TOT approach in stress urinary incontinence (SUI) - outcome in obese female

Quality of life following transobturator sling surgery for female stress urinary incontinence

OBJECTIVE

This descriptive study examines quality of life in women undergoing placement of a midurethral sling for stress urinary incontinence.

MATERIALS AND METHODS

This was a retrospective cohort study based on data from 51 women consecutively undergoing this procedure at a tertiary hospital in the years 2014 and 2015. The main outcome variable was quality of life assessed through the Sandvick severity test and International Consultation on Incontinence Short Quality of Life Questionnaire (ICIQ-IU-SF) at the time points baseline or presurgery, and 6 months and 5 years postsurgery. Factors associated with treatment failure were determined through binary logistic regression.

RESULTS

At 5-year follow up we obtained an absolute reduction of 8.78 points (95% CI 6.43-11.14; p < 0.001) in the ICIQ-IU-SF questionnaire and 4.54 (95% CI 3.25-5.83; p < 0.001) in the Sandvick severity test score, compared to baseline, in the 35 patients that completed follow-up. Out of the 51 patients that were followed, the rate of success in incontinence correction was 86.3% (44/50) with a failure rate of 12% (6/50). Multiparity and previous gynaecological surgery were identified as predisposing factors for treatment failure. Obesity was associated with a worse treatment outcome.

CONCLUSION

Sling treatment for incontinence was successful in 86.3% (44/50) of participants and remained effective 5 years after surgery in terms of quality of life.

The Transobturator Tape Versus Retropubic Tension-Free Vaginal Tape in the Treatment of Comorbid and Elderly Women With Stress Urinary Incontinence: A Retrospective Analysis of Over 800 Women

Background and objective The first-line surgical treatment for female stress urinary incontinence (SUI) involves midurethral slings (MUS), including the transobturator tape (TOT) and the retropubic tension-free vaginal tape (TVT). However, whether offering these procedures to older and comorbid women could lead to increased complications is a question that needs to be seriously addressed. In this retrospective cohort study, we aimed to compare the two procedures and evaluate the impact of age, BMI, and comorbidities on complications. Materials and methods A total of 873 procedures (306 TVTs/567 TOTs) performed between 2007 and 2017 were compared and correlated with regard to age, BMI, and comorbidities. Intraoperative complications included bleeding >50 ml, bladder injury, and anesthesia-associated complications. Postoperative complications included post-void residual volume, pain, hematoma, lower urinary tract infection, revision for loosening tape, and bladder infections. The comorbidities were evaluated based on the American Society of Anesthesiologists (ASA) and Charlson scores. Results A total of 873 MUS were conducted during the study period: 306 TVTs and 567 TOTs. Groupwise comparison between these procedures showed that women in the TOT group were older (p<0.001) with a higher BMI (p<0.001) and a higher ASA score (p<0.001) compared to the TVT group. Nevertheless, significantly more intraoperative complications, especially bladder injuries, were recorded in the TVT group. Postoperative complications occurred in 19.4% of the entire cohort, especially increased post-void residual volume. Postoperative hematoma and tape loosening were significantly more frequent in the TOT group. Age, BMI, and comorbidities showed no significant impact on intraoperative complications; however, the TOT procedure was associated with significantly fewer intraoperative complications [p=0.001, odds ratio (OR): 0.281]. Conclusions Overall, both procedures were associated with a low number of perioperative complications. The TOT technique had a lower incidence of intraoperative complications. It must be highlighted that age and comorbidities had no influence on either the intra- or postoperative complication rates. Hence, we recommend that TOT is employed to treat SUI in older, more obese, and comorbid women.

Exploring the relation between obesity and urinary incontinence: Pathophysiology, clinical implications, and the effect of weight reduction, ICI-RS 2018

AIMS

To evaluate the relationship between obesity and urinary incontinence (UI) and to determine the effect of weight reduction on the severity of incontinence.

METHODS

This is a consensus report of the proceedings of a Research Proposal from the annual International Consultation on Incontinence-Research Society, 14 June to 16 June, 2018 (Bristol, UK): "What are the relationships between obesity and UI, and the effects of successful bariatric surgery?"

