Surgical interventions for women with stress urinary incontinence: systematic review and network meta-analysis of randomised controlled trials

Thermo-Ablative Fractional CO2 Lasers Combined with 1540 nm Wavelengths Is a Promising Treatment Option in Stress Urinary Incontinence

Background/Objectives: Stress urinary incontinence (SUI) is a common and often under-reported condition that significantly impacts quality of life. SUI is more than just a physical issue; it can also affect social interactions, mental health, and emotional well-being due to the embarrassment and limitations it can cause. SUI is often acquired during pregnancy and childbirth as a result of pelvic floor muscle weakness. The aim of this study was to evaluate the effectiveness of an innovative dual-wavelength laser system (CO2 + 1540 nm) in SUI management. Methods: A total of 56 women affected by SUI were enrolled in this study. Half of the patients were treated with CO2 alone, while the other half were treated with the combination of CO2 + 1540 nm wavelengths. The patients were split into four groups based on the type of treatment they received and their menopausal status. Data were acquired at baseline and at various follow-ups (T1, T2, and T3, respectively, after the first, second, and third treatment). The Visual Analog Scale (VAS) (score 0-10) was used. Cystoscopic images were acquired before and at the end of the laser treatment cycle. Results: At the end of the treatment, the patients in each group were very satisfied, on average. In each group, the treatment led to a statistically significant improvement in the SUI VAS score between baseline and follow-up after the first treatment; in both groups 3 and 4, the treatment led to a significant change in the dryness score, both from baseline to T1 (p < 0.05) and also for T2 and T3 compared to baseline. Finally, cystoscopic photos showed an evident increase in mucosa epithelial thickness after the laser treatment cycle. Conclusions: The use of a dual-wavelength laser system (CO2 + 1540 nm) was proven to be well tolerated and safe, with promising outcomes in reducing SUI symptoms, especially in non-menopausal patients.

In vivo biocompatibility and long-term durability of nanofibrillated cellulose as a urethral bulking agent in rats and Beagle dogs

BACKGROUND

Cystoscopy-assisted submucosal injections of urethral bulking agents offer a safe and efficient alternative to surgery for treating urinary incontinence in both dogs and women. To address the concern of their transient therapeutic effect, a preclinical study evaluating the biocompatibility, safety, and durability of nanofibrillated cellulose as a bulking agent was designed. Plant-based nanofibrillated cellulose is considered renewable, biocompatible, and non-degradable in vivo. To the best of our knowledge, no studies of nanofibrillated cellulose injected into the urethral wall of experimental animals have been published to date.

METHODS

After assessing the rheological behavior of nanofibrillated cellulose, a biocompatibility study with 50 rats and a durability study with two Beagle dogs were conducted. In anesthesized rats, deposits of either nanofibrillated cellulose or sodium chloride as an inert control were injected into the urethral wall via a caudal laparotomy. The rats were euthanized for histopathological assessment after 7, 30, and 90 days. In dogs, cystoscopy-assisted injections of nanofibrillated cellulose were followed with magnetic resonance imaging at 14 days and at 2, 3, 6, and 12 months.

RESULTS

The rheological studies demonstrated a gel-like behavior under a wide range of shear stress. Nanofibrillated cellulose induced a moderate host tissue response according to the EN ISO 10993-6 standard, consisting primarily of macrophages, foreign body giant cells, lymphocytes, and plasma cells. No significant difference was observed in the tissue response at different time points. In dogs, the bulking agent was visible in 4/5 (80%) injection sites on magnetic resonance imaging at 12 months post-injection. No signs of migration, abscess formation or any major or long-term complications were observed.

CONCLUSIONS

Nanofibrillated cellulose maintains a chronic but stable and tolerable inflammatory response for up to 90 days in the urethral wall of rats. Durability in the urethral wall of dogs indicates a potential long-term effect.

Capacity assessment for EHR-based medical device post-market surveillance for synthetic mid-urethral slings among women with stress urinary incontinence: a NEST consortium study

Objectives

To evaluate the feasibility for use of electronic health record (EHR) data in conducting adverse event surveillance among women who received mid-urethral slings (MUS) to treat stress urinary incontinence (SUI) in five health systems.

Design

Retrospective observational study using EHR data from 2010 through 2021. Women with a history of MUS were identified using common data models; a common analytic code was executed at each site. A manual chart review was conducted in a per-site random patient subset to establish a reference standard. Automated text processing (Text Processed Integrated (TPI)) was developed and evaluated at each site to determine the surgical approach and synthetic mesh implantation. Patients were characterized and surgical outcomes were ascertained over 730 subsequent days.

Setting

Five large tertiary care academic medical centers.

Participants

Across five health systems, 9,906 eligible patients (mean age 57-60 per site) were identified.

Main outcome measures

Determination of surgical approach, synthetic mesh implantation, and assessment of the duration of surveillance for mortality and reoperation rates following MUS implantation.

Results

In the TPI cohort analysis, 3,331 patients were identified. Surgical approach per site was retropubic (42% to 77%), transobturator (6% to 44%), single incision (0% to 24%), and adjustable sling (0% to <4%). Concordance rates for TPI using chart review were 71%-90% at each site for the surgical approach and 28%-85% for synthetic mesh implantation. Patient follow-up observation rates for mortality and reoperation ranged from 22% to 36% at 90 days, 15% to 30% at 365 days, and 8% to 19% at 730 days.

Conclusion

Using EHR data alone, identification of medical devices and surgical approaches was feasible among women with MUS surgery for SUI, but long-term follow-up ascertainment rates were low. Medical device surveillance using EHR data should be evaluated in the context of the clinical use case, as applicability may vary.

Patients' Perceptions of Stress Urinary Incontinence Treatment: A Scoping Review of Qualitative Studies

INTRODUCTION AND HYPOTHESIS

Treatment options for female stress urinary incontinence (SUI) are often offered in a stepped-care approach. However, the shift towards patient-centred care and shared decision making (SDM) has prompted an increased interest in patients' perceptions of treatment decision making. This scoping review maps the available qualitative research on women's perceptions of the treatment decision-making process for SUI and identifies knowledge gaps.

METHODS

This scoping review was performed according to the Preferred Reporting Items for Systematic review and Meta-Analysis guidelines. Three databases were searched using a systematic search strategy, without restriction in publication date or language. After thorough screening, 19 of the initial 3,473 publications were included.

RESULTS

Four themes were identified; pre-existing experiences and notions that women bring to the consultations (things women consider before their consultation); treatment and patient characteristics (treatment aspects and personal values patients deem important); aspects of the consulting health care professional and facilities (availability of treatment options and counselling styles of physicians); ways of reaching a decision (three different ways that women used to make their decision. There were gaps in the literature on aspects affecting women's treatment preferences, their preferred decision-making style and how they want to be involved in this decision-making process.

CONCLUSIONS

This scoping review provides a global overview of women's perceptions on and preferences for treatment for SUI, and highlights a lack of knowledge on women's ideas of the treatment decision process. To provide clinicians with better guidance for their counselling and decision-making approaches, studies on women's perceptions of the decision-making process and the different decision-making styles are needed.

Workload, Availability of Diagnostic Tools, and Treatment Options for Urinary Incontinence and Other Pelvic Floor Disorders in Women: An Online Survey on Practice and Challenges Faced by Providers of Urogynaecological Healthcare in Ten African Countries

INTRODUCTION AND HYPOTHESIS

Pelvic dysfunction, including urinary incontinence, significantly impacts the quality of life of affected women, diminishing their freedom and dignity. In many African countries, challenges such as limited funding, competing health priorities and cultural stigma on pelvic health further restrict access to care. This information gap may hinder the effective design and implementation of interventions aimed at improving urogynaecological healthcare delivery. The objective of this study was to estimate the urogynaecological workload, the availability of tools to investigate and treat urinary incontinence in women, and to understand the challenges faced by providers of urogynaecological healthcare in 10 African countries.

METHODS

A cross-sectional online survey of urogynaecological service providers.

