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

Which parameters, related to the female urethra and pelvic floor, determine therapy selection for recurrent female stress urinary incontinence: ICI-RS 2023?

INTRODUCTION

The evidence basis for therapy selection in women who have failed primary stress urinary incontinence (SUI) surgery is limited. The ICI-RS group discussed the available data at its meeting in June 2023, particularly the anatomical characteristics as assessed using magnetic resonance imaging (MRI) and ultrasound (US) modalities, functional characteristics associated with storage and voiding urodynamic assessment, as well as the patient characteristics that might influence outcomes. This paper summarizes the evidence base that supported these discussions and offers the basis for research proposals for future groups.

METHODS

A literature search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was performed, and the data is presented. Research questions are based on the knowledge gaps highlighted.

RESULTS

Possible MRI parameters that may influence outcomes were striated urethral sphincter volume, bladder and proximal urethral funneling, pubo-urethral ligament integrity, distance of the bladder neck below the pubococcygeal line, posterior urethra-vesical angle, and bladder neck to levator ani distance. US parameters included sling distance to the urethral lumen and pubis, sling position, bladder neck mobility, and lateral arm asymmetry, twisting, or curling. Urodynamic parameters included detrusor overactivity, Valsalva leak point pressure, maximum urethral closure pressure, and bladder outlet obstruction. Important patient parameters included body mass index, age, and previous interventions.

CONCLUSIONS

Identifying and quantifying causative factors in patients with recurrent SUI, that allow clinicians to modify subsequent treatment choices and techniques may help reduce treatment failure and complications. Formulating algorithms is the next step in optimizing patient counseling, surgical selection, and healthcare allocation.

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.

The impact of partially absorbable midurethral slings in stress urinary incontinence surgery: a cohort study

OBJECTIVES

To evaluate the performance of retropubic midurethral slings (MUS) for the treatment of female stress urinary incontinence (SUI) of a certified continence center and to identify risk factors for sling failure.

METHODS

This was a single-center cohort study including women, who underwent retropubic MUS procedure for SUI between 2012 and 2019 with a follow-up of 12 months. Primary endpoint was cure of SUI assessed by the validated questionnaire International Consultation of Incontinence-Questionnaire-Urinary Incontinence-Short Form. Univariate and multivariate analyses were applied to identify risk factors for sling failure. Wilcoxon signed-rank tests were used as paired samples tests. The significance level was set at 5%.

RESULTS

662 women with a median age of 65 (IQR 19) were included in the investigation. 523 (79.0%) presented with complicated SUI. Cure was reported by 213 (32.2%) women. Independent predictors for failure were obesity, pharmacotherapy for overactive bladder, postoperative sling adjustment and the utilization of partially absorbable mesh (PAS). PAS correlated with a 56% decrease in the odds for achieving cure.

CONCLUSIONS

This investigation questions the role of partially absorbable mesh for stress urinary incontinence procedures and hereby scrutinizes the utilization of implants with inadequate clinical evidence.

Predictors of cure and overactive bladder syndrome after a mid-urethral sling procedure in women with stress urinary incontinence

OBJECTIVES

To determine predictive factors for the cure of stress urinary incontinence (SUI) or persisting or de novo overactive bladder syndrome (OAB) after a mid-urethral sling procedure (MUS) for women with SUI, especially for menopausal women.

STUDY DESIGN

All women who had consecutively received MUS for SUI between January 2008 and July 2019 in a tertiary referral center were reviewed.

MAIN OUTCOME MEASURES

Multivariable Cox proportional hazards model or logistic regression analysis was used to assess the predictors of cure and persisting or de novo OAB after MUS.

