Management of recurrent stress urinary incontinence and urinary retention following midurethral sling insertion in women

Autologous pubovaginal sling for recurrent stress urinary incontinence after two or more failed synthetic midurethral sling

OBJECTIVE

To determine efficacy and safety of salvage autologous pubovaginal sling (PVS) placement after a two or more failed synthetic midurethral sling.

METHODS

Women undergoing autologous PVS placement for two or more failed synthetic MUS between 2008 and 2019 were identified. Those patients were conducted a follow-up examination. Outcomes of surgery were assessed using the cough stress test with a full bladder and symptom questionnaire, including Incontinence Visual Analogue Scale (I-VAS) and Incontinence Quality of Life (I-QOL) questionnaire. Surgical results were categorized into three classes: cured, improved, and failed. Secondary measures included patients' recommendation of autologous fascial sling (AFS).

RESULTS

A total of 18 eligible patients met the criteria, of whom median age at surgery was 67 (52-74) years with a median follow-up of 80 (12-144) months. Preoperatively, all patients were identified by urodynamic test with Valsalva leak point pressure (VLPP) < 60 cmH₂O. All patients had concomitant part sling excision combined with urethrolysis at the salvage operation. At the follow-up examination, sixteen in eighteen (88.89%) patients were cured and improved. The postoperative total score and each individual domain in I-QOL improved significantly compared with the baseline (p < 0.001). Postoperative I-VAS was significantly lower than preoperative (1.3 ± 0.6 vs. 7.8 ± 2.2, p < 0.001). A total of 16 patients (88.89%) recommended the AFS to others. Neither perioperative blood transfusions nor other complications above Clavien level 3 were observed.

CONCLUSIONS

Our study indicates that autologous PVS is effective and safe in women with recurrent stress urinary incontinence after two or more failed synthetic MUS.

Clinical Case Discussion: Repeat Sling Surgery-Should We Offer a Second Sling?

Advantages of secondary sling surgery for persistent or recurrent stress urinary incontinence include low complexity and short operation time, low blood loss, and short hospitalization. Rates of perioperative complications, erosion, and postoperative voiding difficulties are comparable with primary sling surgery. The presence of urethral (hyper)mobility after primary midurethral sling seems to be an important factor affecting success rates of repeat sling surgery.

Complications Following the Insertion of Two Synthetic Mid-urethral Slings and Subsequent Removal

OBJECTIVE

To determine outcomes after removal of two synthetic mid-urethral slings (MUS) at a tertiary care center.

METHODS

Following IRB approval, a retrospective chart review of non-neurogenic, symptomatic women requiring re-operation after ≥2 MUS was performed. Data reviewed by a third party included: demographics, prior anti-incontinence surgery, complications, pelvic/urinary symptoms, subsequent investigations, surgical repair and outcomes (including UDI-6/IIQ-7 questionnaires) at a minimum 6 months follow-up. Cure was defined as being continent, no dyspareunia, and no additional surgical therapy.

RESULTS

Between 2007 and 2014, 21 women met the inclusion criteria. Mean age was 57 years (range: 40-82) and mean follow-up was 30.2 months (range: 6-78). The majority of patients presented with one or more symptoms of voiding dysfunction (95%), urinary incontinence (86%), irritative voiding symptoms (62%), dyspareunia (57%), recurrent urinary tract infections (UTIs) (29%), vaginal extrusion (20%) and erosion involving the urinary tract (5%). Patients had a mean of 2 prior anti-incontinence procedures (range 2-3). Over two-thirds had a combination of retropubic and transobturator MUS. Mean number of pre-operative investigations was 3.5 (1-6) including voiding cystourethrogram, cystoscopy and urodynamics. Two patients had complete remission, 14 partial remission, and five failed. Mean postoperative total UDI-6 and IIQ-7 scores at last clinic visit were 10 (range: 0-16/SD 4.1) and 11 (range: 0-28/SD 10.3), respectively.

CONCLUSION

The management of women with suboptimal outcomes following two synthetic MUS from transvaginal excision results in modest symptomatic improvement but low permanent complete remission and frequent need for additional therapies.

Risk factors for failure of repeat midurethral sling surgery for recurrent or persistent stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

To study the outcomes following repeat midurethral sling (MUS) surgery in patients with persistent or recurrent stress urinary incontinence after failure of primary MUS surgery and risk factors for surgical failure.

METHODS

The medical records of 24 patients who underwent repeat MUS surgery at a single tertiary center from January 2004 to February 2014 were reviewed. The types of MUS used for the repeat surgey were transobturator, retropubic and single incision slings. Objective cure was defined as no demonstrable involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction observed during filling cystometry, and subjective cure was defined as a negative response to Urogenital Distress Inventory six (UDI-6) question 3 during follow-up between 6 months and 1 year postoperatively. The change in the inclination angle between the urethra and pubic axis was measured with introital ultrasonography and the cotton swab test performed.

RESULTS

The objective and subjective cure rates were 79.2 % and 75 %, respectively. There were no differences in demographics between the patients with failure of surgery and those with successful surgery. Significant independent risk factors for failure of repeat MUS surgery were a change in cotton swab angle at rest and straining of <30° (OR 4.6, 95 % CI 2.5 - 7.9°), a change in inclination angle of <30° (OR 4.6, 95 % CI 2.5 - 7.9°), intrinsic sphincter deficiency (OR 3.4, 95 % CI 1.8 - 6.1) and a mean urethral closure pressure of <60 cm H2O (OR 2.9, 95 % CI 1.5 - 4.5). In one patient the bladder was perforated.

CONCLUSIONS

Repeat MUS surgery is safe and has a good short-term success rate, both objectively and subjectively, with independent risk factors for failure related to bladder neck hypomobility and poor urethral function.