RESULTS

Forty-seven responses were analysed, revealing that 40% of gynaecological consultations addressed urogynaecological concerns, with 60% related to prolapse, 40% to bladder issues, 7.5% to bowel problems and 5% to sexual dysfunction. Among bladder issues, 35% involved obstetric fistulas, 22.5% stress urinary incontinence, 12.5% mixed urinary incontinence and 10% overactive bladder. Identified resource gaps included insufficient numbers and training of providers, limited access to diagnostic tools such as urodynamics equipment, and inadequate availability of neuromodulation and advanced surgical options. Key challenges in healthcare delivery were lack of patient awareness and inadequate funding, especially in public-sector facilities.

CONCLUSION

Gaps exist in the access and delivery of urogynaecological healthcare to patients with pelvic floor dysfunction in sub-Saharan Africa. Specific areas of focus should include patient education and capacity building, including human resources, access to affordable screening and diagnostic tools and technologies, and investment in affordable management options.

Noninferiority Randomized Clinical Trial: KIM Sling With Reusable Trocars Versus TVT Exact Sling

IMPORTANCE

The Neomedic Knotless Incontinence Mesh (KIM) sling with sterilizable trocars decreases medical waste versus midurethral slings with disposable trocars. Limited comparative data exist.

OBJECTIVE

The aim of the study was to assess to the success of the retropubic KIM sling compared to the Gynecare TVT Exact sling.

STUDY DESIGN

This was a single-center, randomized noninferiority trial comparing outcomes of 2 retropubic slings-KIM sling and TVT Exact sling-in women with stress urinary incontinence from August 2021 to May 2023. Primary outcome was subjective success at 6 weeks defined by a composite outcome of the response to the question #17 on the The Pelvic Floor Distress Inventory-20 questionnaire and no retreatment of stress urinary incontinence. Secondary outcomes included rates of urinary retention, mesh erosion, and reoperation for mesh complications. Sample size estimate based on noninferiority margin of 14%, equal success of 90%, alpha 0.05, and 80% power with a 20% dropout was 72 per group.

RESULTS

Among 147 patients, 74 (50.3%) were randomized to KIM sling versus 73 (49.7%) to TVT exact. The rates of 6-week success were 68.5% for the KIM sling and 83.3% for the TVT exact with a risk difference 14.8% (95% confidence interval, 1.1-28.5). The KIM sling is not noninferior to the TVT Exact sling. There were no differences in secondary outcomes.

CONCLUSIONS

The KIM sling is not noninferior to the TVT Exact sling for success at 6 weeks based on a composite outcome score. This clinical trial is ongoing to assess outcomes at 6 months and 1 year. ( Clinicaltrials.gov NCT04985799).

Predictive Factors for Poor Outcome after Laparoscopic and Open Colposuspension: A Comparative Analysis Using the BSUG Database

INTRODUCTION

Colposuspension has been a well-accepted surgical treatment for stress urinary incontinence (SUI) since 1961. However, there is limited research on predictors of poor outcomes in both laparoscopic colposuspension (LC) and open colposuspension (OC) procedures. This study aimed to identify predictors linked to patient-reported failure after colposuspension.

METHODOLOGY

This was a retrospective cohort study of women who underwent their first colposuspension surgery. The data were collected prospectively on the British Society of Urogynaecology database. The primary outcome measure was the Patient Global Impression of Improvement (PGII) for incontinence; PGII score 3-7 was defined as failure.

RESULTS

A total of 3104 women (1181 in LC and 1923 in OC) were analysed. On multivariate analyses, having a cystocele stage ≥ 2 was significantly predictive of failure (OR 2.573, 95% CI 1.086-6.098; p = 0.032) in LC. In OC, previous midurethral sling (MUS) procedure (OR 1.807, 95% CI 1.169-2.795; p = 0.008) and previous prolapse surgery (OR 1.954, 95% CI 1.235-3.093; p = 0.004) independently, were significant predictors of failure. OC had higher success (better PGII) than LC (p < 0.001), whilst adverse events such as blood loss, rates of urinary retention and duration of admission (p < 0.001) were lower in LC.

CONCLUSION

Variables found to be independently significant for failed colposuspension were different in the two approaches. Previous pelvic organ prolapse surgery and/or midurethral sling appeared to be the most significant predictors for failed OC, whilst in the LC group, having a stage ≥ 2 cystocele was predictive of failure.

Sonographic Sling Position and the Outcome of the Tension-Free Vaginal Tape-Obturator in Asian Chinese

INTRODUCTION AND HYPOTHESIS

The objective was to assess the sonographic tension-free vaginal tape-obturator (TVT-O) position and the outcome in Asian Chinese women.

METHODS

A prospective cohort study of 254 patients who underwent TVT-O surgery between 2013 and 2022. The sonographic position of the TVT-O was recorded and correlated with the outcomes, including the subjective cure rates, Incontinence Impact Questionnaire 7 (IIQ-7), and retention of urine.

RESULTS

A total of 92.9% reported no stress urinary incontinence after the operation. The IIQ-7 score significantly improved after TVT-O surgery. 88.2% of patients had the TVT-O placed at 50-70% of the urethral length and half of the TVT-O were placed 3-5 mm from the urethra. The cure rate was higher when the tape was in the middle third of the urethra, but the tape position was not associated with postoperative retention of urine in our study.

CONCLUSIONS

Most TVT-Os can be placed in the target zone in a blind procedure in Asian Chinese women. The tape position was related to the outcomes. Early postoperative ultrasound of the tape position may predict the outcome of the surgery.

Management of Complications of Prosthetic Mid-urethral Tape Surgery for Stress Urinary Incontinence in Women

OBJECTIVE

To propose guidelines for the management of complications of prosthetic mid-urethral tape surgery for stress urinary incontinence in women.

METHODS

These guidelines are based on an exhaustive literature review on retropubic and trans-obturator mid-urethral tape complications. The expert panel rated the level of evidence of each study, summarized literature for the treatment of each complication, and proposed guidelines.

RESULTS

Management of these complications is complex and the first treatment is crucial to offer the best functional result to the patient. We propose a standardized approach and guidelines for the management of complications to help physicians to early identify a surgical complication, offer adequate treatment for each complication and provide clear and appropriate information to patients. We detailed management of intraoperative complications as follows: bladder, urethral, vaginal, visceral, and vascular injury; short-term post-operative complications are the following: bleeding/hematoma, voiding dysfunction, pain, infection; and long-term post-operative complications are the following: chronic voiding dysfunction, de novo overactive bladder syndrome, chronic pain, dyspareunia, vaginal, bladder, and urethral tape erosion.

CONCLUSION

These guidelines may help physicians to improve management of prosthetic mid-urethral sling complications that may occur following stress urinary incontinence surgery.

The efficacy and feasibility of fractional CO2 laser therapy for the treatment of urinary incontinence: a multicentric case-control study

BACKGROUND

Female urinary incontinence is a significant public health problem. Conservative treatments require high patient compliance, while surgery often leads to more complications and recovery time. Our aim is to evaluate the efficacy of microablative fractional CO2 laser (CO2-laser) therapy in women with urinary incontinence (UI).

METHODS

This is a retrospective analysis of prospectively collected data on women with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) with predominant SUI subjected to four sessions of CO2-laser therapy performed once a month, between February 2017 and October 2017, with a 12-month follow-up. The subjective Visual Analogue Scale (VAS) 0-10 was used to score and variables were evaluated at baseline and at one, six and 12 months after initiation of therapy. Finally, results were compared to a control group.

RESULTS

The cohort consisted of 42 women. The proportion of patients with vaginal atrophy among those younger than 55 years was substantially lower (3/23; 13%) than among those older than 55 years (15/19; 78.9%). CO2 laser treatment was associated with a significant improvement in VAS scores recorded one-month, six-months, and one-year, after conclusion of therapy (P<0.001). VAS scores improved significantly in patients with either SUI (26/42; 61.9%) or mixed UI (16/42; 38.1%). No major post treatment complications were registered. Women with vaginal atrophy demonstrated significantly better results (P<0.001).

CONCLUSIONS

Results confirm the efficacy and a good safety profile, for CO2 laser treatment in SUI, mostly in women with postmenopausal vaginal atrophy and should be considered as a treatment option for female patients with concomitant SUI and vaginal atrophy.

