Surgical treatments for women with stress urinary incontinence: the ESTER systematic review and economic evaluation

Invasive urodynamic investigations in the management of women with refractory overactive bladder symptoms (FUTURE) in the UK: a multicentre, superiority, parallel, open-label, randomised controlled trial

BACKGROUND

Overactive bladder is a common problem affecting women worldwide, with a negative effect on their social and professional lives. Before considering invasive treatments, guidelines recommend urodynamics to identify detrusor overactivity. However, the clinical-effectiveness and cost-effectiveness of urodynamics has never been robustly assessed in this cohort of women. We aimed to compare the clinical-effectiveness and cost-effectiveness of urodynamics plus comprehensive clinical assessment (CCA) versus CCA only in the management of women with refractory overactive bladder symptoms.

METHODS

We did a multicentre, superiority, parallel, open-label, randomised controlled trial in 63 UK hospitals. Women aged 18 years or older with refractory overactive bladder or urgency predominant mixed urinary incontinence, with failed conservative management and being considered for invasive treatment, were randomly assigned (1:1) to urodynamics plus CCA versus CCA only. Assignment used an internet-based application with stratified random permuted blocks and site and baseline diagnosis as stratum. Primary outcome was participant-reported success at the last follow-up timepoint, measured by the Patient Global Impression of Improvement at 15 months after randomisation. Primary economic outcome was incremental cost per quality-adjusted life-year (QALY) gained modelled over the participants lifetime. Analysis was based on the intention-to-treat principle. This study is registered with ISRCTN registry (ISRCTN63268739).

FINDINGS

Between Nov 6, 2017, and March 1, 2021, 1099 participants were randomly assigned to urodynamics plus CCA (n=550) or CCA only (n=549). At the final follow-up timepoint, participant-reported success rates of "very much improved" and "much improved" were not superior in the urodynamics plus CCA group (117 [23·6%] of 496) versus the CCA-only group (114 [22·7%] of 503; adjusted odds ratio 1·12 [95% CI 0·73-1·74]; p=0·60). Serious adverse events were low and similar between groups. Incremental cost-effectiveness ratio was £42 643 per QALY gained. The cost-effectiveness acceptability curve showed urodynamics had a 34% probability of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY gained, which reduced further when extrapolated over the patient's lifetime.

INTERPRETATION

In women with refractory overactive bladder or urgency predominant mixed urinary incontinence, the participant-reported success in the urodynamics plus CCA group was not superior to the CCA-only group, and urodynamics was not cost-effective at the £20 000 per QALY gained threshold.

FUNDING

UK National Institute for Health and Care Research Health Technology Assessment Programme.

Exploring the role of laser therapy for stress urinary incontinence: a literature review

Stress urinary incontinence (SUI) significantly impacts the quality of life, necessitating innovative treatment options beyond conventional approaches. This comprehensive review aimed to evaluate laser therapy as a promising intervention for SUI management. A systematic search was conducted using the keywords "laser" and "stress urinary incontinence" in the PubMed, Scopus, Web of Science, and Embase databases. The search covers studies from January 1, 2014, to November 30, 2024. A comparative analysis with traditional treatments, such as pelvic floor exercises and medications, underscores the potential advantages and limitations of laser therapy. Clinical studies and research findings are examined to evaluate the efficacy and safety profile of laser therapy, including its short-term success rates and potential complications. Patient experiences and perspectives provide a qualitative dimension, offering insights into the real-world impact and challenges associated with laser therapy for SUI. This review also explores the cost-effectiveness of laser therapy and compares its long-term and short-term effects, positioning it within the broader landscape of SUI management. Future trends and ongoing research are outlined, highlighting the potential integration of laser therapy with multimodal approaches. Recommendations for clinical practice emphasize patient selection criteria and address concerns and expectations, ensuring laser therapy is adopted as a valuable and evidence-based addition to SUI management.

Prevalence, Diagnosis, and Management of Stress Urinary Incontinence in Women: A Collaborative Review

BACKGROUND AND OBJECTIVE

Stress urinary incontinence (SUI), defined as any involuntary leakage of urine associated with physical activity, remains underdiagnosed and undertreated. This review aims to provide an updated overview of the prevalence, diagnosis, and treatment of SUI in women, drawing upon recent evidence-based literature and clinical guidelines.

METHODS

A systematic search of the MEDLINE database was conducted to identify only the most up-to-date and relevant studies published up to February 26, 2024, including the reference ESTER systematic review. The search was limited to systematic reviews published in the preceding 1 yr. Any additional included publications were limited to those published or referenced as part of the existing/current guidelines.

KEY FINDINGS AND LIMITATIONS

Diagnosis of SUI involves a comprehensive assessment, including medical history, physical examination, and in some cases, invasive urodynamics. Pelvic floor muscle training emerges as a first-line management strategy, showing efficacy in symptom improvement when good educational instructions and supervision are provided. Surgical interventions with midurethral and single-incision slings offer a second-line option, although concerns regarding mesh-related complications persist with a decrease in its use. Moreover, the long-term efficacy of single-incision slings remains to be confirmed. Urethral bulking agents, colposuspension, and autologous fascial slings are existing alternatives supported by robust evidence, albeit with a different adverse event profile. Management of complicated and severe SUI remains challenging, with autologous fascial sling and artificial urinary sphincters being established treatments, but high-quality data remain lacking.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Heightened awareness and accessibility to SUI treatment are imperative to address the gap between prevalence and medical care-seeking behavior. Pelvic floor muscle training and surgical interventions represent key modalities. However, a notable escalation in invasiveness and complication rates when transitioning to surgical interventions is clear and has resulted in a hesitance among patients to proceed along the treatment continuum, particularly in light of mesh-related complications. Ongoing research is necessary to optimize outcomes and ensure patient safety, particularly for complicated SUI where data on comparative effectiveness remain limited.

