Effectiveness of midurethral slings in intrinsic sphincteric-related stress urinary incontinence

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Progress in studies on pathological changes and future treatment strategies of obesity-associated female stress urinary incontinence: a narrative review

With the increasing prevalence of obesity worldwide, obesity-related female stress urinary incontinence (FSUI) has become a key health problem. Recent studies indicated that FSUI is primarily caused by obesity-related pathological changes, such as fat droplet deposition, and results in pelvic floor nerve, vascular, and urethral striated muscle injury. Meanwhile, treatments for obesity-associated FSUI (OA-FSUI) have garnered much attention. Although existing OA-FSUI management strategies, including weight loss, pelvic floor muscle exercise, and urethral sling operation, could play a role in symptomatic relief; they cannot reverse the pathological changes in OA-FSUI. The continued exploration of safe and reliable treatments has led to regenerative therapy becoming a particularly promising area of researches. Specifically, micro-energy, such as low-intensity pulsed ultrasound (LIPUS), low-intensity extracorporeal shock wave therapy (Li-ESWT), and pulsed electromagnetic field (PEMF), have been shown to restore the underlying pathological changes of OA-FSUI, which might be related by regulation endogenous stem cells (ESCs) to restore urine control function ultimately in animal experiments. Therefore, ESCs may be a target for repairing pathological changes of OA-FSUI. The aim of this review was to summarize the OA-FSUI-related pathogenesis, current treatments, and to discuss potential therapeutic options. In particular, this review is focused on the effects and related mechanisms of micro-energy therapy for OA-FSUI to provide a reference for future basically and clinical researches.

Old wine into new wineskins: an update for female stress urinary incontinence

PURPOSE OF REVIEW

To review minimally invasive modifications of traditional surgeries for female stress urinary incontinence (SUI) in light of increased demand.

RECENT FINDINGS

Prior to the synthetic mid-urethral sling (MUS), traditional procedures were used to correct SUI. Often these were retropubic colposuspension procedures for a hypermobile urethra and fascial slings for sphincter deficiency but fell out of favor because of increased morbidity compared with synthetic MUS. As controversy rages over use of mesh in female pelvic reconstructive surgery, more women desire nonmesh alternatives. Traditional approaches have been modified to enable colposuspensions and fascial slings to be performed minimally invasively without minimizing efficacy.

SUMMARY

Minimally invasive modifications to traditional procedures for SUI have been available for about a decade but interest has been recently reignited in the setting of patient concern over mesh.

The Role of Pelvic Floor Muscle Training in the Conservative and Surgical Management of Female Stress Urinary Incontinence: Does the Strength of the Pelvic Floor Muscles Matter?

The purpose of this review is to provide an in-depth overview of the role of pelvic floor muscle (PFM) training in the management of stress urinary incontinence (SUI). The definition, epidemiology, and pathogenesis of SUI are described. We review the anatomy of the PFM and the importance of PFM strength in maintaining urinary continence and establishing normal voiding function. A brief description of the surgical options currently available for SUI and the existing data regarding the role of perioperative PFM training for SUI are included. Critical research questions to better evaluate and assess PFM training during the perioperative period are proposed. Promising novel approaches in the treatment of SUI are also presented. This review is useful for physiatrists, urogynecologists, female urologists, and nurse practitioners who specialize in the management and treatment of women with SUI. LEVEL OF EVIDENCE: IV.

Predictive value of clinical history compared with urodynamic study in 1,179 women

OBJECTIVE

to determine the positive predictive value of clinical history in comparison with urodynamic study for the diagnosis of urinary incontinence.

METHODS

retrospective analysis comparing clinical history and urodynamic evaluation of 1,179 women with urinary incontinence. The urodynamic study was considered the gold standard, whereas the clinical history was the new test to be assessed. This was established after analyzing each method as the gold standard through the difference between their positive predictive values.

RESULTS

the positive predictive values of clinical history compared with urodynamic study for diagnosis of stress urinary incontinence, overactive bladder and mixed urinary incontinence were, respectively, 37% (95% CI 31-44), 40% (95% CI 33-47) and 16% (95% CI 14-19).

CONCLUSION

we concluded that the positive predictive value of clinical history was low compared with urodynamic study for urinary incontinence diagnosis. The positive predictive value was low even among women with pure stress urinary incontinence.

Minimum 1-year results of mesh spiral-sling procedure in managing refractory and primary disabling stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We present our minimum 1-year results with a mesh spiral-sling procedure (MSSP) for managing refractory and disabling stress urinary incontinence (SUI) in women.