RESULTS

Obesity is an increasing problem worldwide and is associated with many adverse effects on health and quality of life. From both translational and clinical studies, there is a strong relationship between obesity and the occurrence of UI. Both mechanical and metabolic factors seem to play an important role including systemic inflammation and oxidative stress due to the release of cytokines in visceral adipose tissue. The success rate of anti-incontinence surgery does not seem to be greatly affected by body mass index (BMI), although reliable data and long-term follow-up are currently lacking. Both weight reduction programs and bariatric surgery can result in amelioration of UI. Various studies have shown that weight loss (particularly that associated with bariatric surgery) can reduce incontinence, and the degree of weight loss is positively correlated with improvement in symptoms.

CONCLUSIONS

Obesity is strongly associated with an increased prevalence of both stress and urgency UI. The treatment outcome does not seem to be highly dependent on BMI. Weight reduction is positively correlated with improvement of incontinence symptoms and therefore should be advocated in the management.

24/7 usage of continence pads and quality of life impairment in women with urinary incontinence

AIMS

To compare quality of life (QoL) in women with urinary incontinence (UI) using continence pads during the day versus all day and night; to identify risk factors for a 24-hour pad use; to calculate quality-adjusted life years (QALY).

METHODS

A cross-sectional study in 331 women with lower urinary tract symptoms referred to urogynaecologic examination was conducted. Main outcome measures were the scores of King's Health Questionnaire (KHQ), clinical data, and KHQ-derived utility values.

RESULTS

A total of 270 women with UI were recruited: 176 (57.3%) using continence pads only during the day (group I) and 94 (30.6%) for 24 hours (group II). The groups did not differ in terms of age, menopause, parity, type of UI, stage of POP-Q, and percentage of sexually active subjects. Group II had significantly higher body mass index (BMI) and lower education than group I (P < 0.05). QoL was significantly deteriorated in group II in KHQ Global score and in all domains except one (General Health). Risk factors for 24 hours pad use were as follows: BMI ≥ 30 vs BMI 25-30 (OR = 2.02 (1.09-3.73), P = 0.037), higher scores in KHQ Severity measures (OR = 1.03 (1.02-1.04), P < 0.001), KHQ Global score (OR = 1.03 (1.02-1.05), P < 0.001) and primary compared to secondary (OR = 0.4 (0.19-0.84)) or higher education (OR = 0.41 (0.18-0.94), P < 0.05). Annual QALY was significantly lower in group II (0.9288 ± 0.03 vs 0.9432 ± 0.03, P < 0.001).

CONCLUSION

One-third of women with UI used continence pads for 24 hours. Among these patients QoL and QALY were found lower compared to women using continence pads only during the day. KHQ Severity measures domain was an independent predictor for a 24-hour usage of continence pads.

Intraoperative and early postoperative complications in women with stress urinary incontinence treated with suburethral slings: a randomised trial

Introduction

The midurethral sling has become the current standard for the treatment of female stress urinary incontinence.

Aim

To assess intraoperative complications, early post-operative complications as well as the efficacy of tension-free vaginal tape: retropubic and trans-obturator tape procedures.

Material and methods

The analysis involved 91 tension-free vaginal tape (TVT) and 60 transobturator tape (TOT) procedures. Both groups were comparable in terms of patient characteristics, urodynamic results, and preoperative quality of life (QoL) assessment. The complications were registered, and the effectiveness of the procedures was assessed subjectively by the patients at 1-, 3-, 6- and 12-month follow-up.

Results

A significantly lower risk of intraoperative and early post-operative complications was noted in the case of TOT procedures (OR = 0.35%, 95% CI: 0.13–0.92). Moreover, regardless of the method used, patients with two or more vaginal deliveries in their history had a reduced risk of complications, as compared to nulliparas and uniparas (OR = 0.38%, 95% CI: 0.16–0.91). Previous gynaecological surgery and old age increase the risk of complications with borderline significance (OR = 2.5, 95% CI: 0.97–6.3; OR = 2.3, 95% CI: 0.95–5.5 respectively). The rates of cure, improvement and failure were similar in both groups, as was the significant positive change in post-operative life quality.

Conclusions

TVT and TOT procedures are characterised by a high cure rate and improvement in the post-operative quality of life. However, it seems that the transobturator approach should be the preferred method of treatment of SUI due to the reduced risk of complications, shorter procedure time, and lower intraoperative blood loss.