The Impact of Pelvic Organ Prolapse on the Long-Term Outcomes of Transobturator Tape (TOT) Procedures-A Retrospective Study

Objectives: Transobturator tape (TOT) procedures are a widely used and effective treatment for stress urinary incontinence (SUI), but there is limited research on mesh-related complications and revision surgeries. This study aimed to evaluate the incidence of revision surgeries and mesh-related complications following TOT procedures and identify potential risk factors influencing these outcomes. Methods: This retrospective study analyzed data from patients who underwent TOT procedures at the specialized incontinence center of University Hospital Aachen (UHA), Germany, between January 2010 and May 2023. Patients were divided into three groups: initial surgery without revision, initial surgery with revision, and external referrals requiring revision. Statistical analyses included multivariate logistic regression and predictive cross-validation to identify risk factors for revision and mesh-related complications. Results: Out of 265 TOT procedures performed, the revision rate was 8.7%, and the mesh-related complication rate was 2.6%. Mesh complications, including erosion and wound dehiscence, accounted for 30% of revisions, while 70% of revisions were caused by recurrent stress urinary incontinence (SUI). External referrals showed longer revision intervals compared to UHA patients (53 months vs. 5 months; p = 0.003). Multivariate analysis identified rectoceles as a protective factor against revisions (p = 0.0414), while pre-existing conditions significantly increased revision risk (p = 0.0100). Conclusions: The revision rate following TOT procedures was 8.7%, with mesh-related complications accounting for 2.6%. Pre-existing conditions significantly increased the risk of revision, while rectoceles were associated with improved outcomes. These findings emphasize the importance of identifying patient-specific risk factors to enhance the safety and success of TOT procedures.

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.

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.

Long-Term Outcomes of Tension-Free Vaginal Tape Obturator: Efficacy and Safety at Long-Term Follow-Up

Background/Objectives: The use of tension-free vaginal tape obturator (TVT-O) for the treatment of stress urinary incontinence (SUI) has been widely debated over the last decade due to the lack of evidence on its long-term outcomes. The aim of this prospective study is to assess, for the first time in the available literature, the efficacy and safety of TVT-O implantation in women with pure SUI over a 17-year follow-up period. Methods: We included all women who complained of pure SUI symptoms (confirmed urodynamically) and underwent the TVT-O procedure. An objective cure was defined as the absence of urine leakage during the stress test, while subjective outcomes were assessed by means of the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the Patient Global Impression of Improvement (PGI-I) scale, and a Visual Analogue Scale (VAS). Results: A total of 70 patients who met the inclusion criteria underwent the TVT-O procedure. During the study period, no patients were lost to follow-up, and all women completed the last evaluation at the 17-year mark. At the 17-year mark of follow-up, 62 out of 70 patients (81.4%) were subjectively cured, and 56 out of 70 (80%) patients were objectively cured. These data do not reveal any significant variation in the surgical outcomes over the follow-up period. We recorded seven (10%) tape exposure (three occurred after 10 years and four after 17 years). Among these, one woman was symptomatic for dyspareunia and "hispareunia". All patients with mesh exposure were treated with partial removal and re-suture of the vagina, but only one developed the recurrence of SUI that required a second treatment with a urethral bulking agent (UBA). In all other cases, women reported a complete resolution of symptoms without any worsening of the urinary continence. No significant bladder or urethral erosion was recorded. Conclusions: The 17-year evaluation of the TVT-O procedure has shown that it is a highly effective and safe option for the treatment of female SUI. Although there was an increased risk of tape exposure 17 years after implantation, no serious complications were reported, and no patient required the total removal of the sling.

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.

Sonography as a Diagnostic Tool in Midurethral Sling Complications: A Narrative Review

Despite the established safety and efficacy of midurethral slings (MUS), which are the current gold standard treatment for stress urinary incontinence (SUI), the potential for postoperative complications remains a significant concern for both healthcare professionals and patients. Meanwhile, sonography has emerged as a significant diagnostic tool in urogynecology, and one of the applications of this imaging modality may be the evaluation of complications arising from MUS procedures. This review, based on a comprehensive literature search, focuses on the use of pelvic floor ultrasound (US) in the context of MUS complications. It includes analyses of randomized controlled trials, prospective, and retrospective studies, covering preoperative and postoperative investigations, to assess complications such as persistent and recurrent SUI, urinary retention and obstructive voiding, de novo urgency/overactive bladder, vaginal exposure, sling erosion, pain, and hematoma. The review critically examines the existing literature, with a particular focus on recent publications. Despite the variability in findings, it appears that for each of the discussed complications, the application of pelvic floor US can significantly support the diagnostic and therapeutic process. The paper also identifies potential future directions for the development of US applications in diagnosing MUS complications.

Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register

BACKGROUND

Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them.

OBJECTIVE

This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence.

STUDY DESIGN

This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery.

RESULTS

A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence.

CONCLUSION

The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

Three-year cost utility analysis of mini versus standard slings: A trial based economic evaluation

Objective

To report on the cost-effectiveness of adjustable anchored single-incision mini-slings (mini-slings) compared with tension-free standard mid-urethral slings (standard slings) in the surgical management of female stress urinary incontinence (SUI).

Patients and Methods

Data on resource use and quality were collected from women aged ≥18 years with predominant SUI undergoing mid-urethral sling procedures in 21 UK hospitals. Resource use and quality of life (QoL) data were prospectively collected alongside the Single-Incision Mini-Slings versus standard synthetic mid-urethral slings Randomised Control Trial (SIMS RCT), for surgical treatment of SUI in women. A health service provider's (National Health Service [NHS]) perspective with 3-year follow-up was adopted to estimate the costs of the intervention and all subsequent resource use. A generic instrument, EuroQol EQ-5D-3L, was used to estimate the QoL. Results are reported as incremental costs, quality adjusted life years (QALYs) and incremental cost per QALY.

Results

Base case analysis results show that although mini-slings cost less, there was no significant difference in costs: mini-slings versus standard slings: £-6 [95% CI -228-208] or in QALYs: 0.005 [95% CI -0.068-0.073] over the 3-year follow-up. There is substantial uncertainty, with a 56% and 44% probability that mini-slings and standard slings are the most cost-effective treatment, respectively, at a £20 000 willingness-to-pay threshold value for a QALY.

Conclusions

At 3 years, there is no significant difference between mini-slings and standard slings in costs and QALYs. There is still some uncertainty over the long-term complications and failure rates of the devices used in the treatment of SUI; therefore, it is important to establish the long-term clinical and cost-effectiveness of these procedures.

Single-incision sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence imposes a significant health and economic burden on individuals and society. Single-incision slings are a minimally-invasive treatment option for stress urinary incontinence. They involve passing a short synthetic device through the anterior vaginal wall to support the mid-urethra. The use of polypropylene mesh in urogynaecology, including mid-urethral slings, is restricted in many countries. This is a review update (previous search date 2012).

OBJECTIVES

To assess the effects of single-incision sling operations for treating urinary incontinence in women, and to summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from: CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, and two trials registers. We handsearched journals, conference proceedings, and reference lists of relevant articles to 20 September 2022.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials in women with stress (or stress-predominant mixed) urinary incontinence in which at least one, but not all, trial arms included a single-incision sling.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The primary outcome was subjective cure or improvement of urinary incontinence.