Midurethral sling infectious complications: A systematic review

BACKGROUND

The French Health Authority (Haute Autorité de santé) and French scientific societies (Collège national des gynécologues et obstétriciens français) recommend the use of midurethral slings as the surgical treatment of choice for stress incontinence due to urethral hypermobility and failure of hygienic diet and pelvic rehabilitation. Within a year of implantation, almost 90% of patients no longer experience stress urinary incontinence. Despite their recognized efficacy, retropubic and/or trans-obturator midurethral sling can expose patients to potentially severe infectious complications.

METHODS

A comprehensive literature review using Pubmed, Medline, Embase and Cochrane: "stress urinary incontinence", and/or the following keywords "complications", "infections", "abscess", "prosthetic exposures", "fistula", "erosion", "cellulitis", "fasciitis" in association with the keywords "midurethral slings", "suburethral sling", "tension free vaginal tape" and "trans-obturator tape. In the 330 articles, 61 really dealt with infectious complications following the implantation of synthetic midurethral slings in women.

RESULTS

Preoperative urinalysis and intraoperative antibiotic prophylaxis were rarely reported (n=1 and n=11, respectively). We recorded thirty-six cases of abscess, twenty-one cases of cellulitis, sixteen cases of fistula and forty-one cases of prosthetic exposure. In 95.5% of cases, patients were treated with broad-spectrum antibiotics. Total explantation of the prosthesis was performed in 56% of patients at the initial management, with two-stage explantation performed in 23% of cases, partial explantation was carried out in 12% of cases, and the prosthesis was left in place in 9% of cases. No deaths were recorded.

CONCLUSION

To limit the risk of urinary tract infections and potential prosthetic infections, a prophylactic approach should be adopted by performing a preoperative urinalysis and administering intraoperative antibiotic prophylaxis should be discussed. In the event of prosthetic and/or surgical site infection, broad-spectrum probabilistic antibiotic therapy should be initiated as early as possible until targeted antibiotic therapy. Total explantation of the prosthesis appears to be the most appropriate surgical strategy.

Cough-Induced Detrusor Overactivity-Outcome after Conservative and Surgical Treatment

Background/Objectives: The most common variant of mixed urinary incontinence is stress-induced urge urinary incontinence with the correlating urodynamic findings of cough-induced detrusor overactivity (CIDO). This prospective study assessed the clinical outcomes and leakage improvement among patients with CIDO following conservative or surgical treatment. Methods: We included patients with CIDO treated at our tertiary referral center from January 2018 to July 2021 in this prospective cohort study. The detection of a detrusor contraction after a cough was diagnosed as CIDO by urodynamic multichannel testing. All the patients in our study received personalized care, with behavioral therapy and anticholinergic/betamimetic treatment as a first step. If leakage persisted, patients were given a choice between pelvic floor muscle exercises (PFMEs), periurethral bulking or a midurethral sling. The primary outcome was the mean difference in urine leakage in the pad test before and six months after treatment. Results: Thirty-five patients met the inclusion criteria for CIDO and all presented a positive pad test at baseline (mean: 27 g). All 35 patients participated in behavioral therapy and anticholinergic/betamimetic treatment. Twenty-two patients (62.9%) underwent PFME, twelve patients (34.2%) received periurethral bulking, and nine patients (25.7%) received a midurethral sling. After all the treatments, our cohort showed a significant improvement in the pad test (mean: 5.7 g, p < 0.001). The result was more favorable after periurethral bulking than the midurethral sling (p < 0.001). Conclusions: This study shows the effectiveness of conservative treatment as a first step. In cases needing further treatment, bulking agents may be superior to PFME and midurethral propylene slings, offering new perspectives in the field of urogynecology and urinary incontinence.

Role of Preoperative and Postoperative Endovaginal Ultrasound and 24 h Pad Test in Evaluation of Efficacy of Various Treatment Modalities for Stress Urinary Incontinence

Background

Stress urinary incontinence (SUI) is a common problem affecting the quality of life of women.

Materials and Methods

It is a prospective study conducted over 40 women of SUI by endovaginal ultrasound on rest and Valsalva preoperatively and 6 months postoperatively for levator hiatus (LH), pubovisceral thickness, urethral length, and bladder neck (BN) position. A 24 h pad test was also performed on all women at the same time for grading of SUI. Treatment given was medical in 4 (10%), Burch colposuspension in 18 (45%), and tension-free obturator tape in 18 (45%).

Results

The mean age, parity, and body mass index in the study were 41.60 years, 2.73, and 24.2 kg/m2, respectively. All 40 (100%) patients had SUI with a mean duration of symptoms being 4.04 years. On 24 h pad test, mild SUI was in 4 (10%), moderate SUI in 33 (82.5%), and severe SUI in 3 (7.5%) with mean preoperative 24 h pad test being 36.69 g which significantly reduced to 9.79 g postoperatively (P = 0.001). There was significant change in LH and pubovisceral thickness with treatment of SUI. Overall urethral length increased but there was significant decrease in urethral length on Valsalva after the treatment (0.40 cm vs. 0.28 cm, P = 0.04) and significant reduction in BN descent after Valsalva after treatment (0.41 cm vs. 0.27 cm, P = 0.001).

Conclusion

Endovaginal ultrasound and 24 h pad test are the useful diagnostic modalities for SUI diagnosis and to see the impact of treatment.

Unilateral J-cut division versus partial and subtotal removal techniques in female patients with mesh-related urethral obstruction: Multicentric comparative study

Objective

To compare the functional (obstruction relieving) outcomes and complications of unilateral J-cut division, partial and subtotal vaginal removal techniques were performed for mesh-related urethral obstruction (MRUO) in females.

Methods

Patient review included demographics, a medical history and proforma with details of lower urinary tract symptoms (LUTS), physical and urodynamic findings, detailed surgical reports and follow-up data. Variables were compared between the three groups.

Results

Out of 130 patients with sling revision surgery (SRS), 54 women underwent SRS for MRUO with a median follow-up of 48 (17-96) months. Unilateral J-cut division, partial and subtotal vaginal removal techniques were performed in 12, 31 and 11 patients with a median duration of surgery of 30 (25-34), 40 (35-56) and 60 (60-70) minutes, respectively (p = 0.001). Statistically significant increase in median maximum free urine flow rate and decrease in median post-void residual urine volume were found after SRS in the three groups, while de novo stress urinary incontinence (SUI) developed in 10%, 44% and 60% of the patients in the unilateral J-cut division, partial and subtotal removal groups, respectively (p = 0.007).

Conclusions

The unilateral J-cut division technique was as effective as the partial and subtotal vaginal removal techniques in relieving MRUO with a shorter duration of surgery time (p = 0.001) and lower risk of de novo SUI (p = 0.007). Comparative studies with a larger number of patients are needed.

Midurethral Sling Mesh Exposure Confers a High Risk of Persistent Stress Urinary Incontinence

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the relationship between mesh exposure and persistent stress urinary incontinence (SUI) post-midurethral sling (MUS) surgery.

METHODS

Extensive data collection including patient demographics, obstetric history, existing medical conditions, previous surgeries, and surgical outcomes, encompassing both perioperative and postoperative complications.

RESULTS

Out of 456 patients who underwent the MUS procedure within the specified period, the persistence of SUI was noted in 6.4% of cases. Mesh exposure was observed in 8.8% of these cases. Notably, 25% of patients with mesh exposure suffered from persistent SUI, in stark contrast to 4.6% of those without mesh exposure (p < 0.0001). Further, multivariate analysis indicated that patients with mesh exposure had an approximately 6.5-fold increased likelihood (95% CI: 2.71-15.44) of experiencing persistent SUI compared with those without mesh exposure.

CONCLUSIONS

Mesh exposure is a significant independent risk factor for persistent SUI post-MUS surgery. Patients with mesh exposure are about 6.5 times more prone to persistent SUI than those without. Although mesh exposure is typically managed with expectant measures, vaginal estrogen or mesh excision, current evidence does not support surgical revision of MUS affected by mesh exposure or additional incontinence procedures during mesh excision.