Influence of age, BMI and parity on the success rate of midurethral slings for stress urinary incontinence

Aims

Our aim was to evaluate, in a second data analysis of the prospective randomized controlled trial conducted by Austrian Urogynaecology Working Group, the effect of age, BMI and parity at the time of surgery on short- and long-term outcomes of women primarily treated for SUI (stress urinary incontinence) with midurethral slings.

Methods

In the original study 554 patients received randomly a retropubic (TVT) or a transobturator midurethral (TVT-O) sling procedure. 480 (87%) and 277 (50%) patients were available for a follow-up efficacy evaluation at 3 months and 5 years respectively.

Results

Higher age and BMI at surgery appear to lead to a larger probability to have a positive stress test 5 years after surgery, but not after 3 months. Older patients seem to have a worse perception of improvement 5 years after surgery as compared to younger ones, as described by the PGI-I score. Age and BMI do not affect significantly the quality of life of women surgically treated for SUI, as reflected by the results of King´s Health Questionnaire. Parity does not seem to have any effect on objective and subjective surgical outcomes.

Conclusions

Higher age and BMI at surgery have a detrimental influence on the objective cure rate at 5 years after midurethral sling surgery; higher age also has a negative influence on subjective long-term outcomes. However, these demographic parameters do not influence significantly the quality of life of patients after anti-incontinence surgery. Parity does not show any significant influence on success rate of midurethral sling.

The impact of overweight in the efficiency and complications of midurethral sling in patients with stress urinary incontinence: a systematic review and meta-analysis

AIMS

To compare the efficiency and complications of normal weight and overweight women with stress urinary incontinence (SUI) after surgery.

METHODS

We searched the PubMed, Embase, and Cochrane Library Databases to identify all compared results, including those involving the terms normal weight, overweight, body mass index (BMI), and SUI. After treatment with surgery, the efficiency (subjective cure rate, objective cure rate, UDI-6, and IIQ-7) and complications were compared between the normal weight and overweight groups.

RESULTS

The study inclusion criteria were met by 20 studies involving 3829 patients. The data synthesized from these studies indicated that the subjective and objective cure rates in the normal weight group were significantly more effective than those in the overweight group (RR 1.07; 95% CI 1.04-1.10; P < 0.00001; RR 1.24; 95% CI 1.18-1.30; P < 0.00001), while the IIQ-7 and UDI-6 were no different between the two groups (MD 0.07; 95% CI - 1.44 to 1.58; P = 0.93; MD 0.18; 95% CI - 1.24 to 1.60; P = 0.81). For the data of complications, only the urgency was more in the overweight group (RR 0.68, 95% CI 0.55-0.84, P = 0.0003).

CONCLUSIONS

The objective success rate and subjective success rate of the surgery were higher in normal weight patients than those in overweight patients. Also, the side effects between the two groups were not significantly different.

Obesity and Stress Urinary Incontinence: Impact on Pathophysiology and Treatment

PURPOSE OF REVIEW

Obesity is highly prevalent and is associated with stress urinary incontinence (SUI). The purposes of this review are to assess the pathophysiology of SUI in the obese female and review the outcomes of weight loss and anti-incontinence surgery in this population.

RECENT FINDINGS

While increased intra-abdominal pressure appears to be the common pathophysiologic link between obesity and SUI, neurogenic and metabolic pathways have been proposed. Both surgical and non-surgical weight loss continue to have beneficial effects on SUI; however, long-term outcomes are largely absent. Midurethral sling (MUS) surgery is largely effective in the obese population, with a complication profile similar to that in non-obese women. Obesity has been shown to be a risk factor for failure of MUS. While weight loss should be the primary modality to improve SUI in the obese woman, MUS remains an effective and safe option in those women undertaking surgery.

The Effect of Bariatric Surgery on Urinary Incontinence in Women

BACKGROUND

Little is known regarding the effect of bariatric surgery on urinary incontinence.

METHODS

Between September 2008 and November 2014, 240 female patients underwent bariatric surgery.