RESULTS

A total of 385 women had undergone MUS, of whom 265 (68.8%) were menopausal. The multivariable Cox proportional hazards model revealed that age (hazard ratio = 1.04), and preoperative detrusor overactivity (hazard ratio = 2.26) were independent predictors of persisting/recurrent SUI. Among the 216 women with preoperative OAB, 109 (50.5%) experienced resolution of their OAB after MUS; and among 169 women without preoperative OAB, twenty-five (14.8%) women developed de novo OAB after MUS (p < 0.0001). Preoperative OAB (hazard ratio = 3.97), small voided volume (hazard ratio = 0.83), and preoperative detrusor overactivity (hazard ratio = 1.62) were predictors of postoperative OAB. In addition, six (1.6%) women had mesh extrusion. Parity (odds ratio = 2.08) was the sole predictor of mesh extrusion. Menopause (hazard ratio = 1.69) was a predictor of postoperative OAB in the univariate analysis. However, menopause was not a predictor of cure or OAB in the multivariable analysis.

CONCLUSIONS

Age and preoperative detrusor overactivity were independent predictors of persisting/recurrent SUI. In addition, preoperative OAB, small voided volume, and preoperative detrusor overactivity were predictors of postoperative OAB. These findings could serve as a guide for preoperative consultation for MUS.

Long-term outcomes of transobturator suburethral tapes for female stress urinary incontinence

AIMS

The aim is to evaluate long-term effectiveness and safety of transobturator midurethral slings (TO-MUS) for treating female stress urinary incontinence (SUI). Possible risk factors for failure and complications are also evaluated.

METHODS

A descriptive retrospective study was performed among women with SUI treated at a tertiary urogynecology unit between January 2004 and December 2006. Women with stress-predominant mixed urinary incontinence or with associated pelvic organ prolapse were also included. Postoperative follow-up was performed at 1, 6, and 12 months and yearly thereafter. Outcomes were classified as cured, improved or failed.

RESULTS

Of 896 women operated on over the study period, 565 were suitable for the analysis. Of them, 327 women completed the 5-year, 225 the 7-year, and 172 the 10-year follow-up periods. Success rates were 77.6%, 73.8%, and 73.2% at 5, 7, and 10 years, respectively. On multivariate Cox regression models age, body mass index, and previous incontinence surgery were related to failure. Complications of any type were described in 24.9% of patients, although most of them were mild. Only concomitant prolapse surgery was related to intraoperative and peroperative complications and the inside-out route to an increased odds of groin pain (odds ratio = 4.0).

CONCLUSIONS

This study showed that TO-MUS is an effective and safe procedure in the long-term. The expected outcomes and possible side effects profile should be discussed in detail during the counseling process before opting for a treatment option.

A new titanium-covered transobturator tape for surgical treatment of stress urinary incontinence

Introduction and hypothesis

To assess the long-term satisfaction, cure rate and safety of a new titanium-covered transobturator tape compared to polypropylene tape for the treatment of stress urinary incontinence (SUI).

Methods

A prospective study was conducted with 151 patients. Seventy patients underwent transobturator sling surgery with titanium tape from 2011 to 2019, and a historical control group (CG) of 81 patients was treated with a noncoated tape and underwent incontinence surgery from 1999 to 2009. We compared patient-reported outcome measures (PROMs) with the incontinence outcome questionnaire (IOQ).

Results

The median follow-up was 2½ years in both groups. Based on responses to the IOQ, a statistically significantly shorter time of recovery (IOQ 15: 21.3 ± 26.4 [TG], 40.2 ± 38.5 [CG], p = 0.02), improvement of sex life (IOQ 13: 34.1 ± 29.4 [TG] vs. 65.3 ± 35.6 [CG], p = 0.01) and less voiding dysfunction (IOQ 19: 30.9 ± 28.1 [CG], 9.3 ± 18.6 [TG], p = 0.01) were observed in the TG. Objectively, no postoperative urinary retention was observed in the TG, but four cases were described in the CG. Ten patients needed a reoperation for SUI in the CG compared to three in the TG (p = 0.03).

Conclusion

The titanium-covered transobturator sling had superior recovery time, improved sexual function and reduced reoperation rate compared to a historical polypropylene group.

