Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials

Efficacy of the Sub-Urethral Transobturator KIM System® for Female Urinary Incontinence: Long Term Results

Background/Objectives: Female stress urinary incontinence (SUI) surgical treatment has changed since its beginning. Selecting materials that promote constructive tissue remodelling helps to maintain continence after surgery and minimizes complications. To analyze the long-term urinary continence results in women who underwent SUI surgical correction using the transobturator mid-urethral sling KIM system® (Knotless Incontinence Mesh) and analyze the complications associated with this SUI treatment. Materials and Methods: Prospective study of the first 1000 patients undergoing SUI surgery with the Contasure KIM® sling between April 2007 and December 2018. Results and complications were recorded. Group A represented 94.2% of the sample and were the continent patients after surgery (GA = 942), while Group B accounted for incontinent patients after surgery (5.8%) (GB = 58). Results: The mean age at operation was 60 years. Eutocic deliveries (p = 0.0022), high blood pressure (p = 0.0190), anxiety (p = 0.0084), hemorrhoidectomies (p = 0.0016) and hysterectomies (p = 0.0002) were higher in GB. No differences between groups were found regarding body mass index (GA 26.50; GB 26.93) (p = 0.220649), food or drug allergies (p = 0.0.6547), dystocia (p = 0.2365), diabetes mellitus (p = 0.1715), pelvic surgery (p = 0.8842), other surgery (p = 0.8801) or concomitant treatments that would have an impact on bladder function. Correction of SUI was achieved in 94.2% of cases. Continence persisted over time in 97.98% of continent patients at 4-year follow-up and 90.90% of patients at last follow-up. Mesh caused erosion of the urethra in 0.3% of patients and extruded to the vagina in 0.42%. De novo urinary urgency (2.8%), significant chronic pain (3.6%) and urinary tract infections (3.0%) after surgery were lower than complications reported in reviewed publications. Pain was treated with medication, and all patients were pain-free at the one-year follow-up visit. Conclusions: The mid-urethral transobturator sling KIM system® has good initial and long-term results in patients with stress urinary incontinence, with a low recurrence rate and minimal complications.

The Potential of Non-ablative Erbium (YAG) Laser Treatment for Complications After Midurethral Sling Surgery: A Narrative Review

Midurethral sling (MUS) surgery, using tension-free vaginal tape and transobturator tape, has been widely adopted for the treatment of stress urinary incontinence (SUI). However, postoperative complications, including persistent urinary incontinence, mesh exposure, and pain, have become problematic, and surgical treatments for these complications face challenges, such as invasiveness, treatment-resistant cases, and recurrence. This review provides an overview of the current evidence regarding these complications and the potential of vaginal non-ablative erbium (YAG) laser (VEL) treatment as a minimally invasive option with low risk of complications. Studies have suggested the effectiveness of VEL treatment, performed using devices such as IncontiLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), for persistent urinary incontinence after MUS surgery, pain following mesh removal, and asymptomatic mesh exposure. VEL treatment is expected to be a new treatment option for complications following MUS surgery; however, further large-scale comparative trials are required to verify its efficacy and safety and to establish criteria for its indications. Appropriate assessment of the indications and provision of sufficient information to patients is important when presenting VEL as a treatment option.

Effect of anterior repair on sexual function in heterosexual couples

INTRODUCTION AND HYPOTHESIS

Little is known about the impact of native tissue repair techniques on heterosexual intercourse. This study was aimed at investigating the effect of anterior colporrhaphy on women's and their partners' sexual function.

METHODS

Sexually active women with a male partner who were diagnosed with anterior wall prolapse without any incontinence were prospectively recruited from a single academic center. Demographic data were collected and a Pelvic Organ Prolapse Quantification examination was performed. Before and 3 months post-operatively, women completed two validated questionnaires to assess sexual function, the International Consultation on Incontinence Questionnaire Vaginal Symptoms short form (ICIQ-VS SF) 55, and the Female Sexual Function Index (FSFI), and their male partners completed the International Index of Erectile function-5. Pre- and post-operative results were compared using a paired t test.

RESULTS

This study was conducted in the gynecology department of a university hospital between May 2022 and June 2023, where 50 heterosexual couples were enrolled and underwent isolated anterior repair. The mean age of women and their partners were 44.3 ± 5.12 and 48.1 ± 5.81 respectively. Overall, female sexual function improved significantly from pre- to 3 months postoperatively with a decrease in ICIQ-VS SF scores from 13.3 ± 3.27 to 1.7 ± 1.1 (p < 0.05) and an increase in FSFI scores from 21.74 ± 9.37 to 29.28 ± 9.97 (p < 0.05). The only domain that did not improve was sexual pain. For their male partners, there was a similar significant improvement in sexual function with an increase in scores from 48.71 ± 8.71 to 60.68 ± 8.63 (p < 0.05).

CONCLUSIONS

Isolated anterior repair was associated with improved short-term sexual function amongst heterosexual couples.

Long-term results of a prospective randomized trial comparing tension-free vaginal tape versus transobturator tape in stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

This study was aimed at investigating the long-term effectiveness of minimally invasive mid-urethral sling (MUS) surgery and at comparing the outcomes between retropubic (tension-free vaginal tape, TVT) and transobturator tape (TOT) methods in the treatment of stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) with a predominant stress component in a long-term follow-up of a randomized controlled trial.

METHODS

This work is a long-term follow-up study of a previous prospective randomized trial conducted in the Department of Obstetrics and Gynecology at Oulu University Hospital between January 2004 and November 2006. The original 100 patients were randomized into the TVT (n=50) or TOT (n=50) group. The median follow-up time was 16 years, and the subjective outcomes were evaluated using internationally standardized and validated questionnaires.

RESULTS

Long-term follow-up data were obtained from 34 TVT patients and 38 TOT patients. At 16 years after MUS surgery, the UISS significantly decreased from a preoperative score in the TVT (11.88 vs 5.00, p<0.001) and TOT (11.05 vs 4.95, p<0.001) groups, showing a good long-term success of the MUS surgery in both groups. In comparing the TVT and TOT procedures, the subjective cure rates did not differ significantly between the study groups in long-term follow-up according to validated questionnaires.

CONCLUSION

Midurethral sling surgery had good long-term outcomes in the treatment of SUI and MUI with a predominant stress component. The subjective outcomes of the TVT and TOT procedures were similar after a 16-year follow-up.