Laser and Pelvic Floor Muscle Training for Urinary Incontinence: A Randomized Clinical Trial

IMPORTANCE

Pelvic floor muscle training (PFMT) is considered the first option as a conservative treatment for female stress urinary incontinence (SUI). However, there is still debate whether energy-based devices are effective for treating SUI.

OBJECTIVE

The objective of this study was to assess whether PFMT and fractional CO2 laser therapy may improve symptoms in women with SUI.

STUDY DESIGN

A parallel, randomized, nonblinded, noninferiority trial included 94 of 144 women 18 years or older with SUI randomized into 2 groups. The CO2 laser group (n = 47) received 3 vaginal applications at monthly intervals. The PFMT group (n = 47) underwent 2 weekly sessions. Primary outcome was the mean difference of International Consultation on Incontinence Questionnaire-Urinary Incontinence Short-Form (ICIQ-UI-SF) total scores between groups after 3 and 6 months. Main secondary outcomes were questionnaires for assessment of pelvic floor symptoms (Pelvic Floor Impact Questionnaire-Short Form 7 [PFIQ-7]), sexual function (Female Sexual Function Index [FSFI]), and improvement after treatment (Patient Global Impression of Improvement [PGI-I]).

RESULTS

A reduction in the ICIQ-UI-SF total score, PFIQ total score, and the Urinary Impact Questionnaire score was perceived between baseline and 3-6 months in both groups. CO2 laser did not reach the noninferiority margin when compared with PFMT in both follow-up periods and analyses. Pelvic floor muscle training has improved the FSFI desire domain between baseline and 3-6 months, whereas CO2 laser improved the FSFI orgasm, pain, and total score after 3 months and FSFI orgasm and total score after 6 months. PGI-I assessment has shown an improvement in both groups.

CONCLUSION

Fractional CO2 laser therapy was noninferior to PFMT after 3-6 months of treatment. Both groups presented a reduction in the ICIQ-UI-SF scores, and both methods could be considered for women with SUI.

Transobturator Versus Minisling for Urinary Incontinence: A Randomized Controlled Trial

IMPORTANCE

The comparison between single-incision slings (SISs) and midurethral slings has been documented in the literature, but results vary according to the SIS device.

OBJECTIVES

The purpose of this study is to assess whether SIS (Solyx) is noninferior to transobturator (TOT) (Obtryx) sling for treating women with confirmed stress-predominant urinary incontinence.

STUDY DESIGN

A prospective, parallel, nonblinded, multicenter, noninferiority, randomized controlled study with 114 patients were randomized and followed 6 and 12 months after surgery. Interventions were midurethral TOT sling (Obtryx-halo; n = 58) or SIS (Solyx; n = 56). The primary outcome was improvement in the Patient Global Impression of Improvement (PGI-I). Secondary outcomes were the Kings Health Questionnaire (KHQ) instruments after treatment, subjective improvement, and surgical outcomes.

RESULTS

Both groups were homogeneous ( P = NS) regarding sociodemographic and clinical variables. There was improvement in the PGI-I after 6 ( P = 0.001) and 12 months ( P = 0.001) of treatment for women who underwent TOT sling. After 6 months, KHQ scores improved in the TOT group for the following domains: role limitations ( P = 0.026) and physical limitations ( P = 0.006). After 12 months, the TOT group presented better KHQ scores that were statistically significant from the SIS group in incontinence impact ( P = 0.012), physical limitations ( P = 0.001), and severity measures ( P = 0.017). Moreover, the TOT group presented higher subjective improvement after 6 months ( P = 0.006) than the SIS group. Mesh erosion was higher in the SIS group ( P = 0.006). Reoperations were not statistically different between groups.

CONCLUSION

There were higher scores in the PGI-I score and higher subjective improvement for the TOT sling after 6 and 12 months of treatment when compared with the SIS group.

Evaluation of Outcomes Between the Top-down Versus the Bottom-up Approach for Retropubic Midurethral Sling

INTRODUCTION AND HYPOTHESIS

Retropubic midurethral sling (MUS) placement is the gold standard for the treatment of stress urinary incontinence in the USA. The procedure can be approached from either a top-down or a bottom-up direction, but there is a paucity of contemporary data regarding outcomes between these approaches. The aim of this study was to provide updated clinical outcomes data.

METHODS

This was a retrospective cohort study of women undergoing the retropubic MUS procedure alone or at the time of pelvic organ prolapse repair between 2010 and 2020 at a single academic medical center. The electronic medical record was used to extract demographic data, operative approach, and perioperative complications. The primary outcome was a composite incidence of any perioperative complication.

RESULTS

Of the 309 patients analyzed, 140 (45.3%) underwent top-down and 169 (54.7%) underwent bottom-up retropubic MUS placement. Patients undergoing top-down MUS placement were more likely to be older (mean age 58 vs 54, p=0.02), have a history of diabetes mellitus (20% vs 8.9%, p=0.004), and have had a prior hysterectomy (27% vs 16%, p=0.02). They were less likely to have a concurrent anterior (p<0.001) or posterior repair (p<0.001). Patients undergoing the top-down procedure were less likely to experience sling exposure (p=0.02); complications in the two groups were otherwise similar.

CONCLUSIONS

The top-down approach to retropubic MUS placement was associated with lower rates of mesh erosion in this population of patients. Neither approach is associated with an increased overall risk of complications or de novo overactive bladder symptoms.

Comparison of perioperative adverse events following suburethral sling placement using synthetic mesh, autologous rectus fascia, and autologous fascia lata in a national surgical registry

AIMS

To assess and compare 30-day perioperative adverse events following suburethral sling surgery using synthetic mesh, autologous rectus fascia, and autologous fascia lata in women.

METHODS

This was a retrospective cohort study of patients who underwent fascial or synthetic sling placement for stress urinary incontinence between 2008 and 2021 using the American College of Surgeons' National Surgical Quality Improvement Program database. Current Procedural Terminology codes were used to identify patients undergoing each type of sling procedure. Multivariable regression analysis with stepwise regression was used to assess the odds of composite adverse events (e.g., urinary tract infection, surgical site infection, pulmonary embolism, and other reportable events) between cohorts.

RESULTS

Of the 41 533 female patients who underwent isolated suburethral sling placement without concurrent procedures, 41 292 (99.4%) received a synthetic mesh sling, and 241 (0.6%) received an autologous facial sling. In the fascial sling cohort, 160 (66.4%) underwent rectus fascia harvest and 81 (33.6%) underwent fascia lata harvest. Sling surgeries involving autologous fascia were associated with increased odds of adverse events compared to those involving synthetic mesh, even after adjusting for confounders (adjusted odds ratio [aOR]: 3.63, 95% confidence interval [CI]: 2.56-5.15). Compared to fascial slings from rectus fascia, slings from fascia lata were associated with increased odds of composite adverse events (aOR: 2.11, 95% CI: 1.03-4.04). However, with the exclusion of urinary tract infections, the adverse event rate was similar between slings using the two fascial harvest techniques (aOR: 1.93, 95% CI: 0.81-4.63).

CONCLUSIONS

In this retrospective database study, suburethral sling surgeries using autologous fascia were independently associated with a 3.6-fold increase in odds of 30-day perioperative adverse events compared to sling surgeries using synthetic mesh.

Effectiveness of web-based interventions for women with urinary incontinence: protocol for a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Urinary incontinence (UI) is one of the most common chronic diseases among women, which can endanger their physical and mental health and incur a heavy financial burden on both individuals and society. Web-based interventions (WBIs) have been applied to manage women's UI, but their effectiveness has remained inconclusive. This systematic review and meta-analysis aims to explore the effectiveness of WBIs on self-reported symptom severity, condition-specific quality of life, adherence to pelvic floor muscle training (primary outcomes) and other extensive secondary outcomes among women with UI. We also aimed to investigate whether intervention characteristics (format, interactivity and main technology) have impacts on the effectiveness of primary outcomes.