RESULTS

The prevalence of urinary incontinence preoperatively was 45 % (108). Eighty-two (76 %) completed urinary function questionnaires pre-operatively and post-operatively. Fifty-seven (70 %) underwent laparoscopic gastric bypass, twenty-four (29 %) underwent sleeve gastrectomy and one underwent a banding procedure. Thirty-one (38 %) reported leaking on sneezing or coughing-stress urinary incontinence (SUI). Thirteen (16 %) complained of leaking before reaching the toilet-overactive bladder syndrome (OAB). The remaining thirty-eight (46 %) reported mixed symptoms. The mean pre-operative weight and BMI were 133 (18) kg and 50 (SD = 6.2) kg/m(2) respectively. The mean post-operative BMI drop was 16 (SD = 5.2) kg/m(2). Preoperatively, 61 (75 %) reported moderate to very severe urinary incontinence compared to 30 (37 %) post-operatively (χ (2) = 3.24.67, p = 0.050). Twenty-seven (33 %) patients reported complete resolution of their urinary incontinence. Fifty-one (62 %) patients required incontinence pads on a daily basis pre-operatively, compared to 35 (43 %) post-operatively (χ (2) = 22.211.6, p = 0.00). The mean International Consultation on Incontinence Questionnaire- Urinary Incontinence short form (ICIQ-UI SF) score was 9.3 (SD = 4.4) pre-operatively compared to 4.9 (SD = 5.3) post-operatively (t = 7.2, p = 0.000). The improvement score post-operatively was 8 (SD = 3). A significant difference in the ICIQ-UI SF was identified between OAB and SUI groups when adjusting for age, number of children, type of delivery and pre-op BMI (t = 1.98, p = 0.05).

CONCLUSION

Bariatric surgery results in a clinically significant improvement in urinary incontinence. However, this is not proportional to pre-operative BMI, weight loss, age, parity and mode of delivery.

Association between body mass index and pain following transobturator sling

We aimed to prospectively evaluate the association between body mass index (BMI) and development of postoperative-onset pain in women undergoing transobturator midurethral sling procedures. We conducted a prospective, observational cohort study of women undergoing inside-to-out transobturator midurethral sling. At preoperative visit, height, weight, self-reported activity level and baseline pain were documented. At postoperative visits, patients indicated pain location and severity, procedure success, and satisfaction. We used log binomial regression to calculate risk ratios, controlling for potential confounders. For the 129 women included, median age was 50.0 years and BMI was 27.2 kg/m². Adjusting for age and activity level, overweight and obese women had significantly increased risk of postoperative-onset pain compared to normal BMI women. Overweight women were at 1.70 (95%CI 1.05-2.75) times the risk compared to leaner counterparts, whereas obese women were at 1.76 times the risk (95%CI 1.04-2.89). Neither success nor satisfaction was associated with BMI. Impact statement Over three million midurethral slings have been placed worldwide for the treatment or prevention of stress urinary incontinence. The procedure has been studied in lean, overweight and obese populations, and found to have similar efficacy regardless of BMI. Similarly, the risks of midurethral sling have been well-documented, including the risk of pain after transobturator sling. Little attention has been given to whether this risk of postoperative pain varies based on patient BMI. Our previous work suggesting that leaner patients might be at increased risk of postoperative pain following transobturator sling was limited by the shortcomings of a retrospective study design. In this prospective study, we were able to adjust for age and activity level, finding that higher BMI women were at increased risk of postoperative pain, while reporting similar levels of satisfaction with the procedure. Future research is needed to find what differences in anatomy or physiology can explain this finding. From a clinical standpoint, thorough counselling of all patients but particularly those with elevated BMI, is required so that appropriate expectations regarding recovery can be set preoperatively.

Minimally invasive treatment of female stress urinary incontinence with the adjustable single-incision sling system (AJUST ™) in an elderly and overweight population

Introduction

The prevalence of urinary incontinence is increasing. Two major risk factors are overweight and age. We present objective and subjective cure rates of elderly and overweight patients treated with an adjustable single-incision sling system (AJUST™, C.R. BARD, Inc.).

Materials and Methods

Between 04/2009 and 02/2012 we treated 100 female patients with the single incision sling. Patients were retrospectively evaluated by Stamey degree of incontinence, cough test, pad use, and overall satisfaction. The primary outcomes of the study were objective and subjective cure rates, secondary outcomes were the safety profile of the sling and complications.