MAIN RESULTS

We included 62 studies with a total of 8051 women in this review. We did not identify any studies comparing single-incision slings to no treatment, conservative treatment, colposuspension, or laparoscopic procedures. We assessed most studies as being at low or unclear risk of bias, with five studies at high risk of bias for outcome assessment. Sixteen trials used TVT-Secur, a single-incision sling withdrawn from the market in 2013. The primary analysis in this review excludes trials using TVT-Secur. We report separate analyses for these trials, which did not substantially alter the effect estimates. We identified two cost-effectiveness analyses and one cost-minimisation analysis. Single-incision sling versus autologous fascial sling One study (70 women) compared single-incision slings to autologous fascial slings. It is uncertain if single-incision slings have any effect on risk of dyspareunia (painful sex) or mesh exposure, extrusion or erosion compared with autologous fascial slings. Subjective cure or improvement of urinary incontinence at 12 months, patient-reported pain at 24 months or longer, number of women with urinary retention, quality of life at 12 months and the number of women requiring repeat continence surgery or sling revision were not reported for this comparison. Single-incision sling versus retropubic sling Ten studies compared single-incision slings to retropubic slings. There may be little to no difference between single-incision slings and retropubic slings in subjective cure or improvement of incontinence at 12 months (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.07; 2 trials, 297 women; low-certainty evidence). It is uncertain whether single-incision slings increase the risk of mesh exposure, extrusion or erosion compared with retropubic minimally-invasive slings; the wide confidence interval is consistent with both benefit and harm (RR 1.55, 95% CI 0.24 to 9.82; 3 trials, 267 women; low-certainty evidence). It is uncertain whether single-incision slings lead to fewer women having postoperative urinary retention compared with retropubic slings; the wide confidence interval is consistent with possible benefit and harm (RR 0.47, 95% CI 0.12 to 1.84; 2 trials, 209 women; low-certainty evidence). The effect of single-incision slings on the risk of repeat continence surgery or mesh revision compared with retropubic slings is uncertain (RR 4.19, 95% CI 0.31 to 57.28; 2 trials, 182 women; very low-certainty evidence). One study reported quality of life, but not in a suitable format for analysis. Patient-reported pain at more than 24 months and the number of women with dyspareunia were not reported for this comparison. We downgraded the evidence due to concerns about risks of bias, imprecision and inconsistency. Single-incision sling versus transobturator sling Fifty-one studies compared single-incision slings to transobturator slings. The evidence ranged from high to low certainty. There is no evidence of a difference in subjective cure or improvement of incontinence at 12 months when comparing single-incision slings with transobturator slings (RR 1.00, 95% CI 0.97 to 1.03; 17 trials, 2359 women; high-certainty evidence). Single-incision slings probably have a reduced risk of patient-reported pain at 24 months post-surgery compared with transobturator slings (RR 0.12, 95% CI 0.02 to 0.68; 2 trials, 250 women; moderate-certainty evidence). The effect of single-incision slings on the risk of dyspareunia is uncertain compared with transobturator slings, as the wide confidence interval is consistent with possible benefit and possible harm (RR 0.78, 95% CI 0.41 to 1.48; 8 trials, 810 women; moderate-certainty evidence). There are a similar number of mesh exposures, extrusions or erosions with single-incision slings compared with transobturator slings (RR 0.61, 95% CI 0.39 to 0.96; 16 trials, 2378 women; high-certainty evidence). Single-incision slings probably result in similar or reduced cases of postoperative urinary retention compared with transobturator slings (RR 0.68, 95% CI 0.47 to 0.97; 23 trials, 2891 women; moderate-certainty evidence). Women with single-incision slings may have lower quality of life at 12 months compared to transobturator slings (standardised mean difference (SMD) 0.24, 95% CI 0.09 to 0.39; 8 trials, 698 women; low-certainty evidence). It is unclear whether single-incision slings lead to slightly more women requiring repeat continence surgery or mesh revision compared with transobturator slings (95% CI consistent with possible benefit and harm; RR 1.42, 95% CI 0.94 to 2.16; 13 trials, 1460 women; low-certainty evidence). We downgraded the evidence due to indirectness, imprecision and risks of bias.

AUTHORS' CONCLUSIONS

Single-incision sling operations have been extensively researched in randomised controlled trials. They may be as effective as retropubic slings and are as effective as transobturator slings for subjective cure or improvement of stress urinary incontinence at 12 months. It is uncertain if single-incision slings lead to better or worse rates of subjective cure or improvement compared with autologous fascial slings. There are still uncertainties regarding adverse events and longer-term outcomes. Therefore, longer-term data are needed to clarify the safety and long-term effectiveness of single-incision slings compared to other mid-urethral slings.

Trans-labial or introital ultrasounds for midurethral slings

Stress urinary incontinence is common in adult women. The use of introital or trans-labial ultrasound can help the surgeon (urologist or gynecologist) to better assess the type of incontinence the patient presents in order to guide him in the management of the patient. Often, surgical treatment with a mid-urethral sling (MSU) placement can be chosen in case of failure of non-invasive therapies (such as local estrogen or physical therapy) and if the clinical examination shows an urethral hypermobility. The use of ultrasound can help in this choice. Although rare, complications of MSU can sometimes cause disabling symptoms and be difficult to diagnose. Introital or trans-labial ltrasound can help diagnose them. The objective of this work was to describe the realization of ultrasound of stress urinary incontinence before or after the placement of a MSU, in order to make their realization easier for young surgeons which can use them in current practice.

Ferrostatin-1 alleviates the damage of C2C12 myoblast and mouse pelvic floor muscle induced by mechanical trauma

Ferroptosis is a special form of regulated cell death, which is reported to play an important role in a variety of traumatic diseases by promoting lipid peroxidation and devastating cell membrane structure. Pelvic floor dysfunction (PFD) is a kind of disease affecting the quality and health of many women's lives, which is closely related to the injury of the pelvic floor muscle. Clinical findings have discovered that there is anomalous oxidative damage to the pelvic floor muscle in women with PFD caused by mechanical trauma, but the specific mechanism is still unclear. In this study, we explored the role of ferroptosis-associated oxidative mechanisms in mechanical stretching-induced pelvic floor muscle injury, and whether obesity predisposed pelvic floor muscle to ferroptosis from mechanical injury. Our results, in vitro, showed that mechanical stretch could induce oxidative damage to myoblasts and trigger ferroptosis. In addition, glutathione peroxidase 4 (GPX4) down-regulation and 15-lipoxygenase 1(15LOX-1) up-regulation exhibited the same variational characteristics as ferroptosis, which was much more pronounced in palmitic acid (PA)-treated myoblasts. Furthermore, ferroptosis induced by mechanical stretch could be rescued by ferroptosis inhibitor (ferrostatin-1). More importantly, in vivo, we found that the mitochondria of pelvic floor muscle shrank, which were consistent with the mitochondrial morphology of ferroptosis, and GPX4 and 15LOX-1 showed the same change observed in cells. In conclusion, our data suggest ferroptosis is involved in the injury of the pelvic floor muscle caused by mechanical stretching, and provide a novel insight for PFD therapy.