METHODS AND ANALYSIS

This systematic review protocol was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. 10 electronic databases will be comprehensively searched from their inception to 1 May 2024, along with grey literature searches and manual reviews of relevant reference lists to identify eligible randomised controlled trials. The methodological quality of the included studies will be assessed by two reviewers based on the Cochrane Risk of Bias Tool. Meta-analyses will be conducted via Stata V.12.0. Leave-one-out sensitivity analyses will be performed, and publication bias will be evaluated using funnel plots and Egger's test. Subgroup analyses regarding intervention format, interactivity and main technology will be carried out.

ETHICS AND DISSEMINATION

No ethics approval is needed for this review since no primary data are to be collected. The results of this review will help develop an optimal WBI for women with UI, thereby providing them with maximum benefits. The findings will be disseminated via a peer-reviewed journal or conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42023435047.

Vaginal erbium laser treatment for stress urinary incontinence: A multicenter randomized sham-controlled clinical trial

OBJECTIVE

To evaluate the efficacy and safety of non-ablative vaginal Er:YAG laser device in stress urinary incontinence (SUI) treatment.

METHODS

We conducted a multicenter blinded randomized sham-controlled trial in which women with urodynamic SUI were randomization to active arm using Er:YAG laser therapy, and sham arm using sham handpiece. Patients received two treatments 1 month apart. The primary outcomes measure was 1 h pad weight test measured at 6 months. Secondary outcomes were durability of treatment success at 12 months, and questionnaires for assessment of SUI severity (ICIQ-UI SF), sexual function (PISQ-12) and HRQoL (KHQ), and incidence and severity of device related adverse events and pain (VAS).

RESULTS

A total of 110 participants with SUI were recruited; 73 in the active arm and 37 in the sham arm. Two participants were excluded; one was assigned the wrong treatment and one withdrew their consent. Treatment success was observed in 36% of the sham arm and 59% of the active arm; in the latter, odds of achieving treatment success were more than three-fold higher (OR 3.63, 95% CI: 1.3-11.2, P = 0.02). HRQoL by KHQ showed significant improvement in the active versus the sham arm (OR 0.36, 95% CI: 0.15-0.87, P = 0.003). Similarly, subjective patient assessment of general and sexual function improvement with PISQ-12 and PGI-I showed superior effect over sham (OR 2.8, 95% CI: 1.2-7.0, P = 0.02 and OR 0.13, 95% CI: 0.05-0.36, P < 0.001, respectively).

CONCLUSION

Non-ablative vaginal Er:YAG laser therapy significantly improves SUI symptoms versus sham treatment. Er:YAG laser therapy should be considered as a non-surgical treatment option for SUI patients.

Associations of pelvic floor dysfunction and postnatal mental health: a systematic review

BACKGROUND

Postpartum mental health conditions are common and can have devastating effects for both mother and infant. Adverse birth outcomes increase the risk of postnatal mental health conditions. Pelvic floor dysfunction (PFD) is a common adverse pregnancy outcome that may be a risk factor for postnatal mental health conditions. There are many studies reporting associations between PFD and postnatal mental health conditions, but no reports have synthesised the current literature as it relates to pregnancy and the postpartum period.

METHODS

A research librarian conducted systematic literature searches using terms concerning PFD, postnatal mental health conditions, and pregnancy. Searches were conducted within PubMed, Embase, CINAHL, Cochrane, and Scopus. Two reviewers independently rated each study for inclusion and study quality. No studies were excluded based on quality.

RESULTS

A total of 47 studies were included for review. Articles addressed sexual dysfunction (n = 11), incontinence (n = 21), perineal laceration (n = 13), pelvic organ prolapse (n = 2), and general pelvic floor symptoms (n = 2) and associations with postnatal mental health conditions. Two articles addressed more than one type of PFD. The majority (44 studies) reported associations between PFD and adverse postnatal mental health conditions.

DISCUSSION

Most studies included for review found consistent associations between PFD and adverse mental health conditions. Healthcare providers should screen for PFD and postnatal mental health conditions early in the postpartum period. Future research should investigate whether the treatment of PFD can modify the associations between PFD and postnatal mental health conditions.

Exploring urinary incontinence in hospitalised older women: A mixed methods investigation of prevalence and nurse perspectives

BACKGROUND

Approximately 40% of older women in the community report experiencing urinary incontinence (UI); prevalence within secondary care is unknown. Illness, comorbidities, and hospital environments are likely to lead to higher prevalence.

OBJECTIVES

This study aimed to establish UI prevalence in older women admitted to hospitals and understand the views and knowledge of ward nurses in relation to older women's UI.

DESIGN

An explanatory mixed methods study was conducted including a retrospective study of women ⩾55 years admitted to a large NHS hospital and qualitative interviews with nurses to gain an understanding of views, knowledge and perceptions of women's UI and related care.

METHOD

UI prevalence was determined using the nursing assessment (elimination) and International Classification of Diseases 10th Revision (ICD-10) codes for women ⩾55 years admitted to the hospital (November 2019 to February 2020); continence and demographic electronic patient care records data were extracted. Twenty ward nurses participated in interviews to explore views, knowledge and perceptions of UI care.

RESULTS

11.0% (n = 631) of the cohort (5,757) were recorded as having UI. Nurse interviews revealed six themes: (1) Normalisation and misconceptions of UI: nurses believed UI could not be improved, (2) limited knowledge and training: nurses expressed limited UI knowledge and a training need, (3) pad culture: continence pad use was high, (4) barriers to care: staffing issues were expressed as problematic, (5) UI under-reporting: nurses only categorised women with complete UI and others as "having an accident", (6) catheter use in relation to UI: catheters were reported as a last resort.

CONCLUSION

As community UI prevalence is 40%, our results (11%) suggest that UI is being underreported. Qualitative findings suggest that nurses have limited knowledge and training on continence care and under-report based on UI misconceptions. Our results suggest that ward nurses require dedicated UI training based on older women's needs.

The clinical efficacy and safety of outside-in transobturator sling with additional paraurethral fixation - The prospective longitudinal study

Stress urinary incontinence (SUI) is a common condition that affect 30-40% of women in their lifetime. Midurethral slings (MUS) either suprapubic or transobturator can be safely used in the surgical treatment of SUI. The aim of this study was to collect clinical long-term data regarding safety and performance of transobturator sling with an additional tape fixation in women with urinary incontinence. This prospective longitudinal study was conducted on a group of 2086 female patients diagnosed with stress urinary incontinence. Follow up visits where scheduled 6 weeks, 6 and 12 months after surgery followed by annual checking when possible. Patients underwent transobturator sling procedure from 01.01.2011 to 31.12.2021. All patients had a monofilament tape inserted at the mid-urethra using outside-in technique (TOT) with 2 absorbable sutures parallel to the urethra. Success of surgery was defined as lack of any leakage during cough stress test whereas the subjective cure rate was determined by Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-SF). 87% of patients who were operated at least 10 years before assessment reported ICIQ -SF < 6. Main postoperative complications were storage symptoms - de novo urgency and voiding difficulties. TOT is safe and highly effective surgical treatment for (SUI) in a long-term observation.

Retropubic tape surgery for stress urinary incontinence: can women be cured without voiding dysfunction?

PURPOSE

Retropubic tension free vaginal tape (RP-TVT) has become the gold standard for surgical management of female stress urinary incontinence but is associated with voiding dysfunction (VD). We developed for more than 10 years a reproductible and totally tension free tape procedure. Our goal is to determine efficiency of this technique compared to the incidence of VD.

METHODS

We retrospectively reviewed patients who underwent RP-TVT in our center between 2011 and 2019. Subjective cure, VD (determined as maximum urinary flow rate (Qmax) < 15 mL/s or post void residual (PVR) volume > 150 mL, or tape's section or resection requirement for underactive bladder (UB) with significant PVR) was assessed at 1 year. The main objective was the evaluation of subjective cure and VD at 1 year.

RESULTS

On the 319 patients reviewed, 93% of the patients were dry and 10.9% presented VD at one year. UB (OR = 5.01 [1.55-16.44], p = 0.008), preoperative Qmax < 15 mL/s (OR = 0.89 [0.84-0.95], p = 0.001) and previous incontinence surgery (OR = 4.20 [1.54-11.46], p = 0.005) were associated with VD. Acute urinary retention concerned 4.7% of the population and all were resolved after 6 weeks postoperatively. We reported 0.3% of de novo urgency and patients without VD showed a significant decrease of their voiding time at 1 year.

