SUI, although patients and clinicians should acknowledge the potentially serious complications of TVM. Burch urethropexy and pubovaginal sling offer good SUI cure and may be preferred in women wishing to avoid mesh implants; however, their operative morbidities and more challenging surgical approach may limit their use. Site-specific cystocele or rectocele repairs may be indicated for isolated anterior or posterior vaginal compartment prolapse; however, in women with more severe POP, evidence supports using a vaginal native-tissue repair involving apical suspension as the primary surgical technique. Although abdominal and laparoscopic sacrocolpopexies are both effective in treating POP, their failure and mesh complication rates increase with time. There is insufficient evidence to support the widespread use of uterine-preserving surgical POP repairs at present due to the lack of long-term data. Routine TVM use is not recommended in POP surgeries and should only be considered on a case-by-case basis by trained surgeons, primarily in women with multiple risk factors for POP recurrence. In general, clinicians should individualize SUI and POP treatment options for women based on their symptoms, comorbidities, and risk factors for mesh-related complications.

Complications after minimally invasive sacrocolpopexy with and without concomitant incontinence surgery: A National Surgical Quality Improvement Program (NSQIP) database study

AIMS

To compare surgical complications for patients having minimally invasive sacrocolpopexy (MISCP) with concomitant incontinence procedure, to those having MISCP alone.

METHODS

Patients undergoing MISCP with and without a concomitant incontinence procedure between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. The main outcome of interest was a composite of surgical site infection, bleeding requiring blood transfusion, return to the operating room within 30 days, and surgical stay >48 h. Log-binomial regression was used to identify independent risk factors for the outcome and to generate adjusted effect measures for variables of interest.

RESULTS

Seven thousand ninety-seven women met the inclusion criteria, of which 2433 (34%) underwent a concomitant incontinence procedure. Patients having incontinence procedures were slightly older (59 ± 11 vs 58 ± 12, P < 0.0001) and had longer total operating time (225 IQR 170-267 vs 184 IQR 120-232 min, P < 0.0001). Pre-operative steroid use, wound class III/IV (vs I/II), and longer operative time were independent predictors of the composite outcome. After adjusting for baseline patient characteristics and co-morbidities, no association was observed between concomitant incontinence procedure and the composite outcome (adjusted RR 0.87, 95%CI 0.65-1.18) but there was an increased likelihood of urinary tract infection (adjusted RR 2.47 95%CI 1.89-3.27).

CONCLUSIONS

Despite being associated with a longer operative time, performing an incontinence procedure at the time of MSCIP was not associated with an increased risk of clinically important surgical complications other than urinary tract infection.

Robotic-assisted Sacrocolpopexy with versus without Concomitant Midurethral Sling: A 2-year Follow-up of Urinary Symptoms and Quality of Life

OBJECTIVE

The objective of this study was to assess long-term postoperative urinary incontinence (UI) symptoms and quality of life (QOL) in patients after robotic-assisted sacrocolpopexy (RASC) with or without concomitant midurethral sling (MUS).

MATERIALS AND METHODS

This is a cross-sectional survey of patients comparing long-term postoperative urinary symptoms and QOL measurements in women who underwent RASC with or without MUS. We included all patients from 2011 to 2014 who had RASC with or without MUS. All patients had preoperative urodynamic testing (UDS). Patients who demonstrated stress UI on UDS underwent MUS at the time of RASC. Urinary symptoms and QOL were assessed through the validated Urinary Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7) patient questionnaires.

RESULTS

Sixty-eight patients met inclusion criteria, 46 patients completed follow-up questionnaires, and were included in the final analysis. Average length of time to follow-up from surgery was 24 months (range: 6-36 months). A statistically significant difference in UDI-6 scores between the two groups (RASC vs. RASC + MUS) was observed. Median (25th and 75th percentiles) scores for UDI-6 were 22.92 (8.33 and 32.29, respectively) for the RASC group and 4.17 (0 and 13.54, respectively) for the RASC + MUS group (P = 0.0017). Median scores for IIQ-7 were 0 (0 and 29.73 for the 25th and 75th percentiles, respectively) for the RASC group and 0 (0 and 0, respectively) for the RASC + MUS group (P = 0.1691).

CONCLUSION

Patients who underwent RASC + MUS scored significantly lower on the UDI-6, indicating fewer urinary distress symptoms. Although not statistically significant, patients in the RASC + MUS group had lower IIQ-7 scores, indicating less negative impact on QOL, compared to the RASC-only group.

Two-Year Results of Burch Compared With Midurethral Sling With Sacrocolpopexy: A Randomized Controlled Trial

OBJECTIVE

To evaluate 1- and 2-year urinary continence rates after Burch retropubic urethropexy compared with a retropubic midurethral sling for women with urinary incontinence undergoing sacrocolpopexy.

METHODS

We conducted a planned secondary analysis of a multicenter, randomized, single-blind trial comparing Burch with a sling that enrolled participants from June 2009 to August 2013. Objective outcome measures of continence were assessed at 1- and 2-year follow-up through office visits and validated questionnaires. Overall continence was defined as a negative stress test, no retreatment for stress incontinence, and no self-reported urinary incontinence (International Consultation on Incontinence Questionnaire, Short Form, score, 0). Stress-specific continence was defined as fulfillment of the first two criteria and no self-reported stress-related incontinence. Primary outcomes were assessed with intention-to-treat and within-protocol analyses. Comparisons between groups were evaluated using χ or Fisher exact test.

RESULTS

The two groups were similar in all measured baseline features. Outcome assessments at 2 years were available for 48 of 57 patients (84%) in the sling group and 45 of 56 patients (80%) in the Burch group. With intention-to-treat analysis, the sling group had significantly higher rates of overall continence than the Burch group (49% [28/57] vs 29% [16/56]; 95% CI for absolute risk difference 3.0-38.1; P=.03) at 1- but not 2-year follow-up (47% [27/57] vs 32% [18/56]; 95% CI for absolute risk difference -2.6 to 33.1; P=.10). The sling group had significantly higher rates of stress-specific continence than the Burch group at 1-year (70% [40/57] vs 46% [26/56]; 95% CI for absolute risk difference 6.1-41.4; P=.01) and 2-year (70% [40/57] vs 45% [25/56]; 95% CI for absolute risk difference 7.9-43.2; P=.006) follow-up. No difference was detected in prolapse recurrence, voiding dysfunction, antimuscarinic medication use, urgency incontinence, or patient satisfaction.

CONCLUSION

Among women with baseline urinary incontinence undergoing sacrocolpopexy, the retropubic midurethral sling resulted in higher stress-specific continence rates than Burch retropubic urethropexy at 1- and 2-year follow-up.