C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings

IMPORTANCE

Synthetic mesh midurethral slings have become the criterion-standard treatment for stress urinary incontinence with urethral hypermobility in women. Iatrogenic bladder injury is a known risk of the procedure.

OBJECTIVE

Our objective was to show that a novel "C-clamp technique" can significantly reduce the risk of bladder and urethral injury at the time of bottom-up retropubic synthetic mesh midurethral sling placement.

STUDY DESIGN

We conducted a retrospective review of the electronic medical records using Current Procedural Terminology coding of a single surgeon who performed synthetic mesh midurethral slings. Medical records were reviewed for demographic and clinical data for all bottom-up retropubic synthetic mesh midurethral slings placed using a novel C-clamp technique. All operative reports were reviewed for bladder and urethral injury at the time of implantation of the synthetic mesh midurethral sling using the C-clamp technique.

RESULTS

Two hundred one consecutive bottom-up retropubic synthetic mesh midurethral slings were placed using the C-clamp technique from April 2012 through June 2022. The average age was 51 years (29-86 years); the average weight was 82 kg (46 -139 kg); and the average body mass index was 31 kg/m2 (15-57 kg/m2). No patients sustained a bladder or urethral injury at the time of implantation of a retropubic synthetic mesh midurethral sling using the C-clamp technique.

CONCLUSION

The novel C-clamp technique shows promise in eliminating the risk of iatrogenic bladder and urethral injury at the time of implanting a bottom-up retropubic synthetic mesh midurethral sling.

Cost-effectiveness Analysis: Autologous Rectus Fascial Sling Versus Retropubic Midurethral Sling for Female Stress Urinary Incontinence

IMPORTANCE

There are limited data on the economic comparison between retropubic midurethral sling and autologous fascial sling.

OBJECTIVE

This study aims to evaluate the cost-effectiveness of autologous rectus fascial sling compared with retropubic midurethral sling from both hospital and health care perspectives.

STUDY DESIGN

A decision tree model was developed with 1 year of follow-up. We included variables such as objective success rate, complications and subsequent treatments, and retreatment for incontinence. The model included the index procedure and 1 retreatment for stress urinary incontinence. Cost estimates were calculated from both hospital and health care perspectives. The outcomes were expressed in incremental cost-effectiveness ratio (ICER) or cost per quality-adjusted life-year (QALY). An ICER <$50,000/QALY was considered cost-effective.

RESULTS

From a hospital perspective, the overall cost of retropubic midurethral sling was higher than autologous rectus fascial sling ($2,348.94 vs $2,114.06), but was more effective (0.82 vs 0.80 QALYs). The ICER was $17,452/QALY. From a health care perspective, the overall cost of autologous rectus fascial sling was higher than retropubic midurethral sling ($4,656.63 vs $4,630.47) and was less effective. Retropubic midurethral sling was the dominant strategy, with ICER of -$1,943.32/QALY. If the success rate of autologous rectus fascial sling was ≥84.39%, or the cost of retropubic midurethral sling surgery was > $2,654.36, then autologous rectus fascial sling would become cost-effective.

CONCLUSIONS

Retropubic midurethral sling is the cost-effective treatment from the hospital perspective and the dominant treatment from the health care perspective. However, changes in the costs and success rates of surgical procedures can alter the cost-effectiveness results.

Vaginal Laser Therapy for Stress Urinary Incontinence: A Systematic Review of Prospective Randomized Clinical Trials

The most common type of urinary incontinence in women is stress urinary incontinence (SUI) which negatively impacts several aspects of life. The newly introduced vaginal laser therapy is being considered for treating SUI. This systematic review aimed to evaluate the efficacy of vaginal laser therapy for stress urinary incontinence in menopausal women. We searched the following databases: MEDLINE (via PubMed), EMBASE, Cochrane Library databases, Web of Science, clinical trial registry platforms, and Google Scholar, using the MeSH terms and keywords [Urinary Incontinence, Stress] and [(lasers) OR laser]. In our systematic review, prospective randomized clinical studies on women diagnosed with SUI as per the International Continence Society's diagnostic criteria were included. The Cochrane Risk-of-Bias assessment tool for randomized clinical trials was used to evaluate the quality of studies. A total of 256 relevant records in literature databases and registers and 25 in additional searches were found. Following a review of the titles, abstracts, and full texts, four studies involving 431 patients were included. Three studies used CO2-lasers, and one used Erbium: YAG-laser. The results of all four studies revealed the short-term improvement of SUI following both the Erbium: YAG-laser and CO2-laser therapy. SUI treatment with CO2-laser and Erbium: YAG-laser therapy is a quick, intuitive, well-tolerated procedure that successfully improves incontinence-related symptoms. The long-term impact of such interventions has not been well established as most trials focused on the short-term effects.

Single-incision mini-slings versus standard synthetic mid-urethral slings for surgical treatment of stress urinary incontinence in women: The SIMS RCT

BACKGROUND

Stress urinary incontinence is the most common type of urinary incontinence in premenopausal women. Until recently, synthetic mid-urethral slings (mesh/tape) were the standard surgical treatment, if conservative management failed. Adjustable anchored single-incision mini-slings are newer, use less mesh and may reduce perioperative morbidity, but it is unclear how their success rates and safety compare with those of standard tension-free mid-urethral slings.

OBJECTIVE

The objective was to compare tension-free standard mid-urethral slings with adjustable anchored single-incision mini-slings among women with stress urinary incontinence requiring surgical intervention, in terms of patient-reported effectiveness, health-related quality of life, safety and cost-effectiveness.

DESIGN

This was a pragmatic non-inferiority randomised controlled trial. Allocation was by remote web-based randomisation (1 : 1 ratio).

SETTING

The trial was set in 21 UK hospitals.

PARTICIPANTS

Participants were women aged ≥ 18 years with predominant stress urinary incontinence, undergoing a mid-urethral sling procedure.

INTERVENTIONS

Single-incision mini-slings, compared with standard mid-urethral slings.