CONCLUSION

The placement of RP-TVT without intraoperative tightening seems to be a safe technique ensuring a high cure rate and low occurrences of bladder outlet obstruction.

A 10- to 20-year follow-up after tension-free vaginal tape for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Midurethral slings (MUS) have become the gold standard in the treatment of stress urinary incontinence (SUI). Some information is already available on the outcome of tension-free vaginal tape (TVT) after 10 years or more. Our objective was to assess the current outcome (efficacy, adverse events) of women who had been successfully operated upon for SUI by means of a TVT procedure 10 to 20 years ago.

METHODS

We performed a retrospective cohort study including 291 women (mean age 69.4 years) who underwent a successful TVT procedure (retropubic bottom-to-top route) in a teaching hospital between January 2001 and December 2010. The main outcome measure was the incidence of SUI at 10-20 years' follow-up. Others were incidence of re-operation, tape exposure and de novo overactive bladder symptoms. We carried out a univariate logistic regression analysis to examine the relationship between outcomes and a set of clinical variables.

RESULTS

After a median of 15 years, TVT remains highly effective: 272 women (94%) experienced either no leakage under any circumstance (214=74%) or leakage less than weekly (58=20%). Mesh exposure (8=2.7%; 1.8 events per 1,000 patient-years) and repeat surgery for SUI (11=3.8%; 2.5 events per 1,000 patient-years) were low. Three women (1%) needed to perform intermittent self-catheterisation. Bothersome overactive bladder symptoms (45=15%) were common and associated with polypharmacy, cardiovascular medication and obesity.

CONCLUSION

The efficacy of TVT is demonstrated up to 20 years. The presence of bothersome OAB symptoms in the population may be an indicator of multimorbidity.

Is a Mesh Really a Mess: A Self-Tailored Polypropylene Mesh as a Retropubic Tension-Free Vaginal Tape Under Local Anesthesia in a Tertiary Healthcare Center Experience in India

Objective The primary objective of this study was to evaluate the feasibility of performing retropubic mid-urethral transvaginal tape (TVT) with self-tailored ordinary polypropylene mesh (STOM) under sedation and local anesthesia in female patients with stress urinary incontinence (SUI). The second objective was to evaluate perioperative and immediate postoperative complications, success rates, and cost-effectivity. Materials and methods Forty-two subjects treated for stress urinary incontinence using STOM under local anesthesia were reviewed. Pre- and postoperative evaluation included assessment of valid questionnaires such as the urogenital distress inventory (UDI) and medical, epidemiologic, and social aspects of aging incontinence questionnaire (MESA), uroflowmetry in all cases, and urodynamics in some instances. Success rates and complications were compared with published studies. Results The mean operating time was 27 mins, and the median visual analog scale (VAS) score at 12 hours was three. Postoperative MESA and UDI scores had significant improvement. The mean hospital stay was 18 hours. Mean preoperative and postoperative Q max had no significant difference. With a mean follow-up of 27.32±3.29 months, the cure was seen in 38 patients (90.4%), improvement in three patients (0.07%), and failure in one patient (0.02%). Mesh-related complications (extrusion) occurred in one patient. The sling cost was reduced from approximately $500 (Gynecare TVT sling; Ethicon Inc., Somerville, NJ, USA) to $12.44 (Ethicon 15 x 7.6 cm Prolene (polypropylene mesh); Ethicon Inc., Somerville, NJ, USA) in our study. Conclusion Performing TVT with STOM under sedation and local anesthesia as a daycare procedure was feasible and cost-effective, has a high success rate, and was associated with minimal complications. It should be considered in developing countries with vast patient burdens, such as India.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Surgical Treatments for Women with Stress Urinary Incontinence: A Systematic Review

Stress urinary incontinence affects a large proportion of women in their lifetime. The objective of this review was to describe and compare the latest surgical trends in urinary incontinence and focus on the literature advantages, disadvantages, complications and efficacy of surgical procedures regarding this pathology. Using network meta-analysis, we have identified the most frequently used procedures (Burch surgery, midurethral sling and pubovaginal sling), and we have described and characterized them in terms of effectiveness and safety. Midurethral procedures remain the gold standard for surgical treatment of stress urinary incontinence, although the potential of serious complications following this procedure should be taken into consideration always. There is a clear need for a much more unified evaluation of possible complications and postoperative evolution. This process will help practitioners to adapt and individualize their strategy for each patient.

The experience of women reporting damage from vaginal mesh: a reflexive thematic analysis

Background

The UK's 'First do no harm' report highlighted missed opportunities to prevent harm and emphasised the need to incorporate patient voices into healthcare. Due to concerns about, and the subsequent suspension, of vaginal mesh for urinary incontinence thousands of women face the decision about mesh removal surgery. The aim of this study was to explore and understand the experience of living with complications attributed to vaginal mesh surgery so that this knowledge can contribute to improvements in care for those considering mesh, or mesh removal, surgery.

Methods

This study was embedded in the 'PURSUE' study which explored the experiences of 74 people with urogynaecological conditions in the UK (30th April 2021-17th December 2021). Of these 74 people, fifteen women reported complications that they attributed to vaginal mesh surgery. We used the six stages of reflexive thematic analysis to conceptualise these fifteen accounts.

Findings

Our conceptual model anchors eight themes around two dualities: (1) body parts versus body whole, (2) dominant discourse versus marginal discourse. Our themes indicate that trust can be established through: (1) embodied healthcare that focuses on connecting with patients' lived experience, (2) dialectic communication that recognises patient experiences and remains open to alternative perspectives.

Interpretation

This study raises some important issues for education and practice. Our findings can translate to other health settings where treatments aimed to provide care have caused harm.

Funding

NIHR Policy Research Programme (NIHR202450).

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

SELECTION CRITERIA

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

RESULTS

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

CONCLUSIONS

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

Cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® compared with mid-urethral sling surgery for stress urinary incontinence: A two-arm cohort study

OBJECTIVE

To investigate the cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® (PDMS-U) compared with mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) at 1-year follow-up.

DESIGN

Prospective, two-arm cohort study with 2-year follow-up.

SETTING

International multicentre.

POPULATION

Women with moderate to severe SUI.

MAIN OUTCOME MEASURES

Primary outcome was subjective cure (Patient Global Impression of Improvement).

SECONDARY OUTCOMES

objective cure (negative cough stress test), Urogenital Distress Inventory (UDI-6), complications and re-interventions. Cost-effectiveness outcomes: total costs, quality-adjusted life year (QALY) using IIQ7-scores (Incontinence Impact Questionnaire) and EQ-5D-5L, incremental cost-effectiveness ratio (ICER) and monetary benefit (adjusted for baseline confounders).

RESULTS

In all, 131 PDMS-U and 153 MUS surgery patients were treated. Subjective cure rates for MUS surgery and PDMS-U were, respectively: 101/112 (90%) versus 40/87 (46%), adjusted odds ratio (aOR; for age, body mass index [BMI], severity, type of urinary incontinence and previous SUI procedure) was 4.9. Objective cure rates for MUS surgery and PDMS-U were respectively: 98/109 (90%) versus 58/92 (63%), aOR 5.4. Average total costs for PDMS-U and MUS surgery were €3567 and €6688. ICER for MUS surgery cost €15 598 per IIQ QALY and €37 408 per EQ-5D-5L QALY. With a willingness to pay (WTP) of €25 000, MUS has a 84% chance of being cost-effective using IIQ, whereas PDMS-U has a 99% chance of being cost-effective using EQ-5D-5L.

CONCLUSION

MUS surgery is more cost-effective in realising improved disease-specific quality of life (QoL), while PDMS-U is more cost-effective in realising improved generic QoL.