Previous obstetrical history does not impact short-term mid-urethral sling outcomes

Abstract

Introduction and hypothesis

Pregnancy and delivery are known risk factors for stress and mixed urinary incontinence. The most common surgical treatment is mid-urethral sling (MUS) surgery. This study evaluated the potential impact of the obstetrical history on the short-term subjective and objective failure rates after MUS surgery.

Methods

A registry-based surgical cohort study using data from the Medical Birth Registry of Norway (MBRN) and the national Norwegian Female Incontinence Registry (NFIR). Data from 14,787 women that underwent MUS surgery from 1998 to 2016 with complete registrations in the MBRN were included. Outcomes were 6–12-month postoperative subjective and objective failure rates. The potential impact of obstetrical and constitutional factors on both outcomes was tested in a multivariate logistic regression model.

Results

Several obstetrical variables seemed to impact both outcomes in the univariate analyses. However, in the multivariate analyses, none of the obstetrical variables significantly impacted subjective failure, and only being nulliparous before MUS surgery remained a risk factor for objective failure [aOR 1.60, (95% CI 1.07–2.40), p = 0.022]. High body mass index at time of surgery, non-retropubic slings, high preoperative urgency symptom load, and surgical complications were all strong risk factors for poor outcomes in the multivariate analyses.

Conclusion

Although childbirth is considered a risk factor for developing stress urinary incontinence, childbirth does not appear to affect the result of MUS in parous women. Our results suggest that nulliparous women with SUI may have a different pathophysiology than SUI after childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04836-5.

Incontinencia urinaria: causas y cuidados de enfermería. Una revisión bibliográfica

frecuencia en el sexo femenino y conforme aumenta la edad, provocando una disminución de la calidad de vida.Objetivo: Sintetizar la evidencia científica relacionada con las causas, tratamiento y cuidados de enfermería en la incontinencia urinaria.Metodología: Se ha realizado una revisión bibliográfica sistematizada en las bases de datos Proquest, Pubmed, Google Académico y Scielo, utilizando como términos "incontinencia urinaria" (urinary incontinence), "factoresde riesgo" (risk factor), "intervenciones de enfermería"(nursing intervention) y "procedimientos terapeúticos"(therapeutics), con una limitación de 5 años en la búsqueda. Se incluyeron estudios experimentales y de revisión.Resultados: Se incluyeron 26 artículos: 5 estudios experimentales,18 revisiones sistemáticas y 3 metaanálisis.La incontinencia urinaria está relacionada con la edad, sexo y factores de riesgo, dependiendo del tipo e intensidad de la incontinencia, y características propias del paciente. El abordaje es interdisciplinar, con técnicasmenos invasivas al principio, entre las que destacan la terapia conductual y los ejercicios del suelo pélvico; necesitándose cirugía en algunos casos, según las circunstanciasindividuales de los pacientes y/o la no existenciade mejoría con las técnicas menos invasivas.Conclusiones: La incontinencia urinaria se encuentra estrechamente relacionada con la edad y el sexo; sin embargo, la existencia de factores de riesgo y algunas causas pueden contribuir a aumentar las probabilidadesde su establecimiento. La labor enfermera resulta prometedora en el establecimiento de una detección y actuación precoz ante el problema, teniendo como base siempre para el tratamiento el menor grado de invasión.

Predictors of further anti-incontinence interventions or transvaginal urethrolysis after a pubovaginal sling procedure in women with and without neurologic disorders

BACKGROUND/PURPOSE

The impact of neurologic disorders on the clinical outcome of suburethral sling procedures has seldom been studied. Our aim is to elucidate factors predicting further anti-incontinence interventions or transvaginal urethrolysis after a re-adjustable pubovaginal sling procedure (PVS), especially in patients with neurologic disorders.

METHODS

Medical records of all consecutive women who underwent re-adjustable PVS for stress urinary incontinence (SUI) were reviewed.