MAIN OUTCOME MEASURES

The primary outcome was patient-reported success rates on the Patient Global Impression of Improvement scale at 15 months post randomisation (≈ 1 year post surgery), with success defined as outcomes of 'very much improved' or 'much improved'. The primary economic outcome was incremental cost per quality-adjusted life-year gained. Secondary outcomes were adverse events, impact on other urinary symptoms, quality of life and sexual function.

RESULTS

A total of 600 participants were randomised. At 15 months post randomisation, adjustable anchored single-incision mini-slings were non-inferior to tension-free standard mid-urethral slings at the 10% margin for the primary outcome [single-incision mini-sling 79% (212/268) vs. standard mid-urethral sling 76% (189/250), risk difference 4.6, 95% confidence interval -2.7 to 11.8; p non-inferiority < 0.001]. Similarly, at 3 years' follow-up, patient-reported success rates in the single-incision mini-sling group were non-inferior to those of the standard mid-urethral sling group at the 10% margin [single-incision mini-sling 72% (177/246) vs. standard mid-urethral sling 67% (157/235), risk difference 5.7, 95% confidence interval -1.3 to 12.8; p non-inferiority < 0.001]. Tape/mesh exposure rates were higher for single-incision mini-sling participants, with 3.3% (9/276) [compared with 1.9% (5/261) in the standard mid-urethral sling group] reporting tape exposure over the 3 years of follow-up. The rate of groin/thigh pain was slightly higher in the single-incision mini-sling group at 15 months [single-incision mini-sling 15% (41/276) vs. standard mid-urethral sling 12% (31/261), risk difference 3.0%, 95% confidence interval -1.1% to 7.1%]; however, by 3 years, the rate of pain was slightly higher among the standard mid-urethral sling participants [single-incision mini-sling 14% (39/276) vs. standard mid-urethral sling 15% (39/261), risk difference -0.8, 95% confidence interval -4.1 to 2.5]. At the 3-year follow-up, quality of life and sexual function outcomes were similar in both groups: for the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life, the mean difference in scores was -1.1 (95% confidence interval -3.1 to 0.8; p = 0.24), and for the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised, it was 0 (95% confidence interval -0.1, 0.1; p = 0.92). However, more women in the single-incision mini-sling group reported dyspareunia [12% (17/145), compared with 4.8% (7/145) in the standard mid-urethral sling group, risk difference 7.0%, 95% confidence interval 1.9% to 12.1%]. The base-case economics results showed no difference in costs (-£6, 95% confidence interval -£228 to £208) or quality-adjusted life-years (0.005, 95% confidence interval -0.068 to 0.073) between the groups. There is a 56% probability that single-incision mini-slings will be considered cost-effective at the £20,000 willingness-to-pay threshold value for a quality-adjusted life-year.

LIMITATIONS

Follow-up data beyond 3 years post randomisation are not available to inform longer-term safety and cost-effectiveness.

CONCLUSIONS

Single-incision mini-slings were non-inferior to standard mid-urethral slings in patient-reported success rates at up to 3 years' follow-up.

FUTURE WORK

Success rates, adverse events, retreatment rates, symptoms, and quality-of-life scores at 10 years' follow-up will help inform long-term effectiveness.

TRIAL REGISTRATION

This trial was registered as ISRCTN93264234.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 47. See the NIHR Journals Library website for further project information.

Twenty-Five Years of the Midurethral Sling: Lessons Learned

Midurethral slings (MUS) are widely accepted for the surgical treatment of stress urinary incontinence (SUI) in cases where conservative treatment has failed. They have been shown to be a safe and effective surgical treatment for the management of SUI. However, there have recently been growing concerns regarding the safety profile of mesh procedures, generating international debate and leading to national inquiries into the effectiveness and safety of mesh implants. A multitude of clinical, technical, manufacturer-related, and other health jurisdictional factors are involved in the outcomes of MUS. Appropriate patient selection and informed consent to all treatment options, with proper guidance from healthcare providers, are critical for empowering women to choose an appropriate treatment option based on a personalized decision.

European Association of Urology Guidelines on the Diagnosis and Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 1: Diagnostics, Overactive Bladder, Stress Urinary Incontinence, and Mixed Urinary Incontinence

CONTEXT

Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guideline expands the remit to include these symptoms and conditions.

OBJECTIVE

To summarise the diagnostic section of the non-neurogenic female LUTS guideline and the management of female overactive bladder (OAB), stress urinary incontinence (SUI), and mixed urinary incontinence (MUI).

EVIDENCE ACQUISITION

New literature searches were carried out in September 2021 and evidence synthesis was conducted using the modified GRADE criteria as outlined for all EAU guidelines. A new systematic review (SR) on OAB was carried out by the panel for the purposes of this guideline.

EVIDENCE SYNTHESIS

The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

CONCLUSIONS

Non-neurogenic female LUTS are an important cause of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion based on the best available evidence. This guideline serves to present this evidence to health care providers in an easily accessible and digestible format.

PATIENT SUMMARY

This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to diagnosis of these conditions, as well as the treatment of overactive bladder, stress urinary incontinence, and mixed urinary incontinence.

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.

Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial

BACKGROUND

Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking.

OBJECTIVE

Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed.

STUDY DESIGN

This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile.

RESULTS

The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval, -4.51 to 5.00] vs -4.50 [95% confidence interval, -4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years.

CONCLUSION

Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.

Short and Long Term Follow up and Efficacy of Trans Obturator Tape for Management of Stress Urinary Incontinence

Background

Stress urinary incontinence (SUI) is involuntary leakage of urine on raised intra- abdominal pressure which adversely affects quality of life usually requiring surgical treatment.

Methods

This is a prospective study of efficacy, cure rates and complications of tension free transobturator tape (TOT) surgery on 85 women with SUI. Pre-operatively and 6 months post-operatively International consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) scores were calculated for all patients to know the severity of incontinence and efficacy of tape.

Results

Mean age, parity, body mass index and mean duration of symptoms were 45.78 years, 2.68, 26.38 kg/m2 and 3.85 years, respectively. SUI was demonstrated in all cases on cough stress test and Bonney's test. Mean operative time, blood loss, post-operative analgesic injections, post- operative stay and post- operative catheterisation were 23.28 min, 45.50 ml, 1.2 injections, 1.2 days and 1.2 days. Various complications noted were excessive bleeding (3.52%), urinary retention (7.05%), urinary urgency (8.23%), urinary tract infection (2.35%), surgical site infection (1.17%), groin pain (28.23%) and mesh exposure (3.52%). At 6 months follow-up, the complete cure rate was 83.52% , partial cure rate was 11.76% and failure rate was found to be 4.70% whereas it was 79.16%, 12.0% and 8.33% respectively at 3 years follow up. 2 patients (2.35%) required burch colposuspension and 12 patients (14.11%) required pelvic floor exercises and duloxetine therapy for their symptoms. Mean pre- operative ICIQ-SF score reduced post- operatively (17.8 ± 4.67 to 2.71 ± 1.42) (p value = 0.001).