Single-incision mini-slings versus standard synthetic mid-urethral slings for surgical treatment of stress urinary incontinence in women: The SIMS RCT

BACKGROUND

Stress urinary incontinence is the most common type of urinary incontinence in premenopausal women. Until recently, synthetic mid-urethral slings (mesh/tape) were the standard surgical treatment, if conservative management failed. Adjustable anchored single-incision mini-slings are newer, use less mesh and may reduce perioperative morbidity, but it is unclear how their success rates and safety compare with those of standard tension-free mid-urethral slings.

OBJECTIVE

The objective was to compare tension-free standard mid-urethral slings with adjustable anchored single-incision mini-slings among women with stress urinary incontinence requiring surgical intervention, in terms of patient-reported effectiveness, health-related quality of life, safety and cost-effectiveness.

DESIGN

This was a pragmatic non-inferiority randomised controlled trial. Allocation was by remote web-based randomisation (1 : 1 ratio).

SETTING

The trial was set in 21 UK hospitals.

PARTICIPANTS

Participants were women aged ≥ 18 years with predominant stress urinary incontinence, undergoing a mid-urethral sling procedure.

INTERVENTIONS

Single-incision mini-slings, compared with standard mid-urethral slings.

MAIN OUTCOME MEASURES

The primary outcome was patient-reported success rates on the Patient Global Impression of Improvement scale at 15 months post randomisation (≈ 1 year post surgery), with success defined as outcomes of 'very much improved' or 'much improved'. The primary economic outcome was incremental cost per quality-adjusted life-year gained. Secondary outcomes were adverse events, impact on other urinary symptoms, quality of life and sexual function.

RESULTS

A total of 600 participants were randomised. At 15 months post randomisation, adjustable anchored single-incision mini-slings were non-inferior to tension-free standard mid-urethral slings at the 10% margin for the primary outcome [single-incision mini-sling 79% (212/268) vs. standard mid-urethral sling 76% (189/250), risk difference 4.6, 95% confidence interval -2.7 to 11.8; p non-inferiority < 0.001]. Similarly, at 3 years' follow-up, patient-reported success rates in the single-incision mini-sling group were non-inferior to those of the standard mid-urethral sling group at the 10% margin [single-incision mini-sling 72% (177/246) vs. standard mid-urethral sling 67% (157/235), risk difference 5.7, 95% confidence interval -1.3 to 12.8; p non-inferiority < 0.001]. Tape/mesh exposure rates were higher for single-incision mini-sling participants, with 3.3% (9/276) [compared with 1.9% (5/261) in the standard mid-urethral sling group] reporting tape exposure over the 3 years of follow-up. The rate of groin/thigh pain was slightly higher in the single-incision mini-sling group at 15 months [single-incision mini-sling 15% (41/276) vs. standard mid-urethral sling 12% (31/261), risk difference 3.0%, 95% confidence interval -1.1% to 7.1%]; however, by 3 years, the rate of pain was slightly higher among the standard mid-urethral sling participants [single-incision mini-sling 14% (39/276) vs. standard mid-urethral sling 15% (39/261), risk difference -0.8, 95% confidence interval -4.1 to 2.5]. At the 3-year follow-up, quality of life and sexual function outcomes were similar in both groups: for the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life, the mean difference in scores was -1.1 (95% confidence interval -3.1 to 0.8; p = 0.24), and for the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised, it was 0 (95% confidence interval -0.1, 0.1; p = 0.92). However, more women in the single-incision mini-sling group reported dyspareunia [12% (17/145), compared with 4.8% (7/145) in the standard mid-urethral sling group, risk difference 7.0%, 95% confidence interval 1.9% to 12.1%]. The base-case economics results showed no difference in costs (-£6, 95% confidence interval -£228 to £208) or quality-adjusted life-years (0.005, 95% confidence interval -0.068 to 0.073) between the groups. There is a 56% probability that single-incision mini-slings will be considered cost-effective at the £20,000 willingness-to-pay threshold value for a quality-adjusted life-year.

LIMITATIONS

Follow-up data beyond 3 years post randomisation are not available to inform longer-term safety and cost-effectiveness.

CONCLUSIONS

Single-incision mini-slings were non-inferior to standard mid-urethral slings in patient-reported success rates at up to 3 years' follow-up.

FUTURE WORK

Success rates, adverse events, retreatment rates, symptoms, and quality-of-life scores at 10 years' follow-up will help inform long-term effectiveness.

TRIAL REGISTRATION

This trial was registered as ISRCTN93264234.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 47. See the NIHR Journals Library website for further project information.

A new titanium-covered transobturator tape for surgical treatment of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

To assess the long-term satisfaction, cure rate and safety of a new titanium-covered transobturator tape compared to polypropylene tape for the treatment of stress urinary incontinence (SUI).

METHODS

A prospective study was conducted with 151 patients. Seventy patients underwent transobturator sling surgery with titanium tape from 2011 to 2019, and a historical control group (CG) of 81 patients was treated with a noncoated tape and underwent incontinence surgery from 1999 to 2009. We compared patient-reported outcome measures (PROMs) with the incontinence outcome questionnaire (IOQ).

RESULTS

The median follow-up was 2½ years in both groups. Based on responses to the IOQ, a statistically significantly shorter time of recovery (IOQ 15: 21.3 ± 26.4 [TG], 40.2 ± 38.5 [CG], p = 0.02), improvement of sex life (IOQ 13: 34.1 ± 29.4 [TG] vs. 65.3 ± 35.6 [CG], p = 0.01) and less voiding dysfunction (IOQ 19: 30.9 ± 28.1 [CG], 9.3 ± 18.6 [TG], p = 0.01) were observed in the TG. Objectively, no postoperative urinary retention was observed in the TG, but four cases were described in the CG. Ten patients needed a reoperation for SUI in the CG compared to three in the TG (p = 0.03).

CONCLUSION

The titanium-covered transobturator sling had superior recovery time, improved sexual function and reduced reoperation rate compared to a historical polypropylene group.

Pelvic floor muscle training as an adjunct to a midurethral sling: a single-blind randomised controlled trial

INTRODUCTION AND HYPOTHESIS

This single-blind, randomised controlled trial was aimed at determining whether peri-operative physiotherapist-supervised pelvic floor muscle (PFM) training was superior to standard care (handout) in terms of improvements in stress urinary incontinence (SUI) symptoms, cure rate, and/or post-operative filling or voiding symptoms among women undergoing surgical mid-urethral sling (MUS) insertion for SUI.