RESULTS

A total of 589 women were enrolled, 152 (25.8%) women were found to have persistent or recurrent SUI after surgery, and 39 (6.6%) women underwent further anti-incontinence interventions. Postoperative voiding dysfunction was found in 46 (7.8%) women, and 23 women (3.9%) underwent transvaginal urethrolysis. Low body mass index (hazard ratio = 0.92) and low functional bladder capacity (dL, hazard ratio = 0.83) were factors predicting the presence of persistent/recurrent SUI. However, the presence of spinal cord disorder (hazard ratio = 8.91) and a history of prior surgery for pelvic organ prolapse (hazard ratio = 2.51) were factors predicting further anti-incontinence interventions. A high post-void residual volume (PVR, dL, hazard ratio = 1.52) and preoperative bladder outlet obstruction (BOO, hazard ratio = 5.39) were factors predicting postoperative voiding dysfunction. Similarly, a high PVR (dL, hazard ratio = 1.50) and preoperative BOO (hazard ratio = 5.38) were factors predicting transvaginal urethrolysis. A PVR >1.51 dL was an optimal cut-off value for predicting transvaginal urethrolysis.

CONCLUSION

The presence of spinal cord disorder and prior surgery for pelvic organ prolapse were predictors of further anti-incontinence interventions after re-adjustable PVS. In addition, a large PVR and preoperative BOO were predictors of transvaginal urethrolysis after re-adjustable PVS.

Impact of severe obesity on long-term success and complications of the retropubic midurethral sling

INTRODUCTION AND HYPOTHESIS

With conflicting evidence in the literature, we hypothesised that the long-term subjective outcomes of the retropubic midurethral sling (MUS) are the same in the severely obese and non-obese populations.

METHODS

A retrospective matched cohort study was performed on women with a BMI ≥ 35 and < 30 who had a retropubic MUS placed between 2010 and 2015 using telephone questionnaires. The primary outcome was the success rate of surgery defined by the Urogenital Distress Inventory Short Form (UDI-6) stress subscale. Statistical analysis was performed to test for associations between primary and secondary outcomes across the two groups.

RESULTS

Seventy-eight severely obese (SOG) and 74 non-obese (NOG) were recruited. At a median time from surgery of 3.8 years the success rate was 47.4% in the SOG compared to 64.9% in the NOG (p = 0.03). There was a 22% reduction in the odds of success with every 5 unit increase in BMI (p = 0.03). There were higher rates of mixed urinary incontinence preoperatively (60.3% vs. 37.8%, p = 0.006) and persistent urinary urge incontinence postoperatively (48.7% vs. 32.4% p = 0.04) in the severely obese. Lower PGI-I scores were obtained in the severely obese group indicating less improvement in symptoms from surgery. There was no difference in complication rates between the groups.

CONCLUSION

Long-term subjective outcomes from the retropubic MUS are lower in severely obese women than in non-obese women with no difference in complication rates. High satisfaction and recommendation rates were found in both groups.

Complications and re-operations after tension-free vaginal tape operation in women with stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We evaluate intraoperative and short-term postoperative (≤ 3 months) complications and long-term re-operations (up to 6 years) after tension-free vaginal tape (TVT) operation in women with stress urinary incontinence (SUI).

METHODS

Data from 446 women undergoing TVT operation between 2012 and 2016 at a tertiary referral center was retrospectively collected. Data included patient baseline demographics, information from the TVT operation and the following postoperative period, and scores from patient questionnaires [the International Consultation of Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and Patient Global Impression of Improvement (PGI-I)]. Collected data were investigated for incidence of complications and re-operations, postoperative improvement in patient questionnaires, and association between complications and baseline patient demographics.

