A Comparative Study of Outside-In and Inside-Out Transobturator Tape Procedures for Female Stress Urinary Incontinence: 7-Year Outcomes

Long-term outcomes of transobturator midurethral slings: A critical evaluation of a real-world population

AIMS

The American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction stress urinary incontinence (SUI) guidelines strongly recommend the midurethral sling (MUS) for the index female patient with SUI. While numerous studies report long-term outcomes and complications for the retropubic MUS, these are largely absent for the transobturator MUS and are assessed in this study.

METHODS

This is an Institutional Review Board approved retrospective chart review of all women who underwent a transobturator MUS at a single institution from 2004 to 2010. Pre- and postoperative assessment included a cough-stress test, SEAPI assessment, and validated quality-of-life (QoL) questionnaires. SUI resolution was defined as no subjective or objective SUI, and no additional surgery to achieve stress continence.

RESULTS

Of 437 women, 305 (70%) had a minimum follow-up of 48 months (mean 88; median 92). SUI was resolved in 69% of the entire cohort and 58% of the 78 women who had MUS only. The median time to SUI recurrence was 38 months in the entire cohort and 18 months in the MUS only group. Perioperative complications were infrequent and typically associated with concomitant surgery. A statistically significant improvement was observed in SEAPI scores and all QoL indices postoperatively.

CONCLUSIONS

Long-term resolution of SUI after the transobturator MUS is achieved by 69%, which is commensurate with success rates reported in the literature. Overall, women experience a significant improvement in their QoL after transobturator MUS; however, late recurrences and delayed sequelae may occur. Thus, long-term follow-up is warranted in this population.

De novo or resolved urgency and urgency urinary incontinence after midurethral sling operations: How can we properly counsel our patients?

Purpose

To evaluate de novo and resolved urgency and urgency urinary incontinence (UUI) after midurethral sling operations in patients with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI).

Materials and Methods

Patients who underwent midurethral sling operations because of SUI and MUI between January 2012 and December 2016 were reviewed. Patients were divided into three groups (pure SUI, SUI with urgency, and MUI). Patients with MUI were subcategorized as SUI predominant, equivalent, and UUI predominant. Postoperative de novo, persistent or disappearance of urgency or UUI were compared.

Results

A total of 334 patients were included: 76 with pure SUI, 78 with SUI with urgency, and 180 with MUI. In the MUI group, 138 patients were SUI predominant, 12 patients were equivalent, and 30 patients were UUI predominant. De novo urgency developed in 5 patients (6.6%) in the pure SUI group. In the SUI with urgency group, 51 patients (65.4%) became urgency-free, and 3 (3.8%) developed de novo UUI. UUI resolved in 135 patients (75.0%): 110 (79.7%) in the SUI-predominant group, 9 (75.0%) in the equivalent group, and 16 (53.3%) in the UUI-predominant group. The patients' preoperative perception of predominant UUI was the predictive factor for persistent UUI in the multivariate analysis (hazard ratio, 5.722; p=0.001).

Conclusions

De novo urgency and UUI developed in a relatively small number of patients after a midurethral sling operation. The resolution rate of UUI was significantly low in patients who had previous pelvic surgery or who preoperatively perceived UUI as a more bothersome symptom.

Comparative study of transobturator sling with and without concomitant prolapse surgery for female urodynamic stress incontinence

AIM

To demonstrate the clinical and urodynamic outcomes of transobturator sling (TOT) with or without concomitant prolapse surgery for the treatment of urodynamic stress incontinence (USI).

METHODS

We recruited 143 consecutive patients diagnosed with USI, who received outside-in TOT in a university hospital. Preoperative and postoperative examinations were implemented using structured urogynecological questionnaires, pelvic organ prolapse quantification examination and urodynamic testing. Patient demographics, surgical and urodynamic results were compared between TOT with and without concomitant prolapse surgery.

RESULTS

The mean follow-up was 30.1 months (range 12-57). Postoperative stress urinary incontinence (SUI) occurred in 10 (7%) patients at 3 months and 10 (7%) patients at 12 months postoperatively. There was no significant difference in prevalence of postoperative SUI between groups of TOT only and TOT combined with pelvic surgery. Preoperative urodynamic results demonstrated that TOT only (n = 96) had a higher maximal flow rate and a lower residual urine amount when compared to TOT combined with pelvic surgery (n = 47). A significant decrease in maximal urethral closure pressure (MUCP) was found in 119 patients who received postoperative urodynamic examination. In comparison with preoperative urodynamic data, postoperative urodynamic results showed a significant decrease in MUCP in the TOT combined with prolapse surgery group, but no significant urodynamic changes in the group of TOT only.

CONCLUSION

Both TOT and TOT combined with prolapse surgery can be effective in correcting SUI in patients with USI 12 months postoperatively, with significant changes in MUCP.

Long-term outcomes for transobturator tension-free vaginal tapes in women with urodynamic mixed urinary incontinence

AIMS

To assess the long-term patient reported outcomes following transobturator tension-free vaginal tapes (TO-TVT) in women with urodynamic mixed urinary incontinence (MUI).

METHODS

A secondary analysis of the 9-year follow-up of the E-TOT study: 341 women with predominant stress urinary incontinence symptoms were randomized to undergo either inside-out or outside-in TO-TVT between April 2005 and April 2007. Forty-eight women had preoperative urodynamic MUI and were available for 9-year follow-up. Primary outcome was the patient-reported success rate defined as very/much improved on Patient's Global Impression of Improvement PGI-I. Secondary outcomes included impact on women's quality of life, sexual function, overactive bladder symptoms,and late adverse events. Statistical analysis was performed using SPSS v.23.

RESULTS

Forty-eight women completed the 9-year follow-up, with adjusted response rate of 63%. The success based on the PGI-I was 64.6% (n = 31), with a further 14.6% (n = 7) who reported "improved." There was no significant difference between groups (OR 1.11; 95%CI 0.33, 3.70; P > 0.999). Clinically significant improvement in quality of life was found in 85.3%. Cure of urgency and UUI was reported by 35% and 41%, whereas worsening was reported in 6.5% and 2.3%, respectively. One patient reported chronic groin/leg pain. The small sample size and the sizeable loss to follow-up are limitations in this study.

CONCLUSIONS

This is the first study to report the long-term outcomes of TO-TVT in women with urodynamic MUI; TO-TVT is associated with a good and sustained patient-reported success rate in women with MUI up to 9-years follow-up.