METHODS

Women with SUI were recruited from surgical wait lists at four participating urogynecology clinics. Participants were assessed at baseline (V1) then randomised (1:1 allocation) to receive supervised PFM training or a handout. Immediately following the 12-week intervention period (V2) and at 12 weeks following surgery (V3) the groups were compared based on the Female Lower Urinary Tract Symptoms (FLUTS) questionnaire total score and urinary incontinence, filling, and voiding subscale scores as well as on a standardised 30-min pad test administered by a blinded assessor. Intention-to-treat analyses were performed.

RESULTS

A total of 52 participants were randomised to physiotherapy and 51 to the control group between December 2012 and August 2016. The groups were not different on any outcomes at V1 and all were improved at V3 compared with V1 (p < 0.001). At V3 the physiotherapy group reported significantly fewer UI symptoms (FLUTS UI subscale score) than the control group; yet, there were no group differences in FLUTS overall score or the pad test (p > 0.05). Based on a FLUTS UI subscale score <4, the cure rate at V3 was higher in the intervention group (73%) than in the control group (47%); (2.36 < OR < 3.47, p = 0.012). There were no group differences in cure rate at V3 based on a pad test (p = 0.27). No group differences were found in the filling or voiding symptoms at V3 (p > 0.05). No adverse events were reported.

CONCLUSION

Physiotherapist-supervised PFM training improves SUI cure rates associated with surgical MUS insertion when considering symptoms of SUI, but does not improve post-operative continence function as measured by a pad test, nor does it lead to fewer post-operative voiding or filling symptoms.

The new etiology and surgical therapy of stress urinary incontinence in women

OBJECTIVES

To determine the subjective and objective cure rate of a urethral stabilization procedure (USP) for stress urinary incontinence (SUI) in women; to describe this new surgical intervention; to record its potential complications; to establish the SUI etiology.

STUDY DESIGN

The author conducted a prospective case series study in ambulatory settings and under local anesthesia. Thirty-four consecutive women with uncomplicated SUI subjected to USP, which was performed by reconstructing site-specific defects within the urethral stabilizing mechanism (USM) and using no surgical slings, meshes or absorbable sutures. The paravaginal defect(s) was repaired by transvaginal approach. The endopelvic fascia was sharply separated from the ventral perineal membrane (VPM) just above the anterior urethral meatus. The vestibular bulbs sharply dissected from VPM and advance upwards. The VPM defect(s) reconstructed and vestibular bulbs placed back to the original location. The access to the peri- and the para-urethral region was created by making a lateral vertical incision, aside from the lateral urethral meatus and defects were repaired. The suburethral transverse incision was made beneath the urethral meatus and the stratum-by-stratum surgical dissection conducted until the lateral vaginourethral ligament is visualized bilaterally. The defect(s) within the vaginourethral ligaments was surgically reconstructed, and the vaginal wall repaired. The primary outcome measured subjective and objective cure rates, and the secondary outcome measured the occurrence of potential complications. The five-year postoperative follow-up was conducted.

RESULTS

Two out of thirty-four patients dropped-out from the study. The USP performed without difficulties, and no severe complication observed. One-subject developed superficial wound separation (3.1 %) and one-subject (3.1 %) developed urinary urge incontinence at the 5-postoperative-year. At 60-month follow-up subjective and objective cure rates were a 92 % and an 88 % respectively.

CONCLUSIONS

The urethral stabilization procedure yields a high degree of subjective and objective cure rates without severe complications and is a well-tolerated operation by women. The urethral stabilization procedure is a simple, easy to implement, and reproducible method for uncomplicated stress urinary incontinence in women. Site-specific defects within the urethral stabilizing mechanism constitute the etiology of the stress urinary incontinence in women.

Ambulatory MiniArc Precise Sling under Local Anesthesia for Stress Urinary Incontinence: Feasibility and Outcome

Aims:

The aim of the study is to assess the feasibility of ambulatory stress urinary incontinence (SUI) surgery using the MiniArc Precise single-incision urethral sling without increasing the number of complications.

Settings and Design:

This was a retrospective observational study of prospectively collected data carried out in a Tertiary Referral Hospital in Barcelona, Spain.

Materials and Methods:

Forty patients diagnosed with SUI or stress predominant mixed urinary incontinence (MUI) treated surgically between November 2011 and November 2013. The MiniArc Precise^® sling was inserted under local anesthesia in the ambulatory setting.

Statistical Analysis Used:

Descriptive statistics included frequencies and percentages for categorical variables and mean and range for quantitative variables. The statistical package used was SPSS version 17.0.

Results:

Urodynamic studies showed SUI in 78% of cases and stress predominant MUI in 17%. Clinical findings included SUI in 56% of cases and MUI in 44%, with positive stress tests in all participants. The mean intraoperative pain (1–10 Visual Analog Scale) was 2. All patients were satisfied with the use of local anesthesia in the outpatient setting. Perioperative complications did not occur. One case of urinary retention and two cases of urinary tract infection (UTI) developed within this 1^st month after operation and were successfully managed conservatively. Midterm complications included eight cases of UTI and four de novo urge incontinence.

Conclusions:

Placement of the MiniArc Precise sling under local anesthesia is a feasible and safe technique, which when carried out by an experienced surgeon allows to be done as an outpatient basis without increasing the rate of postprocedural complications.

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.

Long-term efficacy follow-up of tension-free vaginal tape obturator in patients with stress urinary incontinence with or without cystocele

OBJECTIVE

To assess the long-term outcomes of tension-free vaginal tape obturator (inside-out) (TVTO) with or without anterior colporrhaphy.

METHODS

The present prospective follow-up observational study included patients attending the 2nd Department of Obstetrics and Gynecology, Aretaieio Hospital, University of Athens, Greece, between April 3 and December 20, 2017, for follow-up care after treatment for urodynamic stress urinary incontinence (USUI) with or without cystocele. Patients without cystocele had been treated with TVTO only; those with cystocele underwent TVTO with anterior colporrhaphy. The primary outcome was the objective cure rate assessed by the cough stress test during filling cystometry.

RESULTS

Follow-up data were available for 70 patients who underwent TVTO only and 38 who underwent TVTO and anterior colporrhaphy. The mean follow-up period was 13 years. Objective cure was achieved for 57 (81%) patients in the TVTO-only group and 32 (84%) patients in the TVTO and anterior colporrhaphy group. Regarding cystocele management, objective cure was recorded for 35 (92%) patients.