RESULTS

The only intraoperative complication was bladder perforation (2.0%). Postoperative complications included: infection (0.7%), hematoma (0.9%), bleeding (0.2%), pain (0.9%), erosion of the vaginal mucosa (1.1%), persistent SUI (0.7%), and voiding dysfunction > 24 h (10.3%). Re-operations included: operation due to infections (0.4%), incontinence surgery for persistent SUI (0.4%), revision for tape erosion (1.1%), tape mobilization (3.6%), and tape division (0.2%). A significant reduction in urinary incontinence symptoms was observed in the ICIQ-UI SF and PGI-I. The reduction in ICIQ-UI SF did not vary significantly between patients with and without complications. No association between complications and baseline patient demographics was found.

CONCLUSION

This study demonstrated high safety and efficacy of the TVT operation with only minor short-term complications and few long-term re-operations. The ICIQ-UI SF improved significantly postoperatively and was not statistically significantly affected by the occurrence of complications.

Outcomes and failure risks in mid-urethral sling insertion in elderly and old age with urodynamic stress incontinence

INTRODUCTION AND HYPOTHESIS

To study the surgical outcomes and risk factors for failure of three types of mid urethral slings(MUS) surgeries in elderly and old age women with urodynamic stress incontinence(USI).

METHODS

Three different types of MUS surgeries [single incision sling(SIS), trans-obturator tape(TOT), retro-public mid-urethral sling-tension-free vagina tape (TVT)]were performed among three age groups of women (young <64 yr, elderly 65-74 yr and old >75 yr) with USI. They were followed up for 1 year.

RESULTS

Complete postoperative data was available for 688 women. After 1 year, overall objective cure rate was 88.2% and subjective cure rate was 85.9%. Among the young, elderly, and old age women objective cure rates were 91.0%, 80.6%, 66.7% and subjective cure rates were 89.2%, 77.6%, 58.3% respectively. Urodynamic parameters demonstrated flow rate, higher post-void bladder residual, smaller cystometric capacity, and lower maximum urethral closure pressure were significantly lower among old and elderly group. Subjectively, urinary distress inventory-6 (UDI-6) and incontinence impact questionnaire-7(IIQ-7) improved significantly in all groups with significant changes from baseline only in older women. Intrinsic sphincter deficiency(ISD) was found to be significantly associated with failure in older women. Other preoperative comorbidities were equally distributed among all the three age groups. The operative time, perioperative complications, and length of hospital stay showed no difference between the study groups.

CONCLUSIONS

MUS surgery is safe for the young and aging patients with USI and demostrated significant improvement in its outcomes, but objective and subjective cure rates decreases with age. ISD was also found to be significantly associated with failure.

Impact of age on outcomes of midurethral sling procedures in women

INTRODUCTION AND HYPOTHESIS

Trans-obturator tape (TOT) and tension-free vaginal tape (TVT) comprise minimally invasive surgical management for stress urinary incontinence (SUI). The aim of this retrospective cohort study was to investigate outcomes of TOT and TVT among different age groups of women.

METHODS

Medical records of patients who underwent TOT and TVT from January 2010 to December 2015 were reviewed. Patients were stratified into three groups according to age. All patients were interviewed routinely before and after surgery. The primary outcome was cure rate after surgery. Secondary outcomes included hospital stay, operative time, blood loss in surgery, and complication rate. A total of 616 patients diagnosed with SUI and 262 patients who had not undergone any concurrent surgery were eligible for study inclusion.

RESULTS

A total of 616 patients diagnosed with SUI and 262 patients who had not undergone any concurrent surgery were eligible for study inclusion. There were 81 patients in group 1 (≤ 50 years), 97 patients in group 2 (51-59 years), and 84 patients in group 3 (≥ 60 years). After surgery, there were no significant differences in cure rates among the three groups (96.3% vs. 94.8% vs. 97.6%, P = 0.623). There were also no significant differences in operation time, blood loss, hospital stay, and complication rate among the three groups. When analyzing the TOT group (217 patients) and TVT group (45 patients) separately, primary and secondary outcomes did not differ significantly according to age group.

CONCLUSIONS

As surgical management for SUI, midurethral sling procedures, both TOT and TVT, were found to be safe and effective among different age groups.