The role of bladder neck suspension in the era of mid-urethral sling surgery

INTRODUCTION

Mid-urethral slings are currently considered to be the gold standard for the surgical treatment of stress urinary incontinence, replacing bladder neck suspension techniques which previously occupied this position. In recent years, however, there have been concerns with regard to the use of synthetic material in vaginal surgery.

METHODS

We performed a review of the literature to discuss the role of bladder neck suspension techniques in the current clinical setting.

CONCLUSIONS

Bladder neck suspension techniques consist of vaginal techniques, needle suspension techniques and retropubic techniques. The latter two techniques have been proven to offer durable outcomes for stress urinary incontinence. As compared to autologous slings, the long-term success rates may be considered inferior, but so is the rate of complication, resulting in higher patient satisfaction. Bladder neck suspension techniques may have a role in treating recurrent and/or persisting stress urinary incontinence after (failed) sling surgery and remain of particular interest in patients with stress urinary incontinence when performing concomitant surgery, for example for prolapse.

The changing face of urinary continence surgery in England: a perspective from the Hospital Episode Statistics database

OBJECTIVE

To quantify changes in surgical practice in the treatment of stress urinary incontinence (SUI), urge urinary incontinence (UUI) and post-prostatectomy stress incontinence (PPI) in England, using the Hospital Episode Statistics (HES) database.

PATIENTS AND METHODS

We used public domain information from the HES database, an administrative dataset recording all hospital admissions and procedures in England, to find evidence of change in the use of various surgical procedures for urinary incontinence from 2000 to 2012.

RESULTS

For the treatment of SUI, a general increase in the use of synthetic mid-urethral tapes, such as tension-free vaginal tape (TVTO) and transobturator tape (TOT), was observed, while there was a significant decrease in colposuspension procedures over the same period. The number of procedures to remove TVT and TOT has also increased in recent years. In the treatment of overactive bladder and UUI, there has been a significant increase in the use of botulinum toxin A and neuromodulation in recent years. This coincided with a steady decline in the recorded use of clam ileocystoplasty. A steady increase was observed in the insertion of artificial urinary sphincter (AUS) devices in men, related to PPI.

CONCLUSIONS

Mid-urethral synthetic tapes now represent the mainstream treatment of SUI in women, but tape-related complications have led to an increase in procedures to remove these devices. The uptake of botulinum toxin A and sacral neuromodulation has led to fewer clam ileocystoplasty procedures being performed. The steady increase in insertions of AUSs in men is unsurprising and reflects the widespread uptake of radical prostatectomy in recent years. There are limitations to results sourced from the HES database, with potential inaccuracy of coding; however, these data support the trends observed by experts in this field.

Cystoscopy and other urogynecologic procedures

Female pelvic medicine and reconstructive surgery (FPMRS) is a rapidly expanding surgical specialty that focuses on the evaluation and treatment of pelvic floor disorders in women. Evaluation and treatment of several pelvic floor disorders can be accomplished with office-based procedures, yielding significant advantages to the patient, physician, and health system. This article describes the common and more useful office-based procedures for the FPMRS physician, covering 4 major categories: cystourethroscopy, procedures for stress urinary incontinence, procedures for urge urinary incontinence, and management of surgical complications.

Effectiveness of mesh compared with nonmesh sling surgery in Medicare beneficiaries

OBJECTIVE

To assess the effectiveness of mesh compared with nonmesh slings placed in different surgical settings as measured by the frequency of complications within 1 year.

METHODS

We performed a retrospective cohort study of Medicare beneficiaries undergoing sling surgery from 2006 to 2008 in hospital outpatient departments and hospital-based ambulatory surgery centers. Slings were identified and categorized according to the use of mesh by Healthcare Common Procedure Coding System codes and temporary "C" Healthcare Common Procedure Coding System codes. Patients were followed for 1 year after each procedure to identify complications. Logistic models were fit to assess relationships among sling type, surgical setting, and various complications.

RESULTS

We identified 6,698 Medicare beneficiaries who underwent mesh sling procedures and 445 Medicare beneficiaries who underwent nonmesh sling procedures. The overall frequency of complications was similar between the two groups at 69.8% and 72.6% in the mesh and nonmesh groups, respectively (P=.22). Infectious complications were the most common complication at 45.4% and 50.1% of the mesh and nonmesh groups, respectively (P=.06). Patients undergoing mesh procedures were less likely than patients undergoing nonmesh procedures to require management for bladder outlet obstruction (13.9% compared with 19.3%, adjusted odds ratio [OR] 0.66, 95% confidence interval [CI] 0.52-0.85) and were less likely to have a subsequent sling removal and revision or urethrolysis (2.7% compared with 4.7%, adjusted OR 0.56, 95% CI 0.35-0.89).

CONCLUSION

Frequencies of most complications were similar regardless of the use of mesh except for the management of bladder outlet obstruction. These results did not differ based on the surgical setting where the sling procedure was performed.

LEVEL OF EVIDENCE

II.

Persistent and recurrent stress urinary incontinence following mid-urethral tape surgery in women: a UK perspective

Stress urinary incontinence is a common health problem that affects a large proportion of women in Britain. It poses physical and psychological implications for the affected women and is a frequent indication for referral to tertiary urology centres. Midurethral tape surgery (MUTS) has established itself as the standard first-line surgical treatment as a result of its low morbidity, short hospital stay and high long-term success. Failure of the initial surgery can present as persistent or recurrent symptoms. This is a major challenge to the treating urologists as a result of the complicated nature of the condition and the lack of strong evidence supporting individual treatment modalities. In this article we discuss the factors associated with MUTS failure and the surgical options for its treatment.