CONCLUSION

At 13-year follow-up, anterior colporrhaphy demonstrated a cure rate of 92% in the management of cystocele, and 84% in the management of cystocele and USUI when combined with TVTO. TVTO alone for the management of USUI had an objective cure rate of 81%.

A comparison of the National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) guidelines for the assessment and management of urinary incontinence in women

Objective:

The objective of this paper is to identify the similarities and key differences between the National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) guidelines on the management of urinary incontinence (UI) in women.

Methods:

We reviewed the most recent iterations of both full guidelines to identify all key recommendations and their associated level/grade of evidence. Guidance on the management of urinary incontinence in men and neuropathic patients was excluded.

Results:

There is a significant overlap in the recommendations of both guidelines. Key differences include the indications for performing urodynamics, pharmacological agents in stress UI, the dose of botulinum toxin A (200 units by NICE, 100 units by EAU), the hierarchy of surgical options for primary stress UI and the role of the multi-disciplinary team (MDT).

Conclusion:

This review provides the various stakeholders involved in the management of female UI with a summary of the strength of evidence supporting the recommendations by these two key guidelines. We have provided an evidence-based framework to support clinical experience from which to base management decisions.

Urinary incontinence in women

Urinary incontinence symptoms are highly prevalent among women, have a substantial effect on health-related quality of life and are associated with considerable personal and societal expenditure. Two main types are described: stress urinary incontinence, in which urine leaks in association with physical exertion, and urgency urinary incontinence, in which urine leaks in association with a sudden compelling desire to void. Women who experience both symptoms are considered as having mixed urinary incontinence. Research has revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. A full diagnostic evaluation of urinary incontinence requires a medical history, physical examination, urinalysis, assessment of quality of life and, when initial treatments fail, invasive urodynamics. Interventions can include non-surgical options (such as lifestyle modifications, pelvic floor muscle training and drugs) and surgical options to support the urethra or increase bladder capacity. Future directions in research may increasingly target primary prevention through understanding of environmental and genetic risks for incontinence.

Structural differences and architectural features of two different polypropylene slings (TVT-O and I-STOP) have no impact on biocompatibility and tissue reactions

Introduction

To evaluate the impact of design features of the synthetic mid-urethral slings on tissue integrity and inflammatory responses.

Material and methods

In total 30 female Sprague-Dawley rats were implanted with type I monofilamentous, macroporous polypropylene meshes: Gynecare TVT-Obturator tape^® (Ethicon Inc., Johnson & Johnson, Somerville, NJ, USA) and I-STOP^® (CL Medical Inc., Lyon, France). All animal groups were sacrificed at set time intervals – 6 weeks, 3 months, 6 months, 9 months and 12 months – and the abdominal wall was harvested with mesh strips for histological evaluation.

Results

All mesh strips appeared to be well incorporated into the abdominal wall, and no signs of shrinkage was noticed. All specimens showed a thin/delicate, loose, fibrous interface between the synthetic graft plate and abdominal wall, along with mild inflammatory reactions from 6 weeks to 12 months.

Conclusions

Both mesh brands induced comparable, minimal foreign body reactions and integrated well into the host tissues despite differences in architectural features. TVT-O^® and I-STOP^® evoked similar low-grade inflammatory responses up to 12 months in this animal model.

Structural differences and architectural features of polypropylene slings used in this study have had no impact on tissue integrity and inflammatory responses.

Surgery for recurrent stress urinary incontinence: the views of surgeons and women

Introduction and hypothesis

The objectives were to explore the views of women with recurrent stress incontinence (SUI) with regard to treatment preferences and the acceptability of randomisation to a future trial, and to survey the views of UK specialists on treatment preferences and equipoise regarding different treatment alternatives.

Methods

An online survey of the British Society of Urogynaecology (BSUG) and British Society of Urological Surgeons (BAUS) was carried out. Qualitative semi-structured interviews with a purposive sample of surgeons and women suffering from recurrent SUI from three UK centres.

Results

Two hundred fifty-six survey replies were received (176 gynaecology; 80 urology). Comparing the treatments offered, urogynaecologists were more likely to offer pelvic floor exercises (p < 0.05), and repeat midurethral tape (MUT) (p < 0.001). From the Surgical Equipoise Scale (SES) responses, “no preference” was rarely the commonest response. Marked differences for several options existed; midurethral tape dominated responses whenever it appeared. Twenty-one clinicians were interviewed. Treatment preferences were complex, influenced by a range of factors (reason for failure, patient comorbidity, investigations, personal experience, training). A future trial was regarded as important. Eleven women were interviewed. Most had considered more than one option, but felt that decision-making was more a process of elimination rather than a positive process. Randomisation to a study was regarded as unacceptable by most.

Conclusions

No consensus exists among surgeons about preferred treatment options for recurrent SUI, and personal experience and training dominate decision-making. For patients, choices were usually based on an elimination of options, including that of a repeat failed procedure. This contrasts with surgeons, who mostly preferred a repeat MUT above other options. Any future comparative study will be challenging.

Simultaneous self-created transobturator tape and laparoscopic extraperitoneal vaginal support in patients with stress urinary incontinence and prolapse of the anterior and apical vaginal compartments

OBJECTIVE

Stress urinary incontinence (SUI) is frequently associated with prolapse of the apical and anterior vaginal compartments. The standard treatment of SUI is transobturator tape (TOT). The usual treatment of prolapse (anterior colporrhaphy) has a high recurrence rate. The aim of this study is to evaluate the results of the treatment of SUI and concomitant anterior and apical prolapse with self-created transobturator tape and simultaneous laparoscopic anterior and apical support.

STUDY DESIGN

A total of 36 patients with SUI and prolapse of the anterior and apical compartments were underwent operations. The mean follow-up was 18 months. Self-created transobturator tape and laparoscopical support of the anterior and apical compartment prolapse were performed in all patients. The most important symptoms of prolapse and incontinence, the anatomical outcome, and complications were evaluated before and after the surgery.

RESULTS

Treatment of incontinence and anterior and apical prolapse was successful in 33/36 (91.7%), 30/36 (83.3%) and 31/36 (86.1%) patients, respectively (p<0.0001). There is a significant reduction of vaginal bulging and pelvic pressure (p<0.0001). Frequency and urgency were significantly reduced (p<0.0007 and p<0.03 respectively). There was no significant deterioration of the posterior compartment. The most important complications were bladder perforation in 2/36 (5.5%) patients and temporary urinary retention in 3/36 (8.3%) patients (Clavien-Dindo grade 3).