METHODS

Thirty-four women were treated with MSSP between 2007 and 2011. Six had incomplete data and were excluded from analysis. Study cohort comprised 21 women with refractory (mean number of previous surgeries 2.2; range 1-6) and seen with primary disabling SUI. All patients had marked intrinsic sphincter deficiency (ISD) with a Valsalva leak-point pressure (VLPP) <60 cm H2O. Preoperative workup included assessing the impact of voiding symptoms using the International Consultation on Incontinence Questionnaire--Short Form (ICIQ-SF), estimating the daily number of pads, and urodynamic studies. Preoperative and postoperative findings were compared using the Wilcoxon signed-rank test.

RESULTS

Intraoperative unilateral bladder-neck perforation occurred in two women during dorsal urethrolysis. With a mean follow-up of 26 months (range 12-48), SUI was cured in 71.4% of patients. Distal urethral reconstruction with vaginal mucosal flaps was performed in two patients with short urethral length (<2.5 cm) due to recurrence of SUI 10 months after MSSP. Mean ICIQ-SF score decreased from 19.4 ± 3.6 preoperatively to 7.3 ± 2.8 postoperatively (p = 0.001). Mean daily pad number decreased from 5.2 preoperatively to 1.2 postoperatively (p = 0.02). Urethral or vaginal erosion was not observed in any case during follow-up.

CONCLUSION

Using spiral slings may be a viable option in managing refractory and disabling SUI.

Positioning of a suburethral sling at the bladder neck is associated with a higher recurrence rate of stress urinary incontinence

OBJECTIVES

The purpose of this study was to investigate the relationship between the suburethral sling position and the outcome of anti-incontinence surgery.

METHODS

From 1998 to 2010, the medical records of 153 consecutive women with stress urinary incontinence undergoing the pubovaginal sling procedure were retrospectively reviewed. All patients received preoperative and postoperative transrectal sonography of the bladder and urethra, and the suburethral sling position was used to compare the postoperative continence status and lower urinary tract symptoms.

RESULTS

The mean patient age ± SD was 60.7 ± 10.6 years (range, 34-85 years), and the mean follow-up was 66.3 ± 42.1 months (range, 6-149 months). The slings were located at the bladder neck in 18 patients (11.8%), proximal urethra in 81 (52.9%), middle urethra in 45 (29.4%), and distal urethra in 9 (5.9%). The overall rate of recurrent stress urinary incontinence was 24.2% (37 patients). Among the 153 patients, there was a significantly higher stress urinary incontinence recurrence rate in the bladder neck group (bladder neck, 50.0%; proximal urethra, 18.5%; middle urethra, 22.2%; and distal urethra, 33.3%; P = .037). De novo urge and voiding symptoms occurred in 19.0% and 20.3% of overall patients, respectively. There was no significant difference in either de novo urge or voiding symptoms among groups.

CONCLUSIONS

Positioning of the suburethral sling at the bladder neck appears to be associated with a higher stress urinary incontinence recurrence rate. Patients with slings located at the proximal and middle urethra had the best postsurgical continence rates. The suburethral sling position had no direct association with de novo urge or voiding symptoms.

Single-incision sling system as primary treatment of female stress urinary incontinence: prospective 12 months data from a single institution

OBJECTIVE

To investigate the success and complication rates for Mini-Arc(TM) single incision sling in the treatment of female stress urinary incontinence (SUI).

MATERIALS AND METHODS

A total of 119 female patients with pure SUI were enrolled in a prospective study. From these, 105 were available with a minimum follow-up of 6 months and a mean follow-up of 12 months. Success, as determined by patient- reported outcomes, and complication rates, as well as impact of learning curve, body mass index (BMI), intrinsic sphincter deficiency (ISD), incontinence severity and age were investigated.

RESULTS

Cure rate was 80% and improvement rate was 11%. Pain intensity was minimal on a visual analogue scale and transient urinary retention occurred in three patients, one requiring sling section. De novo urgency was reported by 6% of women. Severe incontinence was less likely to be cured: 70% if >5 pads per day (ppd); 94% if <2 ppd; 94% if 2-4 ppd, P < 0.05). There was no difference in success rates between the first 50 and the last 50 patients. BMI, ISD and age also did not influence success rate.

CONCLUSION

Mini-Arc™ attained high success rates at 1 year follow-up. The procedure was easy to learn and was associated with very low and mild morbidity. Severe incontinence was identified as a risk factor for failure.

Retropubic versus transobturator midurethral synthetic slings: does one sling fit all?

The purpose of this article is to evaluate the recent evidence base for the choice between transobturator and retropubic approaches to midurethral slings used to treat stress urinary incontinence. While the retropubic and transobturator approaches to midurethral sling surgery for stress urinary incontinence demonstrate equivalent efficacy across a number of randomized controlled trials, they do not appear to be equivalent when particular patient populations are considered separately. The retropubic approach appears to be a better option in patients with intrinsic sphincter deficiency and limited urethral mobility.