Conclusion

Study demonstrates short and long-term efficacy and safety of TOT for surgical management of SUI.

Long-term outcomes of Altis® single-incision sling procedure for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

In women with predominant stress urinary incontinence (SUI), recent data are still controversial regarding the short-term outcomes of mini-slings and there is a lack of evidence about the outcomes in the long term. Our aim was to evaluate the long-term effectiveness and complication rates of Altis® (Coloplast).

METHODS

A total of 145 women with clinical SUI were implanted with an Altis® sling between April 2012 and December 2015. Women completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) before the intervention and in the following consultations. A telephone interview was performed in January 2021 and 131 women (90%) were available for re-evaluation. The main outcome was treatment success, defined as no self-reported SUI symptoms and no reintervention. Secondary outcomes included response to ICIQ-SF (cure defined as ICIQ-SF = 0) and Patient Global Impression of Improvement (PGI-I) questionnaires, de novo overactive bladder (OAB) symptoms and adverse events.

RESULTS

The overall treatment success was 73.3% at a median follow-up of 8 years. The ICIQ-SF cure rate was 66.1%. In the PGI-I, 70.4% answered that they were much better or very much better. Later postoperative complications included 2 cases (1.5%) of vaginal extrusion (requiring surgical removal of the eroded mesh segment), 3 (2.3%) cases of infravesical obstruction (which led to sling section), de novo urgency in 20 patients (15.3%), and mild dyspareunia in 2 (1.5%) patients.

CONCLUSIONS

The Altis® sling was safe and effective in a long-term follow-up, improving the quality of life in patients with SUI.

Vaginal Pessaries for Pelvic Organ Prolapse or Stress Urinary Incontinence: A Health Technology Assessment

BACKGROUND

Pelvic organ prolapse (POP) is the downward descent of the female pelvic organs into or through the vagina. The symptom that most strongly correlates with and is most specific for POP is a feeling of vaginal bulging. Stress urinary incontinence (SUI) is an involuntary loss of urine upon physical exertion or sneezing or coughing. Conservative (non-surgical) treatment options for both conditions include vaginal pessaries. We conducted a health technology assessment of vaginal pessaries for the treatment of POP and SUI, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding vaginal pessaries, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using ROBIS, the Cochrane Risk of Bias tool, and the Newcastle-Ottawa Scale and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 10-year horizon from a public payer perspective. We also analyzed the budget impact of publicly funding vaginal pessaries for individuals with pelvic organ prolapse and/or stress urinary incontinence in Ontario. We explored the underlying values, needs, and priorities of those who have lived experience with POP and/or SUI, as well as the preferences and perceptions of both patients and providers of vaginal pessaries.

RESULTS

We included 15 studies in the clinical evidence review. Compared with no treatment for people with SUI, pessaries were associated with a significant improvement in some symptoms at 14 days follow-up (SUI subscore of Urinary Symptom Profile, mean difference -2.20; 95% CI -3.47 to -0.93; GRADE: Very low). Compared with pelvic floor muscle training (PFMT), pessaries were associated with no difference in improvement at 12 months follow-up for some symptoms (Urinary Distress Inventory subscale of the Pelvic Floor Distress Inventory, risk ratio = 0.86; 95% CI 0.64 to 1.16; GRADE: Low). For people with POP, pessaries were associated with a significant improvement in the Pelvic Organ Prolapse Distress Inventory score and in sexual function compared with PFMT plus feedback/electrical stimulation/lifestyle advice at 12- and 24-month follow ups (GRADE: Low). Pessary continuation rate at 12 months follow up was reported to be 60% (44/74 patients) (GRADE: Very low).When evaluating various POP and SUI treatments in sequential order, pessaries were within the most cost-effective treatment sequence; therefore, it is likely to be a cost-effective intervention for treating POP and SUI. There was a high degree of certainty that pessaries were cost-effective in a population with POP, and a moderate degree of certainty in a population with SUI. When the treatment sequence of pessaries and surgery was compared with surgery alone, the pessaries treatment sequence dominates surgery in the cohort with POP, and in the cohort with SUI pessaries had an incremental cost-effectiveness ratio (ICER) of $1,033 per QALY gained. The annual budget impact of publicly funding vaginal pessaries in Ontario over the next 5 years ranges from $0.3 million in year 1 to $0.5 million in year 5 for POP, and $0.2 million in year 1 to $0.3 million in year 5 for SUI.We included one study in our quantitative evidence review and spoke to 29 people in our direct patient engagement. The evidence indicated that patient preferences vary and that patients accept the risks of their chosen treatment option. The 24 people we spoke with who had direct experience with vaginal pessaries reported that their POP and/or SUI limited their social activities and restricted their activity levels, taking a huge emotional toll. Many were hesitant or even fearful of surgery due to side effects and perceived failure rate of the surgery. Most people reported that pessaries relieved most or all of their symptoms, allowing them to return to their normal daily activities. However, wait times for pessary fittings could be as long as 2 years, and out-of-pocket expenses could be a barrier for people without extended insurance.

CONCLUSIONS

For people with SUI, vaginal pessaries may improve symptoms compared with no treatment, but the evidence is very uncertain. Pessaries may result in little to no difference in longer-term improvement of SUI symptoms compared with PFMT. For people with POP, pessaries may improve some longer-term symptoms, as well as sexual function compared with PFMT. For people with symptomatic POP and SUI, vaginal pessaries may be a cost-effective intervention to be used within a stepped care model (a sequence of interventions followed after the current treatment proves ineffective). We estimate that publicly funding vaginal pessaries in Ontario would result in a total 5-year budget impact of $2.0 million for POP and $1.3 million for SUI. People with POP and/or SUI reported pessary use as being an effective treatment option to manage their symptoms.

Current Overview of Surgical Options for Female Stress Urinary Incontinence

Stress urinary incontinence (SUI) is a highly prevalent health condition that significantly impacts the quality of life. Traditional methods of treatment for SUI, such as pubovaginal sling and Burch colposuspension, have been replaced by the midurethral sling because of its high efficacy, low complication and morbidity rates, and short learning curve. Although multiple behavioral and operative treatments exist, midurethral slings are the gold standard for the treatment of SUI in women. However, several reports have raised concerns about complications caused by the synthetic mesh used in midurethral slings. Therefore, surgical treatment for SUI in women must be chosen with care, taking into account potential complications. Herein, we review the current safety issues pertaining to the use of meshes, the efficacy of traditional surgeries, old and new midurethral slings, and recent data comparing the efficacy and safety of different surgical options. This review is aimed at developing practical guidelines for choosing surgical options for women with SUI.