CONCLUSION

Simultaneous laparoscopic anterior and lateral extraperitoneal support and transobturator tape are effective in the treatment of patients with both conditions.

Ultrasound Evaluation of Midurethral Sling Position and Correlation to Physical Examination and Patient Symptoms

OBJECTIVE

The primary objective was to evaluate the position and angle variation between 3 different midurethral slings (MUSs) using 3-dimensional ultrasound (US) technology. The secondary objective was to compare differences in findings on physical examination and symptoms of incontinence and sexual dysfunction between subjects.

METHODS

This was a cross-sectional study of 61 subjects who had undergone MUS placement without concomitant anterior or apical compartment prolapse surgery (21 retropubic [RP], 19 out-to-in transobturator [TOT], 21 in-to-out transobturator [TVT-O]). Subjects completed validated questionnaires (Sandvik Incontinence Severity Index, Urogenital Distress Inventory 6) and underwent a pelvic examination and standardized 2-dimensional and 3-dimensional ultrasonography evaluation.

RESULTS

On translabial US, the median RP sling angle was 108.2 degrees (72.6-135.9), significantly more acute than the angle of TOT and TVT-O slings (119.3 degrees [72.3-140.4, P = 0.02] and 118.5 degrees [99.0-154.7, P = 0.004]). There was no difference in the sling angles between the TOT and TVT-O slings (P = 0.86). No difference was noted in the position of the sling along the urethra (P = 0.82). The TOT sling was more often palpable (57.8%, P = 0.02) compared with the RP or TVT-O groups.Fifteen patients (4 RP, 5 TOT, 6 TVT-O) reported discomfort during intercourse that they attributed to the MUS. Three of 19 TOT subjects reported that their partner experienced pain with intercourse because of the sling. However, sexual function and urinary symptoms were not statistically different between the 3 groups.

CONCLUSIONS

On 3-dimensional US, RP sling angle was found to be significantly more acute than the angles of the TOT and TVT-O slings, and there was no difference between the 2 transobturator slings. The TOT sling was more often palpable on examination, but this finding did not correlate with increased pain on palpation.

Five-year follow-up study of Monarc transobturator tape for surgical treatment of primary stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We hypothesized that transobturator tape (TOT) is safe and efficacious for the treatment of urodynamic stress incontinence in the long term.

METHODS

We conducted a prospective study of patients with confirmed urodynamic stress incontinence (USI) who underwent a Monarc^TM TOT procedure in a tertiary center between February 2006 and March 2009 without other concurrent surgical procedures. Urodynamics were conducted at 1 and 3 years postoperatively. Subjective evaluation included Incontinence Impact Questionnaire (IIQ-7), Urinary Distress Inventory Questionnaire (UDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Objective cure was defined as no urinary leakage demonstrable on provocative filling cystometry and/ or 1-h pad test of <2 g. Subjective cure was based on a negative response to question 3 in UDI-6. Paired-samples t test, chi-square, and Fisher exact tests were applied; p < 0.05 was considered significant. The log-rank tests were used to compare event-free survival.

RESULTS

Sixty patients were enrolled, and 56 were evaluated at 5 years postoperatively. The majority were middle aged, postmenopausal, and overweight. Mean operating time was 31.1 ± 8.9 min, intraoperative complications were minor, and median period of follow-up was 80.3 ± 9.6 months. At 5 years of follow-up, objective and subjective cure rates were 89.3 % and 87.5 %, respectively. No mesh-related complications were seen. One patient needed a repeat midurethral sling procedure, and one patient each had bladder and bowel cancer.

CONCLUSION

Monarc TOT was safe and retained its high cure rate in the short- and long-term treatment of stress urinary incontinence.

Use of surgeon-tailored polypropylene mesh as a needle-less single-incision sling for treating female stress urinary incontinence: Preliminary results

OBJECTIVE

To evaluate the safety and efficacy of a procedure using surgeon-tailored polypropylene mesh (STM) through a needle-less single-incision technique for treating stress urinary incontinence (SUI), aiming to decrease the cost of treatment, which is important in developing countries.

PATIENTS AND METHODS

In all, 43 women diagnosed using a cough stress test were treated from January 2011 to June 2013 at the Urology and Gynaecology Departments (dual-centre), Cairo University Hospitals. Previous surgery was not a contra-indication. Patients with a postvoid residual urine volume of >100 mL, a bladder capacity of <300 mL, impaired compliance or neurological lesions were excluded. The Stress and Urge incontinence Quality of life Questionnaire (SUIQQ) and urodynamic variables were compared before and after surgery. The variables were compared between the baseline and postoperative follow-up values using a paired t-test, a Wilcoxon signed-rank test or McNemar's test.

RESULTS

The mean age was 42.7 years and 20 (47%) patients had associated urgency UI (UUI), whilst 21 (49%) had intrinsic sphincter deficiency. The median (range) operative duration was 14 (5-35) min. There were no complications during surgery. The mean (SD, range) follow-up was 28.1 (5.1, 18-36) months. Postoperative complications were vaginal discharge (5%), failure of wound healing (5%), dyspareunia (5%) and UTI (5%). The sling was removed in one case. SUI, UUI and quality-of-life indices improved significantly after surgery. There were no significant differences in pressure-flow studies before and after surgery. In all, 38 (88%) patients were cured, four (9%) improved and in one only the treatment failed (2%).

CONCLUSION

This technique is simple, safe, effective, reproducible and economical for treating SUI. The STM was easy to insert in a short operation.

Surgeon-tailored polypropylene mesh as a needleless single-incision sling versus TVT-O for the treatment of female stress urinary incontinence: a comparative study

PURPOSE

To compare safety and efficacy of surgeon-tailored polypropylene mesh through needleless single-incision technique (STM) versus tension-free vaginal tape-obturator (TVT-O) aiming to decrease cost of treatment of stress urinary incontinence (SUI). This is important in developing countries due to limited healthcare resources.