Results

The overall success rate in this population was 84.6% with a mean follow-up of 9.3 months. The average usage of pads per day decreased from 4.9 to 1.6 and was significantly lower in patients with a BMI <30 (p=0.004). Postoperative residual SUI was also lower in patients with a BMI <30 (p=0.006). Postoperative satisfaction was better in patients with a lower BMI, but this difference did not reach a level of significance (p=0.055). There were no complications such as bleeding, bladder injury, or tape infection.

Conclusions

In elderly and obese patients a considerable success rate is achievable with this quick and minimal invasive procedure. However, the success rate shows a clear trend in favor of a lower body-mass-index. The cut-off point has been identified at a BMI of 30. The AJUST™ system can be regarded as safe and beneficial for elderly and obese patients.

Can the suburethral mesh angle be used to predict trans-obturator tape results?

ABSRACT

PURPOSE: The primary aim of our study was to evaluate mesh movement on ultrasonography and to compare the relationship between suburethral mesh angle and incontinence recurrence.

METHODS

This study was carried out at the University of Selcuk, Konya, Turkey, Beyhekim State Hospital, Konya, Turkey and the Mus State Hospital between September 2012 and January 2015. In total, the results from 109 patients were evaluated in the statistical analysis. The suburethral mesh angle (SMA) is the angle between the two arms of the trans-obturator tape (TOT) mesh under the urethra. This angle was measured at 10 days, 6 months and 1 year after surgery. Potential risk factors for incontinence recurrence and SMA were compared in logistic regression models. The best cut-off value for SMA was calculated to predict incontinence recurrence.

RESULTS

The mean resting SMA did not change with time during follow-up (p = 0.373). However, when comparing coughing SMA values, the first day measurement was significantly different from the other measurements. Another comparison was performed according to the cSMA value at each visit. The difference was significant from the first day. Lung disease and the change in the SMA (cSMA) on day 10 were significant predictors of treatment failure. The cSMA on day 10 to predict first-year treatment failure was 10°, with 61% sensitivity and 96% specificity.

CONCLUSIONS

Measurement of the SMA can be used as a prognostic factor in TOT surgery. Further research is required to determine the importance of SMA as a prognostic factor.

Does body mass index influence the outcome of midurethral sling procedures for stress urinary incontinence?

INTRODUCTION AND HYPOTHESIS

Whether midurethral sling (MUS) procedures are as effective in obese women as they are in women of normal weight is still a matter of controversy. The objective of this study was to determine if body mass index (BMI) influences the outcome of MUS procedures for stress urinary incontinence (SUI).

METHODS

We searched electronic databases including EMBASE, MEDLINE, Web of Science and Ovid evidence-based medicine reviews to identify studies that explored the association between BMI and outcomes of MUS procedures. The studies were rated using the Newcastle-Ottawa scale; the meta-analysis was performed using Review Manager 5.3 software.

RESULTS

This review included 11 studies, 6 prospective cohort studies and 5 retrospective studies, with a total of 2,846 patients. The objective success rates of MUS in patients with BMI >25 kg/m² (overweight and obese) were lower than in patients with BMI 18.5 - <25 kg/m² (normal weight; RR = 0.93, 95 % CI 0.89 - 0.97; P = 0.002). The objective success rates were not significantly different between the overweight group (BMI 25 - <30 kg/m²) and the obese group (BMI ≥30 kg/m²; RR = 0.95, 95 % CI 0.89 - 1.01; P = 0.08). There were no significant differences in subjective outcomes among the different BMI groups: BMI ≥25 kg/m² versus 18.5 - <25 kg/m² (RR = 1.03, 95 % CI 0.97 - 1.10; P = 0.29), and BMI ≥30 kg/m² versus 25 - <30 kg/m² (RR = 0.98, 95 % CI 0.92 - 1.04; P = 0.55).

CONCLUSIONS

The objective success rates of MUS were lower in overweight and obese patients; however, the subjective outcomes of MUS were not significantly different among normal weight, overweight and obese patients. The MUS procedure is as effective in obese women as in women of normal weight, and therefore surgeons should not consider BMI >25 kg/m² as a risk factor when discussing the suitability of the MUS procedure in a patient with SUI.