Secondary urethral sphincter function of the rabbit pelvic and perineal muscles

Perineal and pelvic floor muscles play an important role in continence by providing mechanical support to pelvic organs. It is also known that the pubococcygeus muscle (PcM) contracts in the storage phase and is inactive during voiding, while the bulbospongiosus muscle (BsM) is active during the voiding phase. Recent evidence suggested an additional role of these muscles in supporting urethral closure in rabbits. However, the individual role of perineal and pelvic muscles as urethral sphincters is not well-defined. Here we evaluated the individual, sequential and synergistic roles of the PcM and BsM in assisting urethral closure and defined the optimal electrical stimulation parameters that can effectively contract these muscles and increase the urethral pressure (P _ura ) in young nulliparous animals (n = 11). Unilateral stimulation of either the BsM or PcM at 40 Hz induced modest increases in average P _ura (0.23 ± 0.10 and 0.07 ± 0.04 mmHg, respectively). Investigation on the changes in P _ura evoked by stimulation frequencies between 5 and 60 Hz show that sequential contralateral PcM-BsM activation at 40 Hz induced a 2-fold average P _ura increase (0.23 ± 0.07 mmHg) compared to that evoked by PcM stimulation. Simultaneous activation of PcM and BsM at 40 Hz also showed an increased average P _ura (0.26 ± 0.04 mmHg), with a 2-fold increase in average P _ura observed during the unilateral sequential PcM-BsM stimulation at 40 Hz (0.69 ± 0.2 mmHg). Finally, stimulation at 40 Hz of the bulbospongiosus nerve (BsN) induced an approximate 4-fold increase in average P _ura (0.87 ± 0.44 mmHg; p < 0.04) compared to that elicited by BsM stimulation, confirming that direct nerve stimulation is more effective. Together, this study shows that in the female rabbit, both perineal and pelvic muscles support of the urethral function during continence, and that unilateral stimulation of the BsN at 40-60 Hz is sufficient to achieve maximal secondary sphincter activity. The results also support the potential clinical value of neuromodulation of pelvic and perineal nerves as bioelectronic therapy for stress urinary incontinence.

Midterm postoperative results of mid-urethral slings. Role of ultrasound in explaining surgical failures

INTRODUCTION

Surgical treatment for stress urinary incontinence (SUI) with mid-urethral sling (MUS) is considered to have a high success rate. However, between 5% and 20% of MUS fail, with inadequate surgical implantation being a possible cause of SUI persistence or recurrence. Misplacement of a MUS can be determined by pelvic floor ultrasound (PF-US). The aim of this study was to investigate the role of PF-US in patients with persistent or recurrent urinary incontinence (UI) symptoms after MUS surgery for SUI with a midterm follow-up.

MATERIALS AND METHODS

A historical cohort study including women undergoing MUS surgery for SUI between 2013 and 2015 was designed. The primary outcome was to correlate the sonographic parameters of MUS with SUI cure (negative International Continence Society-Uniform Cough Stress Test, Incontinence Questionnaire-Short Form < 5 points and no symptoms of SUI), at 5 years postsurgery. Secondary outcomes were changes of maximum urethral closure pressure (MUCP) and symptoms of urgency urinary incontinence (UUI) at 1 and 5 years after surgery.

RESULTS

Eighty-seven patients (80 transobturator-MUS, 7 retropubic-MUS) were included. At 5 years all patients referred improvement of UI and objective cure of SUI was demonstrated in 81.2%. The MUS was sonographically correct in 67 (98.5%) of the 68 patients with cure of SUI. The MUS was considered incorrectly placed in only 4 (28.6%) of the 14 patients with noncured SUI. MUCP decreased from 61.9 to 48.8 cmH₂ O at 5 years of follow-up (p < 0.01) and up to 53% of women had UUI symptoms after surgery, with a nonsignificant decrease compared to baseline.

CONCLUSION

Patients cured of SUI had sonographically correct MUS by PF-US. Less than one-third of cases of SUI persistence or recurrence after MUS surgery could be explained by a sonographically incorrect sling. Low urethral resistance and/or UUI symptoms could help to explain the remaining failures. Complete functional and anatomic studies, including urodynamics and PF-US, should be performed before deciding on the next management strategy in patients with SUI persistence or recurrence after MUS.

The Clinical Effects of Pixel CO2 Laser on Bladder Neck and Stress Urinary Incontinence

Background: Our study aims to assess Pixel CO2 laser efficacy for female stress urinary incontinence (SUI). Methods: In the study, 25 women with SUI were included and scheduled for vaginal Pixel CO2 Laser (FemiLift™, Alma Lasers, Israel) treatment. All subjects had a baseline and 6-month post-treatment assessment that included three-dimensional perineal ultrasound and validated questionnaires. Results: Data showed that monthly three-session vaginal Pixel CO2 Laser treatment significantly improved SUI symptoms, as evidenced by validated questionnaires, including UDI-6, IIQ-7, ICIQ, and vaginal laxity questionnaire (p < 0.05). The Pixel CO2 Laser efficacy in vaginal treatment was 20/25 (80%), and the perineal sonography showed that laser treatment significantly decreased bladder neck mobility and middle urethral area (during resting and straining). Permanent adverse events were not found. Conclusions: The results of our study suggested that for the treatment of mild to moderate SUI symptoms, Pixel CO2 Laser is effective and safe; however, more studies and a longer follow-up should be conducted to confirm its efficacy and durability.

Burch colposuspension for stress urinary incontinence: a 14-year prospective follow-up

We aimed to evaluate the long-term effectiveness and safety of Burch colposuspension (BC) for stress urinary incontinence (SUI). In this prospective cohort study, 84 patients with SUI undergoing BC were enrolled from February 2004 to January 2010. Data on long-term subjective success and postoperative complications were collected at clinic visits and by telephone follow-up. During a mean follow-up period of 14.2 years, 68% (57/84) patients completed the follow-up. A total of 68.4% of patients (39/57) reported absence of SUI symptoms, 73.6% (42/57) were subjectively satisfied according to the Patient Global Impression of Improvement, and 68.4% (39/57) reported subjective success regarding urinary symptoms via the Urinary Distress Inventory Short Form. However, 28.1% (16/57) suffered at least one long-term postoperative complication and incident. Specifically, 1 in 25 (4.0%) sexually active patients reported dyspareunia, 3 patients (5.3%) had de novo overactive bladder, and 6 patients (10.5%) reported voiding dysfunction. Four patients (7.0%) reported new onset prolapse symptoms, and 3 patients (5.3%) underwent secondary urinary incontinence surgery. Our study indicated that Burch colposuspension is an effective procedure for SUI, and the cure effect was largely maintained for the 14-year follow-up period, with relatively low complication rates. BC should be considered a surgical option for SUI.

Use of Urodynamics by Gynecologists and Urologists in Brazil

OBJECTIVE

 Urodynamic studies (UDSs) are a set of tests that assess the storage and emptying of urine, and they are widely used by gynecologists and urologists in the management of urinary incontinence (UI), despite the discussion about its indications. The objectives of the present study were to verify whether UDSs are routinely used in the conservative and surgical approaches to female UI, their other clinical indications, and to compare the responses of Brazilian gynecologists and urologists.

METHODS

 The present is an opinion survey applied from August 2020 to January 2021 through a semistructured questionnaire about the clinical practice sent by e-mail to all participants. The responses were compared through statistical analyses.

RESULTS

 Of the 329 participants, 238 were gynecologists (72.3%) and 91, urologists (27.7%). Most gynecologists (73.5%) and urologists (86.6%) do not request UDSs before the conservative treatment of UI; but UDSs are indicated in the preoperative period of anti-incontinence surgeries. Most participants request UDSs in the initial approach to overactive bladder (gynecologists: 88.2%; urologists: 96.7%), and the urologist has greater chance to request this study (odds ratio [OR] = 3.9). For most participants, it is necessary to request uroculture before the UDSs.

CONCLUSION

 Most Brazilian gynecologists and urologists who participated in the present study do not request UDSs before the conservative treatment of UI, according to national and internacional guidelines, and often request it before the surgical treatment for female UI. The indication of this exam in the initial approach of idiopathic overactive bladder should be reviewed by the participants.

Burch Procedure: A Historical Perspective

INTRODUCTION

 The Burch procedure (1961) was considered the gold standard treatment for stress urinary incontinence (SUI) before the midurethral slings (MUSs) were introduced, in 2001.

