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

Randomized controlled trial comparing mini-sling with transobturator sling for the treatment of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is the involuntary loss of urine on effort and is a condition that negatively interferes with various aspects of a woman's life. This study aimed to demonstrate the non-inferiority of the less invasive single-incision mini-sling (SIMS) method in objective and subjective cures in relation to tension-free transobturator tape (TOT) in two analyses, per protocol and intention to treat, and secondarily to evaluate complications and quality of life.

METHODS

This study was a randomized controlled trial (RCT). Participants in this study included 105 women with a clinical diagnosis of stress predominant urinary incontinence and urodynamic results demonstrating SUI and absence of detrusor overactivity. Patients were evaluated pre- and postoperatively through anamnesis, physical examination, urinalysis, urine culture and susceptibility testing, simplified pad test, the Urinary Incontinence-Specific Quality of Life Instrument (I-QOL) and Urogenital Distress Inventory Short Form (UDI-6).

RESULTS

Regarding the objective cure, SIMS was non-inferior to TOT (p < 0.05). However, the same was not found for the subjective cure (p > 0.05). There were no differences in the complication rates (p > 0.05). However, in the TOT group, bladder perforation (2.4%), tape exposure (2.4%) and urinary retention occurred, lasting > 7 days (2.4%). In both groups, there was improvement in quality of life after surgery, without significant differences (p > 0.05).

CONCLUSIONS

The non-inferiority of SIMS in relation to TOT was only demonstrated in the objective cure. There were no significant differences between groups regarding complications and quality of life.

The Outcome of a Single-Incision Sling versus Trans-Obturator Sling in Overweight and Obese Women with Stress Urinary Incontinence at 3-Year Follow-Up

Background: Being overweight or obese is a risk factor for incontinence and has negative impacts on the surgical outcomes. Compared with trans-obturator sling (TOS), single incision sling (SIS) is a new generation of anti-incontinence surgery. However, the data on SIS in overweight and obese women remains limited. Methods: This retrospective study analyzed the objective and subjective cure rate of overweight and obese women who underwent sling surgeries. Other evaluations included valid questionnaires to assess quality of life and 1-hour pad test to quantify urine leakage. Surgical characteristics and adverse events were also analyzed. Results: A total of 217 patients were analyzed with a median follow-up period of 37.3 months (range, 9–84 months). For overweight and obese patients, the objective and subjective cure rate were comparable (all p > 0.05). However, the SIS group had worse post-operative incontinence-related symptom distress (p < 0.001) and 1-hour pad test (p = 0.047). On the other hand, SIS had a shorter surgery time (p = 0.017) and lower pain score (p < 0.001). Conclusions: Compared with TOS, SIS had non-significant cure rates in the overweight and obese women. SIS had worse urine leakage and incontinence symptoms, but less surgical and wound pain in obese women. Thorough pre-operative counseling is necessary.

Single incision slings: Are they ready for real life?

AIM: To review of the efficacy and safety outcomes of different single incision slings (SIS) systems, also in comparison with traditional slings.

METHODS: A literature search was conducted in PubMed/MEDLINE database. The research was restricted to randomized and/or prospective trials and retrospective studies, published after 2006, with at least 20 patients with non-neurogenic stress urinary incontinence (SUI). The studies had to assess efficacy and/or safety of the SIS with a minimum follow-up of 12 mo. All the paper assessing the performance of tension free vaginal tape secur were excluded from this review. The final selection included 19 papers fulfilling the aforementioned criteria. Two authors independently reviewed the selected papers.

RESULTS: Four different SIS systems were analysed: Ajust^®, Ophira^®, Altis^® and MiniArc^®. The average objective cure rate was 88%. Overall no statistically significant differences were found between SIS and traditional mid-urethral slings (MUS) in terms of objective cure (all P > 0.005). Only one paper showed a statistically lower success rate in MiniArc^®vs Advantage^® slings (40% vs 90%) and higher rates of failure in the SIS group. Since there was a great variability in terms of tests performed, it was not possible to compare subjective cure between studies. The vast part of the studies showed no major complications after SIS surgery. We also observed very low reported pain rates in SIS patients. The RCTs on Ajust^® and MiniArc^®, showed better outcomes in terms of post-operative pain compared to MUS. None of the patients reported long- term pain complains.