PATIENTS AND METHODS

A retrospective cohort study was done at Urology and Gynecology Departments (dual-center), Cairo University, from January 2011 to August 2013. STM was inserted in 72 females, while TVT-O was inserted in 48 females. Females evaluated by cough stress test, stress and urge incontinence quality of life questionnaire (SUIQQ), Q max and abdominal leak point pressure (ALPP) were included. Different factors were compared between both groups using paired t, Wilcoxon's signed rank, McNemar, Chi-square, Fisher's exact, independent t or Mann-Whitney tests.

RESULTS

Age, parity, previous surgeries, ALPP, intrinsic sphincter deficiency (ISD), associated prolapse and associated prolapse repair were comparable in both groups. No significant difference was found between both groups in postoperative complications (except groin pain), cure, SUIQQ indices improvement and Q max decline. In total, 65 (90 %) cured, 6 (8 %) improved while failure was detected in one (1 %) patient in STM group, while 42 (87 %) cured, 4 (8 %) improved and failure was detected in two (4 %) patients in TVT-O group. Presence of ISD (p = 0.565), urgency (p = 0.496), UUI (p = 0.531), previous surgeries (p = 0.345), associated urogenital prolapse (p = 0.218) or associated prolapse repair (p = 0.592) did not lead to any significant difference in outcome between both groups. Cost of mesh decreased from US$500 (TVT-O) to US$10 (STM).

CONCLUSION

Outcome of STM is comparable to TVT-O. Furthermore, STM is more economic.

Diagnosis and surgical treatment of stress urinary incontinence

Stress urinary incontinence (SUI) is a major problem affecting more than 20% of the nation's female population, with increasing prevalence as our population continues to age. Incontinence places a great burden on individuals, and the economic effect is large. Stress urinary incontinence occurs when there is involuntary leakage of urine during coughing, laughing, sneezing, or physical activity. It can be diagnosed during physical examination and by using low-cost office diagnostics. Although nonsurgical treatments provide some benefit, surgical interventions have demonstrated superiority with respect to subjective and objective cure and better long-term improvement. Corrective surgeries for SUI can be grouped into four categories: 1) slings (midurethral slings and slings placed at the ureterovesical junction), 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters. The success and failure of each approach needs to be assessed in the context of individual patients and their circumstances. Slings and retropubic urethropexy are considered first-line surgical options. Since the advent of minimally invasive retropubic midurethral slings such as the tension-free vaginal tape, transobturator tension-free vaginal tape, and single-incision sling, retropubic urethropexy have fallen out of favor. Warnings about mesh use may contribute to a resurgence of retropubic urethropexy procedures such as the Burch procedure. A Burch procedure should still be considered for patients who have an aversion to mesh or if they are undergoing concurrent abdominal approach surgery. Urethral bulking agents are usually reserved for patients with a fixed, nonmobile urethra who cannot tolerate an operative experience or have failed previous antiincontinence procedures. Artificial sphincters should be considered an operation of last resort.

The influence of the modifiable life-style factors body mass index and smoking on the outcome of mid-urethral sling procedures for female urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this observational study was to investigate the influence of body mass index (BMI) smoking and age on the cure rate, rate of complications and patient satisfaction with mid-urethral sling (MUS) procedures.

METHODS

Pre-, peri- and postoperative (8 weeks and 1 year) data were retrieved from the Swedish National Register for Gynecological Surgery of MUS procedures (retropubic procedures, n = 4,539; transobturator procedures, n =1,769) performed between January 2006 and December 2011. Multiple logistic regression analyses were performed between the outcome variables and BMI and smoking, presented as adjusted odds ratios (adjOR) with 95 % confidence interval (CI).

RESULTS

Subjective 1-year cure rate was 87.4 % for all MUS procedures (88.3 % with the retropubic technique and 85.2 % with the transobturator technique (p = 0.002). Preoperative daily urinary leakage and urgency were more common with increasing BMI, but surgery reduced symptoms in all BMI groups. Lower cure rate was seen in women with a BMI >30 (0.49; CI 0.33-0.73), in diabetics (0.50; CI 0.35-0.74) and women aged > 80 years (0.18; CI 0.06-0.51). Perioperative complications were more common in the retropubic group (4.7 % vs 2.3 % in the transobturator group, p=0.001) and in women with BMI < 25. Smoking did not influence any of the outcome variables.

CONCLUSIONS

The overall 1-year cure rate for MUS procedures was 87 %, but was negatively influenced by BMI >30, diabetes and age > 80 years. Perioperative complications were more common with the retropubic procedure than with the transobturator technique, and in women with a BMI < 25. Smoking did not impact on any of the studied outcome variables.

Twelve-month outcomes following midurethral sling procedures for stress incontinence: impact of obesity

OBJECTIVE

To evaluate impact of body mass index (BMI) ≥30 on objective and subjective cure rates 12 months after midurethral sling surgery.

DESIGN

Secondary analysis.

SETTING

Three hospitals in Calgary, Canada, 2005-07.

POPULATION

A total of 182 women enrolled in a randomised control trial of tension-free vaginal tape versus transobturator tape.

METHODS

Women were classified as obese or nonobese from height and weight on day of surgery. Women underwent postoperative standardised pad tests, self-reporting of urinary incontinence, and quality of life scores. Categorical data compared with chi-square or Fisher's exact, continuous data compared with Mann-Whitney U test.

MAIN OUTCOME MEASURES

Primary outcome was objective cure, defined as <1 g urine loss on postoperative 1-hour pad test. Secondary outcomes were subjective cure of incontinence (no stress incontinence in previous 7 days), presence of urinary urgency in previous 7 days, Urogenital Distress Inventory (UDI-6) scores, Incontinence Impact Questionnaire (IIQ-7) scores, and surgical complication rates.

RESULTS

Objective cure differed, with 85.6% of nonobese women leaking <1 g on 1-hour pad test, versus 67.8% of obese women (P = 0.006, risk difference [RD] 17.8%, 95% confidence interval [95% CI] 4.2-31.4%). Subjective cure was 85.8% for nonobese women versus 70.7% for obese women (P = 0.016, RD 15.1%, 95% CI 1.9-28.4%). For both groups, improvement was seen for postoperative UDI-6 (median -33.3 [-44.4 to -22.2] and -27.2 [-44.4 to -16.7]) and IIQ-7 scores (median -26.2 [-45.2 to -14.3] and -23.8 [-42.9 to -14.3]). No differences existed in rates of operative complications between the two groups.

CONCLUSION

Twelve months after midurethral sling surgery, obese women experience lower rates of cure than those who are nonobese.