OBJECTIVE

 This historical perspective of the Burch's timeline can encourage urogynecological surgeons to master the Burch technique as one of the options for surgical treatment of SUI.

SEARCH STRATEGY AND SELECTION CRITERIA

 A bibliographic search was performed in the PubMed and National Library of Medicine (NIH) databases with the terms Burch colposuspension AND history AND stress urinary incontinence in the last 20 years. The original article by Burch (1961) was included. The references were read by three authors. The exclusion criterion was studies in non-English languages. Biomedical Library Special Collections were included as historical relevant search.

DATA COLLECTION, ANALYSIS AND MAIN RESULTS

 Some modifications of the technique have been made since the Burch procedure was first described. The interest in this technique has been increasing due to the negative publicity associated with vaginal synthetic mesh products. Twenty-nine relevant articles were included in the present review article, and numerous trials have compared Burch colposuspension with MUS.

CONCLUSION

 This historical perspective enables the scientific community to review a standardized technique for SUI. Burch colposuspension should be considered an appropriate surgical treatment for women with SUI, and an option in urogynecological training programs worldwide.

Twisting of transobturator midurethral slings: does it matter?

INTRODUCTION AND HYPOTHESIS

We assessed rotation/twisting of transobturator midurethral slings (TOTs) and tested for associations with de novo chronic pain and voiding dysfunction.

METHODS

A retrospective pilot study including patients seen after Monarc™ TOT surgery at a single tertiary hospital in 2005-2016. Patients underwent an interview, clinical examination, uroflowmetry and 4D pelvic floor ultrasound. Volume datasets were analyzed blinded against all other data. Sling rotation/twisting was evaluated in volumes obtained at rest. The sling axis was measured relative to the vertical in the midline and in the most lateral parasagittal slice. Total sling rotation was calculated by summation of absolute angle differences between midline and lateral angles. "Corkscrew" rotation was noted when direction of rotation was opposite on the contra-lateral side.

RESULTS

The study included 215 patients. Fifty-two (24%) were excluded, leaving 163. Mean age was 57 years (28-87; SD 12), mean BMI 29.4 kg/m² (18.3-47.4, SD 6). Follow-up was at a median of 17 months (IQR 11-27). Chronic de novo pain was reported by 15 women (9%; dyspareunia by 11 and pelvic/vaginal pain by 4). On imaging, mean total sling rotation was 144° (12-335, SD 56). In the majority (n = 103, 63%) it rotated counter-clockwise from its midline position and in 30 (18%) it rotated clockwise. "Corkscrew" rotation was noted in 30 (18%). De novo chronic pain was associated with lower BMI and vaginal sling exposure but not with sling rotation. The latter was not found to be associated with voiding dysfunction either.

CONCLUSIONS

Monarc™ TOTs rotate considerably throughout their course. The degree of twisting or rotation and its direction was not found to be associated with de novo postoperative chronic pain or voiding dysfunction.

Vaginal Laser Therapy for Female Stress Urinary Incontinence: New Solutions for a Well-Known Issue-A Concise Review

Background and Objectives: Insufficient connective urethra and bladder support related to childbirth and menopausal estrogen decrease leads to stress urinary incontinence (SUI). The aim of this review is to narratively report the efficacy and safety of new mini-invasive solutions for SUI treatment as laser energy devices, in particular, the microablative fractional carbon dioxide laser and the non-ablative Erbium-YAG laser. Materials and Methods: For this narrative review, a search of literature from PubMed and EMBASE was performed to evaluate the relevant studies and was limited to English language articles, published from January 2015 to February 2022. Results: A significant subjective improvement, assessed by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF) was reported at the 6-month follow up, with a cure rate ranged from 21% to 38%. A reduction of effect was evidenced between 6 and 24-36 months. Additionally, the 1-h pad weight test evidence a significant objective improvement at the 2-6-month follow up. Conclusions: SUI after vaginal laser therapy resulted statistically improved in almost all studies at short-term follow up, resulting a safe and feasible option in mild SUI. However, cure rates were low, longer-term data actually lacks and the high heterogeneity of methods limits the general recommendations. Larger RCTs evaluating long-term effects are required.

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence

OBJECTIVE

To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m2), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review

OBJECTIVE

To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications.

DATA SOURCES

A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal.

METHODS OF STUDY SELECTION

All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible.

TABULATION, INTEGRATION, AND RESULTS

We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent.

CONCLUSION

Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD 42018093099.

Role of Incontinence Severity Index in Evaluating Severity and Impact of Treatment Of Stress Urinary Incontinence

Background

Stress urinary incontinence (SUI) is a common ailment in affecting quality of life. This study was performed to see role of incontinence severity index (ISI) in evaluating severity of SUI and to see the impact of treatment of SUI.

Materials and Methods

A total of 40 women with the diagnosis of SUI on history and clinical examination were enrolled. ISI was calculated on all the women before treatment. All women were treated with either conservative treatment (pelvic floor exercises, life style modification, and duloxetine therapy) (4, 10%) or Burch's colposuspension (18, 45%) or tension-free obturator tape (18, 45%) as per clinical situation after discussion with patients. ISI was again calculated 6 months after treatment.

Results

Mean age, parity, body mass index in the study were 41.60 years, 2.73, and 24.2 kg/m², respectively. All 40 (100%) patients had SUI with the mean duration of symptoms being 4.04 years. A total of 11 (27.5%) had moderate SUI (ISI 3-6), while 24 (60%) had severe SUI (ISI 8-9), while 5 (12.5%) had very severe SUI (ISI 12). Range of pretreatment ISI was 3-12 with mean being 8.8 ± 3.2. Posttreatment ISI reduced significantly with range of 1-4 and mean of 1.3 ± 0.4 (P < 0.001). The reduction was significant for all the groups, but there was no significant difference in efficacy of three treatment groups. Statistical analysis was done using SPSS IBM Version 2-1-0 using Chi-square test, Fisher's Extract test, and ANOVA test as appropriate.

Conclusion

ISI is a useful modality to evaluate the severity of SUI and to see the impact of treatment modalities on SUI.

Comparison of Clinical Efficacy and Urodynamic Changes Using Single-incision Slings (MiniArc® vs. Solyx™) for the Treatment of Female Stress Urinary Incontinence

Objective:

To compare the clinical efficacy and urodynamic parameter changes between the MiniArc and the Solyx sling for the treatment of female urodynamic stress incontinence (USI).

Materials and Methods:

One-hundred and thirty (MiniArc n = 79, BS-Solyx n = 51) patients were included in this study. Cough stress test (ST), pad test (PT), Incontinence Impact short form Questionnaire (IIQ-7), Urogenital Distress Inventory six-item questionnaire (UDI-6), Sexual Questionnaire-Short Form (PIS-Q), and urodynamic parametric changes were assessed to determine objective and subjective outcomes following the procedure. Objective cure was defined as negative ST and PT <2 g and subjective cure was defined as “No” to the answer of UDI-6 Question #3. Predictors of surgical failure were also determined.

Results:

All Solyx users, as opposed to 91.1% of MiniArc patients, obtained objective cure at postoperative 3 months (P = 0.042). No significant difference in subjective cure rates (93.7% vs. 90.2% at 3-months (P = 0.513); 89.9% vs. 80.4% at 1 year for Solyx and MiniArc patients, respectively (P = 0.126)) and improvement scores in UDI-6 and IIQ-7 were observed. The Solyx group incurred more de novo urgency (17.6% vs. 6.3% at 3 months (P = 0.042); 23.5% vs. 7.6% at 1 year (P = 0.01)). Both procedures yielded significant decrements in maximal urethral closure pressure (P < 0.001) and average flow rate (P = 0.015). The preoperative PT and sling type were strong predictors of surgical failure, where the Solyx tape reported lower odds (odds ratio = 0.174, P = 0.02) compared to the MiniArc sling.

Conclusion:

Single-incision mini-slings are safe and effective treatment for female USI. The Solyx SIS demonstrated superiority over the MiniArc in this study based on its higher objective cure rate and lower risk for surgical failure.