CONCLUSION: SIS showed similar efficacy to that of traditional slings but lower short-term pain, complication and failure rates.

Short-term outcomes of adjustable single-incision sling (Ajust™) procedure for stress urinary incontinence: a prospective single-center study

OBJECTIVES

Slings have become the most widely performed surgical procedure for stress urinary incontinence (SUI) in last two decades. As the third generation sling, the efficacy of the early single-incision mini-sling was controversial. The aim of this study was to determine whether the new adjustable single-incision sling (Ajust™) is safe and effective in management of female SUI at 6-18 months follow-up.

STUDY DESIGN

69 patients with SUI according the inclusion and exclusion criteria were considered adjustable single-incision sling (Ajust™) from September 2012 to September 2013. 67 patients finished 6-18 months follow-up. The data about clinical parameter, operation, complication, Urogenital Distress Inventory-Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7) and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) in Chinese were collected in preoperative, 6-month and 12-month follow-up.

RESULTS

All patients underwent successful adjustable single-incision sling (Ajust(TM)) placement. The subjective cure rate and objective cure rate was 82.0%, 92.5% in 6-month follow-up and 82.3%, 91.2% in 12-month follow-up respectively. There were no significant perioperative complications such as bladder perforation, major bleeding requiring blood transfusion in the present study. Sling exposure was observed in two patients (3.2%).

CONCLUSIONS

Adjustable single-incision sling (Ajust(TM)) was a safe and effective option for treating female SUI and was associated with comparable subjective and objective success rates when compared to standard midurethral slings (TVT-O) at a 6-18 months follow-up.

Stress urinary incontinence surgery with sling MiniArc: a 4-year results

OBJETIVES

The aim of this publication is to describe retrospectively the results of the surgical technique of AMS MiniArc for the treatment of female urinary incontinence, evaluate its results at 4 years follow-up.

MATERIAL AND METHODS

We present a retrospective cohort study of 135 patients, 110 (81.5%) had urinary incontinence and 25 (18.5%) mixed urinary incontinence. All these procedures were performed with local anesthesia and in "out patient surgery". Patients were monitored in the outpatient clinic at 6 months (control 1), one year (control 2) and annually (control 3, 4, and 5). During the following up, clinical history was made in every woman with ICIQ-SF questionnaire, that included a fourth question to evaluate the degree of satisfaction after surgery, as well as physical examination. We considered objective cure when negative stress with full bladder. We use the SPSS program (V19.0) for statistical analysis of the results.

RESULTS

The mean follow-up was of 59 months (range from 33 to 72 months). When evaluating the success rate of anti-incontinence surgery, 86.7% of patients showed objective cured (80.8% with MUI and 89.2% with SUI). The ICIQ-SF decreased average of 12.7 points, 85.7% patients were very or fairly satisfied.

CONCLUSION

The AMS MiniArc is an optim anti-incontinence procedure a medium term. But the results should be interpreted with caution given the limitations of the study.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis

OBJECTIVE

Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery.

STUDY DESIGN

We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs).

RESULTS

For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS.

CONCLUSION

Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Short-term outcomes of Altis single-incision sling procedure for stress urinary incontinence: a prospective single-center study

INTRODUCTION AND HYPOTHESIS

Data on Altis® (Coloplast), a new adjustable single-incision sling (SIS) procedure for the treatment of female stress urinary incontinence (SUI), are scarce. Our aim was to evaluate the efficacy and complication rates of this procedure.

METHODS

In this prospective observational study, a total of 52 women with SUI were implanted with an Altis sling in an ambulatory setting. Before and after intervention (3, 6, and 12 months), women completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF). In addition, patients underwent a cough stress test at each evaluation and a post-voiding residual urine volume estimation at 3 months. The main outcomes measured were subjective cure (ICIQ-SF = 0), subjective improvement (ICIQ-SF >0 and < preoperative ICIQ-SF), and objective cure (negative cough stress test and no pad usage) rates. De novo overactive bladder (OAB) symptoms, changes in voiding habits and adverse events were also analyzed.

RESULTS

The subjective cure rate at 12 months was 84.0%, with an additional improvement rate of 8.0%. The objective cure rate was 90.2%. Later postoperative complications included 1 case of vaginal extrusion (requiring surgical removal of the eroded mesh segment), 3 cases of vaginal exposure of the adjustment thread (managed conservatively), de novo urgency in 3 patients, and mild dyspareunia in 2 patients.