Female urinary incontinence: effective treatment strategies

Urinary incontinence is a dysfunction that tremendously affects women's quality of life, involving social, emotional and economic aspects. Although various treatments for urinary incontinence have been described, it is important to know which of them are truly effective. This review seeks to determine the current available therapies for women with stress urinary incontinence and overactive bladder syndrome, based on the best scientific evidence.

Effect of local infiltration analgesia on post-operative pain following TVT-O: a double-blind, placebo-controlled randomized study

PURPOSE

To evaluate the effect of a protocol of local anesthesia and epinephrine associated with sedo-analgesia on post-TVT-O pain in comparison with infiltration of saline and epinephrine.

METHODS

Forty-two patients undergoing TVT-O were randomized into two groups to receive periurethral infiltration with epinephrine only (group A, n = 21) or with epinephrine plus 1 % lidocaine hydrochloride (group B, n = 21). Post-operative pain was assessed using a visual analog scale (VAS) from 0 (absence of pain) to 10 (maximum pain possible), 1, 6, 12 and 24 h after the procedure. The total amount of analgesia was recorded and the proportion of women reporting a pain VAS score ≥4, 1 h after the procedure was calculated. ANOVA for repeated measures and Bonferroni correction, the Student's t test for independent samples, the Mann-Whitney U test, the Fisher exact test, or the χ (2) test for parametric was used.

RESULTS

Pain level was significantly lower in group B 1 (p = 0.01) and 6 h (p = 0.05) after surgery, but not 12 and 24 h after the procedure. No significant difference was observed in the proportion of women requesting analgesia and in the total dosage of analgesics between the two groups. A significant higher proportion of women in group A reported a pain VAS score higher than four 1 h after surgery in comparison with patients in group B.

CONCLUSIONS

This randomized study seems to indicate that systematic infiltration before TVT-O positioning with local anesthetic may reduce immediate post-operative pain.

Development of quality indicators for women with urinary incontinence

AIMS

To develop a means to measure the quality of care provided to women treated for urinary incontinence (UI) through the development of quality-of-care indicators (QIs).

METHODS

We performed an extensive literature review to develop a set of potential quality indicators for the management of UI. QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. Nine experts ranked the indicators on a nine-point scale for both validity and feasibility. We analyzed preliminary rankings of each indicator using the RAND Appropriateness Method. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which the indicators were rated a second time individually using the same nine-point scale.

RESULTS

QIs were developed that addressed screening, diagnosis, work-up, and both non-surgical and surgical management. Areas of controversy included whether routine screening for incontinence should be performed, whether urodynamics should be performed before non-surgical management is initiated, and whether cystoscopy should be part of the pre-operative work-up of uncomplicated stress incontinence. Following the expert panel discussion, 27 of 40 potential indicators were determined to be valid for UI with a median score of at least seven on a nine-point scale.

CONCLUSIONS

We identified 27 quality indicators for the care of women with UI. Once these QIs are pilot-tested for feasibility, they will be applied on a larger scale to measure the quality of care provided to women with UI in the United States.

Minimally invasive techniques for female stress urinary incontinence, how, why, when

AIM

The main purpose of this paper is to summarize the recent experience that has been obtained till now in the surgical treatment of urinary stress incontinence with less invasive techniques.

MATERIALS AND METHODS

We used current literature and papers published in MEDLINE and Cochrane library. The keywords used for this review were Stress urinary incontinence, Tension-free vaginal tape (TVT), Transobturator tape (TOT, TVT-O), and Single-incision mini-slings (SIMS).

RESULTS

Tension-free vaginal tape and the transobturator urethral suspension are the most commonly used surgical approach for women who suffer from stress urinary incontinence, with long-term success rates ranging from 84 to 95 %. TVT is shown to be as effective as the older colposuspension, associated with less post-operative complications, shorter hospital stay and shorter recovery period. Bladder perforations that have been mentioned with the TVT inserter apparently do not result in any clinically significant morbidity. Major vascular and bowel injuries have been reported at rates of 0.07 and 0.04 %, respectively. Studies between TVT-O and TOT show equal effectiveness with slightly lower cure rates than TVT group, but TOT had a significant lower risk of bladder and vaginal perforations. There were no significant differences in objective cure rates between 'inside-out' and 'outside-in' transobturator tapes. Very recently a meta-analysis does not support routine use of SIMS in clinical practice, moreover suggested the retropubic TVT as the preferred choice for the management of stress urinary incontinence due to familiarity, its effectiveness, minimal invasiveness and low complication and morbidity rates as a primary procedure. Similar results have been announced in a randomized control trial in USA.

CONCLUSIONS

Certainly, larger randomized clinical trials with longer follow-up about the mentioned techniques are needed to accurately determine the efficacy and safety of the mentioned minimally invasive techniques.

Surgery versus physiotherapy for stress urinary incontinence

BACKGROUND

Physiotherapy involving pelvic-floor muscle training is advocated as first-line treatment for stress urinary incontinence; midurethral-sling surgery is generally recommended when physiotherapy is unsuccessful. Data are lacking from randomized trials comparing these two options as initial therapy.

METHODS

We performed a multicenter, randomized trial to compare physiotherapy and midurethral-sling surgery in women with stress urinary incontinence. Crossover between groups was allowed. The primary outcome was subjective improvement, measured by means of the Patient Global Impression of Improvement at 12 months.

RESULTS

We randomly assigned 230 women to the surgery group and 230 women to the physiotherapy group. A total of 49.0% of women in the physiotherapy group and 11.2% of women in the surgery group crossed over to the alternative treatment. In an intention-to-treat analysis, subjective improvement was reported by 90.8% of women in the surgery group and 64.4% of women in the physiotherapy group (absolute difference, 26.4 percentage points; 95% confidence interval [CI], 18.1 to 34.5). The rates of subjective cure were 85.2% in the surgery group and 53.4% in the physiotherapy group (absolute difference, 31.8 percentage points; 95% CI, 22.6 to 40.3); rates of objective cure were 76.5% and 58.8%, respectively (absolute difference, 17.8 percentage points; 95% CI, 7.9 to 27.3). A post hoc per-protocol analysis showed that women who crossed over to the surgery group had outcomes similar to those of women initially assigned to surgery and that both these groups had outcomes superior to those of women who did not cross over to surgery.