Economic analysis of Electrical Muscle Stimulator with Multipath technology for the treatment of stress urinary incontinence: a UK-based cost-utility analysis

Background: Stress urinary incontinence (SUI) is a debilitating and highly prevalent condition in the UK. The condition is associated with a significant economic burden for affected patients and society. Current treatment options for SUI include minimally invasive therapies, medication and surgical intervention for the most serious cases. Electrical Muscle Stimulator with Multipath technology is a recently developed device for the treatment of SUI that relies on neuromuscular external electrical stimulation (NEES) technology. The clinical efficacy of the device has been proven in previous studies, but existing evidence surrounding its economic viability is limited.Objectives: To assess the cost-utility of the Electrical Muscle Stimulator with Multipath technology Therapy device for the treatment of SUI amongst women in a UK setting.Methods: An economic model was developed to consider the cost-utility (cost per quality-adjusted life-year [QALY] gained) of Electrical Muscle Stimulator with Multipath technology compared with current practice. A Markov model was developed, with costs and health effects estimated over the lifetime of the patient in the base-case analysis. The model was developed to reflect the treatment pathways typically followed by patients with SUI in the UK. Parameter uncertainty was explored in deterministic and probabilistic sensitivity analyses.Results: Base-case results indicate that Electrical Muscle Stimulator with Multipath technology results in cost savings and QALY gains over the patient's lifetime. In the "cure" analysis, the intervention is £250 less costly and leads to a 0.03 QALY gain per patient, while in the "improvement analysis", the intervention is £327 less costly and leads to a 0.13 QALY gain per patient. Results from the probabilistic sensitivity analyses show that the likelihood of Electrical Muscle Stimulator with Multipath technology being cost-effective is greater than 74% across all willingness-to-pay thresholds in the two analyses presented.Conclusions: Electrical Muscle Stimulator with Multipath technology is a potentially cost-effective treatment option for patients with SUI who have failed first-line treatment. It could reduce costs to the health care service and improve quality-of-life for selected patients over their lifetime.

Comparison of outcomes of Burch colposuspension and transobturator tape and single incision needleless procedures (DynaMesh®-SIS minor) for the surgical treatment of female stress urinary incontinence patients who underwent combined pelvic reconstructive surgery or hysterectomy

PURPOSE

Women with stress urinary incontinence (SUI) often require combined pelvic reconstructive surgeries because of shared risk factors of pelvic organ prolapse. The purpose of this study was to evaluate efficacies of Burch colposuspension, transobturator tape (TOT), and single-incision needleless (DynaMesh^®-SIS minor) procedures in patients with SUI who also underwent combined pelvic reconstructive surgery or hysterectomy.

METHODS

We performed this retrospective cohort study that comprising 122 patients who either underwent Burch colposuspension (n:43), TOT (n:40), or SIS (n:39) procedures along with pelvic reconstructive surgery or hysterectomy between January 2010 and July 2018. During the clinical follow-up, we analyzed cure rates, and surgical success rates of SUI surgery, quality of life, and symptom severity by IIQ-7, UDI-6, SSI, SSQ-8, OAB-V8, and PGI-I scale scores. The primary outcome was surgical success, whereas secondary outcomes included complications and patient-reported outcomes in the quality of life.

RESULTS

We found that surgical success rates were higher in Burch group than SIS group and higher in TOT group than in SIS group (88.4% vs 61.5% and 87.5% vs 61.5%, p = 0.003). The quality of life was lower in SIS group than in Burch group.

CONCLUSIONS

Both Burch and TOT are effective procedures in patients with SUI who require additional pelvic surgeries. Although surgical outcomes of SIS procedure in patients with SUI who underwent concomitant pelvic surgeries in our study were not promising, further studies with SIS are needed to clarify these observations.

Is There Outcome Reporting Heterogeneity in Trials That Aim to Assess the Effectiveness of Surgical Treatments for Stress Urinary Incontinence in Women?

CONTEXT

Inconsistent reporting of effectiveness outcomes in surgical trials of stress urinary incontinence (SUI) has hindered direct comparisons of various surgical treatments for SUI.

OBJECTIVE

To systematically review the verbatim outcome names, outcome definitions, and tools used to measure the outcomes in surgical trials of SUI in women.

EVIDENCE ACQUISITION

Trials of women with SUI who have undergone surgical interventions were included. We conducted a systematic review (SR) on outcomes reported in randomized controlled trials of surgical management published in 2014-2019, covering the following databases: MEDLINE, EMBASE, CENTRAL, and CDSR. Verbatim outcome names extracted from the included studies were categorized and then grouped into domains using the Williamson-Clarke (W/C) outcome taxonomy. A matrix was also created to visualize and quantify the dimensions of outcome reporting heterogeneity in SUI trials.

EVIDENCE SYNTHESIS

A total of 844 verbatim outcome names were extracted, of which, 514 varied terms were reduced to 71 standardized outcome names. They were further categorized into 11 domains from the W/C taxonomy. There were 7.24 different terms on average to describe each outcome, and the four outcomes with the most heterogeneity evident in terms used to describe them were "urinary retention", "reoperation", "subjective cure rate" and "quality of life". Each of them had ≥20 different terms. Only 28% of the outcome definitions were reported and a variety of measuring tools was noted, particularly in subjective outcomes. High heterogeneity was found in the outcome names, outcome definitions, choice and number of measuring instruments of the outcomes, and choice and number of outcomes reported across studies.

CONCLUSIONS

This SR provides objective evidence of heterogeneity in outcome reporting in SUI surgical trials. Our categorization of outcomes highlights the difficulties in summarizing the current evidence base. A core outcome set, developed using the methods advocated by the Core Outcome Measures in Effectiveness Trials (COMET) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) initiatives, is required.

PATIENT SUMMARY

In this research, we have highlighted the diversity in outcomes reporting in stress urinary incontinence (SUI) surgical trials and have categorized the outcomes. We support the development of a core outcome set for SUI, which will promote future clinical researchers to measure the same outcome in the same way in all trials. This will, in turn, help researchers summarize the evidence more effectively and aid decision making for patients and doctors.