CONCLUSIONS

The Altis sling is a safe and effective SIS procedure for the treatment of SUI with a short-term follow-up.

Mini-arc for the treatment of female stress urinary incontinence: long-term prospective evaluation by patient reported outcomes

Single-incision slings were introduced in the surgical treatment of female stress urinary incontinence (SUI) to lessen the morbidity associated with traditional midurethral slings. However, long-term reports on patient satisfaction are still scarce. This study describes the outcome of women treated with Mini-Arc at a mean follow-up of 45 months. In a previous report on 105 women with 15-month mean follow-up, 84 (80%) were found cured and 12 (11%) improved. Now, with a mean follow-up of 45 months, cured/improved patients were reassessed by telephone and completed Patient Global Impression of Improvement (PGI-I), Patient Global Impression of Severity (PGI-S), rated their improvement in a 0-100 scale, and answered if they would recommend the procedure. At 45-month follow-up, 73 women cured/improved were available for evaluation. Over 80% of the cured patients rated the improvement of SUI by the PGI-I as "very much better" or "much better," reported their urinary tract condition to be "normal" on PGI-S, and described their improvement >70%. Ninety percent would recommend this procedure to a friend. The improved-patient population is very small (n = 7). This study shows that the majority of patients cured/improved after Mini-Arc placement maintain a high degree of satisfaction at a long-term evaluation.

Efficacy of TVT-SECUR and factors affecting cure of female stress urinary incontinence: 3-year follow-up

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the efficacy of the TVT-SECUR procedure for treating stress urinary incontinence (SUI) and to identify factors affecting cure during 3 years of follow-up.

METHODS

We prospectively followed patients until 1 year postoperatively and contacted them to revisit the clinic at 3 years. Ninety-six women who underwent TVT-SECUR (H type: 42, U type: 54) were followed up for at least 3 years. Patients were evaluated using the Severity Index for Urinary Incontinence, the Incontinence Quality of Life questionnaire, and the Bristol Female Lower Urinary Tract Symptom-Short Form questionnaire at baseline and at each postoperative visit. Patient satisfaction and complications were evaluated. Surgical outcome was assessed according to the Severity Index for Urinary Incontinence. Multivariate regression analysis was used to identify preoperative factors independently associated with cure.

RESULTS

The 3-year success rate was 91.7 % (cure 72.9 %, improved 18.8 %). The success rate was maintained from 94.8 % at 1 year to 91.7 % at 3 years, but the cure rate decreased significantly from 85.4 % at 1 year to 72.9 % at 3 years. Patient satisfaction rate was 85.4 %. Cure rates were lower in patients with Valsalva leak point pressure (VLPP) <60 cmH(2)O (79.5 % vs. 52.2 %, p = 0.010). Multivariate analysis showed that only low VLPP was associated with a lower cure rate.

CONCLUSIONS

The cure rate of female SUI after the TVT-SECUR procedure was not sustained, but the overall success rate was maintained over time. Low VLPP predicted failure to sustain cure.

A randomized controlled trial comparing three vaginal kits of single-incision mini-slings for stress urinary incontinence: surgical data

OBJECTIVE

Single-incision mini-slings (SIMS) are new minimally invasive devices used for female stress urinary incontinence (SUI). To date, several SIMS are available, but few and uncontrolled comparative data have assessed their safety and feasibility. The aim of the present clinical study was to compare three different SIMS in an ambulatory setting.

STUDY DESIGN

One hundred and twenty patients with SUI were randomized to receive three SIMS: Ajust, MiniArc, and TVT Secur System. Surgical data were compared.

RESULTS

Significantly (P<0.05) lower surgical difficulty and higher patient satisfaction were detected in the MiniArc group when compared to the Ajust and TVT Secur System groups. A significantly (P<0.05) higher feasibility under local anesthesia and in ambulatory setting was also detected for the MiniArc group. The overall complication rate was significantly (P<0.05) lower in the MiniArc group than in the TVT Secur System group.

CONCLUSIONS

MiniArc is simpler to insert under local anesthesia and in an ambulatory setting. It is safer than the TVT Secur System, and is related to higher patient satisfaction.

Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review

We reviewed the incidence, predisposing factors, presentation and management of complications related to the use of synthetic mesh in the management of stress urinary incontinence and pelvic organ prolapse repair. Immediate complications, such as bleeding, hematoma, injury to adjacent organs during placement of mesh and complication of voiding dysfunction are not discussed in this review, since they are primarily related to technique. A PubMed search of related articles published in English was done from April 2008 to March 2011. Key words used were urinary incontinence, mesh, complications, midurethral sling, anterior prolapse, anterior vaginal repair, pelvic organ prolapse, transvaginal mesh, vault prolapse, midurethral slings, female stress urinary incontinence, mesh erosion, vaginal mesh complications, and posterior vaginal wall prolapse. Since there were very few articles dealing with the management of mesh-related complications in the period covered in the search we extended the search from January 2005 onwards. Articles were selected to fit the scope of the topic. In addition, landmark publications and Manufacturer and User Facility Device Experience (MAUDE) data (FDA website) were included on the present topic. A total of 170 articles were identified. The use of synthetic mesh in sub-urethral sling procedures is now considered the standard for the surgical management of stress urinary incontinence. Synthetic mesh is being increasingly used in the management of pelvic organ prolapse. While the incidence of extrusion and erosion with mid-urethral sling is low, the extrusion rate in prolapse repair is somewhat higher and the use in posterior compartment remains controversial. When used through the abdominal approach the extrusion and erosion rates are lower. The management of mesh complication is an individualized approach. The choice of the technique should be based on the type of mesh complication, location of the extrusion and/or erosion, its magnitude, severity and potential recurrence of pelvic floor defect.

Single-Incision Slings (SIS) - a New Option for the Surgical Treatment of Female Stress Urinary Incontinence

The new development of single-incision slings (SIS) for the treatment of female stress urinary incontinence offers comparable results with only minimal side effects and will find wide acceptance in modern incontinence surgery. This mini-sling is inserted over a single vaginal incision and fixed on both sides to the pelvic wall tissue with special anchors, without passing through the groin and avoiding a blind tape passage. Compared with the established sub-urethral tapes, there are comparable success rates with fewer complications. Randomised prospective studies are needed to evaluate whether, in the long run, the benefits of the single incision technique can be correlated with satisfying continence results.

Exploratory study assessing efficacy and complications of TVT-O, TVT-Secur, and Mini-Arc: results at 12-month follow-up

BACKGROUND

Contemporary surgical treatment of female stress urinary incontinence (SUI) includes retropubic and transobturator (TO) midurethral slings (MUS). Case series of single-incision slings (SIS) have shown similar outcomes with lower morbidity.

OBJECTIVE

Our aim was to assess the cure rates, complications, and quality-of-life impact of one standard TO MUS and two SIS.

DESIGN, SETTING, AND PARTICIPANTS

Ninety consecutive patients with clinically and urodynamically proven SUI were enrolled in an exploratory randomised phase 2 trial. Patients with previous SUI surgery, major pelvic organ prolapse, mixed incontinence, or detrusor overactivity were excluded.

INTERVENTIONS

Patients were treated randomly with TVT-O, TVT-Secur, or Mini-Arc.

MEASUREMENTS

Postoperative visits were scheduled at 6 and 12 mo. The King's Health Questionnaire (KHQ) was repeated at 6 mo. Cure was defined as the absence of urine leakage, no pad use, and a negative cough test at 12 mo. Pain and other complications were also investigated.

RESULTS AND LIMITATIONS

Cure rate was 83% after TVT-O, 67% after TVT-Secur, and 87% after Mini-Arc. Improvement was found in 10%, 13%, and 7% of the patients, respectively. Failures were 7% after TVT-O and Mini-Arc and 20% after TVT-Secur. TVT-O and Mini-Arc improved at least 15 points in >80% of the patients in six KHQ domains, whereas TVT-Secur could only achieve improvement in three of the nine domains. The pain score was lower in the Mini-Arc group. Complications were more numerous after TVT-O. This study has the limitations inherent in a phase 2 trial with a follow-up limited to 12 mo.

CONCLUSIONS

Mini-Arc offers cure and improvement rates similar to TVT-O, whereas TVT-Secur may yield an inferior outcome. These findings recommend the urgent launch of large randomised phase 3 studies comparing conventional MUS with SIS, with Mini-Arc the advised option.