CONCLUSIONS

For women with stress urinary incontinence, initial midurethral-sling surgery, as compared with initial physiotherapy, results in higher rates of subjective improvement and subjective and objective cure at 1 year. (Funded by ZonMw, the Netherlands Organization for Health Research and Development; Dutch Trial Register number, NTR1248.).

EAU guidelines on surgical treatment of urinary incontinence

CONTEXT

The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology.

OBJECTIVE

We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.

Recent status of the treatment of stress urinary incontinence

The therapeutic options for management of stress urinary incontinence can be conservative, pharmacological or surgical. The treatment of patients with stress urinary incontinence should be tailored to the individual to optimize care. A multitude of surgical techniques have emerged to treat this condition in recent years. The objective of the present review was to present an overview of current practice in the management of stress urinary incontinence while considering the evidence supporting the clinical effectiveness of these procedures.

Diagnosis and office-based treatment of urinary incontinence in adults. Part two: treatment

Urinary incontinence is a common problem in both men and women. In this review article we address treatment of the various forms of incontinence with conservative treatments, medical therapy, devices and surgery. The US Preventive Services Task Force, The Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Conservative therapy with education, fluid and food management, weight loss, timed voiding and pelvic floor physical therapy are all simple office-based treatments for incontinence. Medical therapy for incontinence currently is only available for urgency incontinence in the form of anticholinergic medication. Condom catheters, penile clamps, urethral inserts and pessaries can be helpful in specific situations. Surgical therapies vary depending on the type of incontinence, but are typically offered if conservative measures fail.

Comparison of candidate scaffolds for tissue engineering for stress urinary incontinence and pelvic organ prolapse repair

OBJECTIVES

To identify candidate materials which have sufficient potential to be taken forward for an in vivo tissue-engineering approach to restoring the tissue structure of the pelvic floor in women with stress urinary incontinence (SUI) or pelvic organ prolapse (POP).

MATERIALS AND METHODS

Oral mucosal fibroblasts were seeded onto seven different scaffold materials, AlloDerm ( LifeCell Corp., Branchburg, NJ, USA), cadaveric dermis, porcine dermis, polypropylene, sheep forestomach, porcine small intestinal submucosa (SIS) and thermoannealed poly(L) lactic acid (PLA) under both free and restrained conditions. The scaffolds were assessed for: cell attachment using AlamarBlue and 4,6-diamidino-2-phenylindole (DAPI); contraction using serial photographs; and extracellular matrix production using Sirius red staining, immunostaining and scanning electron microscopy. Finally the biomechanical properties of all the scaffolds were assessed.

RESULTS

Of the seven, there were two biodegradable scaffolds, synthetic PLA and natural SIS, which supported good cell attachment and proliferation. Immunostaining confirmed the presence of collagen I, III and elastin which was highest in SIS and PLA. The mechanical properties of PLA were closest to native tissue with an ultimate tensile strength of 0.72 ± 0.18 MPa, ultimate tensile strain 0.53 ± 0.16 and Young's modulus 4.5 ± 2.9 MPa. Scaffold restraint did not have a significant impact on the above properties in the best scaffolds.

CONCLUSION

These data support both PLA and SIS as good candidate materials for use in making a tissue-engineered repair material for SUI or POP.

Surgical treatment of recurrent stress urinary incontinence in women: a systematic review and meta-analysis of randomised controlled trials

CONTEXT

Recurrent stress urinary incontinence (R-SUI) represents a management dilemma; however, only a limited number of randomised controlled trials (RCTs) have assessed the various surgical procedures used for its treatment.

OBJECTIVE

To assess the effectiveness and complications of various surgical procedures for the treatment of female R-SUI.

EVIDENCE ACQUISITION

A prospective peer-reviewed protocol was prepared a priori. A systematic literature review of all published RCTs comparing surgical procedures for treatment of R-SUI was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Data were analysed using RevMan 5.

EVIDENCE SYNTHESIS

We conducted a literature search from 1945 to February 2013. Data were available for a total of 350 women in 10 RCTs with a mean follow-up of 18.1 mo. Meta-analysis was possible for the comparison of retropubic tension-free vaginal tape (RP-TVT) versus transobturator tension-free vaginal tape (TO-TVT) in five RCTs (n = 135). There was no statistically significant difference between RP-TVT and TO-TVT in the patient-reported improvement (odds ratio [OR]: 0.84, 95% confidence interval [CI], 0.41-1.69) or objective cure/improvement (OR: 1.75; 95% CI, 0.86-3.54). One RCT showed a trend towards a higher rate of patient-reported and objective cure/improvement with the inside-out TO-TVT compared with the outside-in; however, it was not statistically significant (OR: 3.00; 95% CI, 0.85-10.57, and OR: 3.32; 95% CI, 0.96-11.41, respectively). There was no significant difference between Burch colposuspension and RP-TVT (one RCT) in patient-reported improvement (OR: 0.33; 95% CI, 0.01-8.57) or objective cure/improvement (OR: 0.52; 95% CI, 0.13-2.05).

CONCLUSIONS

This meta-analysis shows no evidence of a significant difference in patient-reported and objective cure/improvement rates between RP-TVT and TO-TVT in the surgical treatment of women with R-SUI. However, due to the relatively low number of patients, the analysis might be underpowered. This review highlights the poor level of evidence in this field and the need for well-designed clinical trials to address this important clinical dilemma.

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.

Surgical management of female SUI: is there a gold standard?

Many surgical options exist for women with stress urinary incontinence (SUI). The traditional gold standards of Burch retropubic colposuspension and pubovaginal slings are still appropriate treatment options for some patients, but randomized controlled trials have demonstrated that synthetic midurethral slings are just as effective as these traditional procedures but with less associated morbidity. Thus, midurethral slings--inserted via a retropubic or transobturator approach--have become the new gold standard first-line surgical treatment for women with uncomplicated SUI. Retropubic midurethral slings are associated with slightly higher success rates than transobturator slings, but at the cost of more postoperative complications. Pubovaginal slings remain an effective option for women with SUI who have failed other procedures, have had mesh complications, or who require concomitant urethral surgery. Single-incision slings have a number of benefits, including decreased operative times and early return to regular activities, but they are yet to be shown to be as effective as midurethral slings. Both retropubic and transobturator midurethral slings are effective for patients with mixed urinary incontinence, but the overall cure rate is lower than for patients with pure SUI. Based on the literature a new gold standard first-line surgical treatment for women with SUI is the synthetic midurethral sling inserted through a retropubic or transobturator approach [corrected].