Surgical treatments for women with stress urinary incontinence: a systematic review of economic evidence

BACKGROUND

Surgical interventions for the treatment of stress urinary incontinence (SUI) in women are commonly employed following the failure of minimally invasive therapies. Due to the limited information available on the relative cost-effectiveness of available surgeries for treating SUI, a de novo economic analysis was conducted to assess costs and effects of all relevant surgeries. To inform the economic analysis, the objective of this review was to identify and assess the quality of existing economic evaluation studies on different surgical interventions for the treatment of SUI in women.

METHODS

The following databases were searched during the review process: Medical Literature Analysis and Retrieval System Online (MEDLINE), MEDLINE In-Process, Excerpta Medica Database (Embase), National Health Service Economic Evaluation Database (NHS EED), and Health Management Information Consortium and Cost-Effectiveness Analysis Registry (CEA registry). The key criteria for inclusion were that the study population included women with SUI and that the surgical interventions considered were utilised as either a primary or a follow-up surgery. The review included only full economic evaluations. Studies were quality assessed using the Drummond checklist for economic evaluations. No quantitative synthesis of the results by meta-analysis was conducted due to the high methodological heterogeneity.

RESULTS

Twenty-six economic evaluations were included, of which 13 were model-based analyses. Surgical treatments assessed most frequently were mid-urethral slings and open and laparoscopic colposuspension. There were some differences in the methodological approaches taken, including differences in type of economic analysis, perspective, time horizon, types of resource use, and costs and outcomes that were included in the analysis. The majority of studies conducted a cost-utility analysis from a health system perspective and applied a time horizon of between 1 and 5 years. The cost-effectiveness results suggest that single-incision mini-sling and mid-urethral slings are among the most cost-effective options.

CONCLUSIONS

The review has shown that methods used for the economic evaluation of surgical treatments for SUI vary widely in terms of study design, analysis type, compared alternatives, time horizon, costing methodologies and effect outcomes. Future economic evaluation studies on surgical treatments for SUI may be improved by the application of available guidelines.

SYSTEMATIC REVIEW REGISTRATION

Registered in PROSPERO in 2016, CRD42016049339.

TVT-O for treatment of pure urodynamic stress urinary incontinence: Efficacy and adverse effects at 13-years follow-up

AIM

To assess the efficacy and safety of tension-free vaginal tape-obturator (TVT-O) 13 years after implantation for the treatment of female pure stress urinary incontinence (SUI). This is the longest-term evaluation available of TVT-O outcomes.

METHODS

A multicenter, prospective study was conducted in five tertiary referral centers in three countries. All consecutive women with urodynamically proven pure SUI treated by TVT-O were included. Data regarding subjective outcomes (International Consultation on Incontinence Questionnaire-Short Form, Patient Global Impression of Improvement, and patient satisfaction scores), objective cure (stress test) rates, and adverse events were collected during follow-up. Univariable and multivariate analyses was performed to investigate outcomes.

RESULTS

One hundred sixty-eight women had TVT-O implantation. At 13 year after surgery, 150 of 157 patients (95%) declared themselves cured (P = .8). Similarly, at 10-year evaluation, 148 of 160 patients (92%) were objectively cured. No significant deterioration of objective cure rates was observed over time (P = .1). The multivariate analysis showed that previous anti-incontinence procedures and obesity independently predicted the subjective (odd ratio [OR]: 6.2 [95% confidence interval [CI], 1.8-13.6]; P = .02 and OR, 1.8 [95% CI, 1.3-3.0]; P = .03, respectively) and objective failure of TVT-O (OR, 5.8 [95% CI, 1.6-13.2]; P = .02 and OR, 1.6 [95% CI, 1.2-3.2]; P = .03, respectively). We found four cases of sling exposure; all of them occurred after the 10-year follow-up.

CONCLUSIONS

The 13-year results of this study showed that TVT-O is a highly effective and safe option for the treatment of SUI. We found that there is a significantly higher risk of having a sling exposure over 10 years after the procedure; however, the incidence is very low.

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

OBJECTIVES

To compare the effectiveness and safety of surgical interventions for women with stress urinary incontinence.

DESIGN

Systematic review and network meta-analysis.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials evaluating surgical interventions for the treatment of stress urinary incontinence in women.

METHODS

Identification of relevant randomised controlled trials from Cochrane reviews and the Cochrane Incontinence Specialised Register (searched May 2017), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Medline In-Process, Medline Epub Ahead of Print, CINAHL, ClinicalTrials.gov, and WHO ICTRP. The reference lists of relevant articles were also searched. Primary outcomes were "cure" and "improvement" at 12 months, analysed by means of network meta-analyses, with results presented as the surface under the cumulative ranking curve (SUCRA). Adverse events were analysed using pairwise meta-analyses. Risk of bias was assessed using the Cochrane risk of bias tool. The quality of evidence for network meta-analysis was assessed using the GRADE approach.

RESULTS

175 randomised controlled trials assessing a total of 21 598 women were included. Most studies had high or unclear risk across all risk of bias domains. Network meta-analyses were based on data from 105 trials that reported cure and 120 trials that reported improvement of incontinence symptoms. Results showed that the interventions with highest cure rates were traditional sling, retropubic midurethral sling (MUS), open colposuspension, and transobturator MUS, with rankings of 89.4%, 89.1%, 76.7%, and 64.1%, respectively. Compared with retropubic MUS, the odds ratio of cure for traditional sling was 1.06 (95% credible interval 0.62 to 1.85), for open colposuspension was 0.85 (0.54 to 1.33), and for transobtrurator MUS was 0.74 (0.59 to 0.92). Women were also more likely to experience an improvement in their incontinence symptoms after receiving retropubic MUS or transobturator MUS compared with other surgical procedures. In particular, compared with retropubic MUS, the odds ratio of improvement for transobturator MUS was 0.76 (95% credible interval 0.59 to 0.98), for traditional sling was 0.69 (0.39 to 1.26), and for open colposuspension was 0.65 (0.41 to 1.02). Quality of evidence was moderate for retropubic MUS versus transobturator MUS and low or very low for retropubic MUS versus the other two interventions. Data on adverse events were available mainly for mesh procedures, indicating a higher rate of repeat surgery and groin pain but a lower rate of suprapubic pain, vascular complications, bladder or urethral perforation, and voiding difficulties after transobturator MUS compared with retropubic MUS. Data on adverse events for non-MUS procedures were sparse and showed wide confidence intervals. Long term data were limited.

CONCLUSIONS

Retropubic MUS, transobturator MUS, traditional sling, and open colposuspension are more effective than other procedures for stress urinary incontinence in the short to medium term. Data on long term effectiveness and adverse events are, however, limited, especially around the comparative adverse events profiles of MUS and non-MUS procedures. A better understanding of complications after surgery for stress urinary incontinence is imperative.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016049339.