First assessment of short-term efficacy of Er:YAG laser treatment on stress urinary incontinence in women: prospective cohort study

OBJECTIVES

This is the first assessment of efficacy and safety of the Er:YAG laser in the treatment of stress urinary incontinence. The aim of this study was to assess the short-term outcome of a non-invasive laser treatment for mild-to-severe stages of this condition and to check its applicability in different body mass index and age groups.

METHODS

A prospective cohort, single-center study at the Ob/Gyn Clinic, Zagreb, Croatia recruited a consecutive sample of 73 female patients suffering from stress urinary incontinence. The procedure was performed with a 2940-nm Er:YAG laser (XS Dynamis, Fotona, Slovenia) designed to achieve heating up of vaginal mucosa to around 60°C, 500-700 μm in depth.

RESULTS

The score in the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form was reduced to a median of 46% (95% confidence interval 33-67%; p < 0.001). The reduction was significantly higher in women with normal body mass index (67%) than in overweight women (25%), as well as in women younger than 39 years (100%) compared with those older than 60 years (8%) (p < 0.001). No serious adverse events were noticed.

CONCLUSION

This study of Er:YAG laser therapy in women has demonstrated a clinically relevant, short-term improvement of stress urinary incontinence, with minimal adverse events of a transient nature.

Do severe obese patients with stress urinary incontinence benefit from transobturator tape procedure? 3-year surgical outcome

INTRODUCTION

We evaluate the impact of severe obesity on surgical outcomes of the transobturator tape (TOT) procedure in patients with stress urinary incontinence (SUI).

METHODS

In total, 32 women with severe obesity (body mass index [BMI] >35 kg/m(2)) were included in the study. All patients were preoperatively evaluated with history, pelvic examination, ultrasonography, and cough stress test. All patients completed the International Consultation on Incontinence Questionnaire-Short form (ICIQ-SF) preoperatively and at the postoperative follow-up. Cure of incontinence was defined as being completely dry after surgery. Cure was assessed subjectively and objectively. Subjective improvement defined as an International Consultation on Incontinence Questionnaire-Short form (ICIQ-SF) score ≤12 and satisfaction with surgery. Failure was defined as having no change or worsening of urinary incontinence after surgery. Postoperative patient satisfaction was assessed using a visual analog scale.

RESULTS

The mean follow-up time and mean BMI were 40.9 ± 20.9 months and 38 ± 3 kg/m(2), respectively. According to preoperative ICIQ-SF questionnaire scores, 20 patients (62.5%) had severe and 12 patients (37.5 %) had very severe urinary incontinence symptoms. No patient had slight or moderate symptoms. None of the patients experienced worsening symptoms after surgery. Objective cure, subjective cure, subjective improvement and patient satisfaction rates were 81.2%, 46.8%, 37.5%, and 84.3% respectively. Our overall complication rate was 9.3%. None of the patients experienced intraoperative complications.

CONCLUSION

In experienced hands, TOT is an effective and safe procedure to treat SUI, with minimal complications in severe obese women.

Obesity and pelvic floor dysfunction

Obesity is associated with a high prevalence of pelvic floor disorders. Patients with obesity present with a range of urinary, bowel and sexual dysfunction problems as well as uterovaginal prolapse. Urinary incontinence, faecal incontinence and sexual dysfunction are more prevalent in patients with obesity. Uterovaginal prolapse is also more common than in the non-obese population. Weight loss by surgical and non-surgical methods plays a major role in the improvement of these symptoms in such patients. The treatment of symptoms leads to an improvement in their quality of life. However, surgical treatment of these symptoms may be accompanied by an increased risk of complications in obese patients. A better understanding of the mechanism of obesity-associated pelvic floor dysfunction is essential.

[Female incontinence surgery: state of the art]

Female urinary incontinence represents a medical and social problem with huge impact regarding both patient's quality of life and social costs. The diagnosis is important for therapeutic choice and should consider some factors: the degree of urethral mobility, urodynamics parameters, patient's will and expectations, information about surgical complications and risks. Nowadays suburethral sling evolution and bulking therapy for selected cases consent to perform miniinvasive surgery; the most relevant problem concerns the management of postoperative complications: in this sense autologous slings are used after urethrolisis. In most difficult cases, it is possible to consider artificial sphincter as the best option.