Comparison of TOA and TOT for Treating Female Stress Urinary Incontinence: Short-Term Outcomes

Adjustable slings versus other surgical methods in female stress urinary incontinence: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The objective of this study was to evaluate the efficacy and safety of different adjustable slings compared to other surgical methods for the treatment of stress urinary incontinence (SUI) among women.

METHODS

The inclusion criteria were as follows: randomized controlled trials (RCTs) and non-RCTs assessing adult women with SUI. The exclusion criteria were as follows: other types of urinary incontinence, studies that combined conservative interventions and pharmacological treatment, pregnant and lactating patients. Databases were searched up to November 2022 to identify articles evaluating the effectiveness and safety of different adjustable slings compared to other surgical methods for the treatment of SUI among women. The systematic review was conducted in accordance with the PRISMA 2020 checklist and registered in PROSPERO. Risk-of-bias assessment tools recommended by the Cochrane Society were used to evaluate the risk of bias in the included studies.

RESULTS

Eighteen clinical trials were included in this systematic review, and 11 studies were included in the meta-analysis. Fourteen studies were RCTs, and four were retrospective studies. Only RCTs were included in the meta-analyses. There was no statistically significant difference in the objective cure rate, subjective cure rate, or long-term postoperative complication rate between Ajust single-incision mini-slings (SIMS) and standard mid-urethral slings (SMUS) or MiniArc SIMS. However, the operation time in the adjustable SIMS group was significantly shorter (RR = -4.20, 95% CI: [-7.51, -0.89], p = 0.01).

CONCLUSIONS

This systematic review and meta-analysis revealed that adjustable SIMS is equally effective when compared with SMUS for the treatment of SUI among women. Moreover, the operation time for the adjustable SIMS was shorter. However, additional well-designed studies with standard outcome measures and complete follow-up periods will help to increase confidence in the choice of different options for treating SUI among women.

Sexual Quality of Life After Treatment of Stress Urinary Incontinence With Adjustable Tension-free Mesh System in Women Who Were Sexually Active Before Surgery

OBJECTIVE

To assess the sexuality and quality of life of sexually active women with stress or mixed urinary incontinence (SUI or MUI) after surgery with adjustable tension-free suburethral mesh system (transobturator adjustable tape or transvaginal adjustable tape).

MATERIALS AND METHODS

This intervention study with 2 years of follow-up (visits at 3 months, 1 year, and 2 years) involved 60 women with SUI or MUI who underwent surgery using transobturator adjustable tape or transvaginal adjustable tape during 2008-2014 in a Spanish region. The variables of interest measured pre- and postintervention were the global scores on the following questionnaires: (1) the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire-12; (2) the International Consultation on Incontinence Questionnaire; and (3) the Incontinence Quality of Life Questionnaire. Mixed linear models were constructed to determine the effect of the intervention on the outcome variables.

RESULTS

A significant improvement (P <.001) was seen over time in all the questionnaires, although between the 1- and 2-year visits there was a slight deterioration in all of them.

CONCLUSION

The technique provided an improved quality of life and sexuality, which was maintained at all the postoperative visits compared with baseline.

Is the adjustable TVA mesh effective for the long-term treatment of female stress incontinence?

OBJECTIVES

To assess the long-term safety and efficacy of the adjustable TVA mesh in treating stress urinary incontinence.

MATERIAL AND METHODS

Pseudoexperimental study, before and after, conducted in a university urology department. Eighty-two patients were invited to participate from January 2002 to March 2005. Thirty-two patients agreed to participate and were implanted an adjustable TVA mesh. The preoperative study included a medical history review, physical examination with full bladder, flowmetry, residue study, complete urodynamic study and the self-administered questionnaires I-QoL and ICIQ-SF. In the postoperative assessment, the PGI-I questionnaire was added, but a complete urodynamic study was not performed.

RESULTS

Twenty-nine (90.6%) and 28 (87.5%) patients were continent in the stress test at 1 and 10 years, respectively. Twenty (62.5%) and 16 (50%) patients had no urine escape at 1 and 10 years, respectively. Twenty-eight (87.5%) and 25 (78%) patients were satisfied 1 and 10 years after the surgery, respectively. Twenty-eight (87.5%) and 21 (62.5%) patients had a good quality of life at 1 year and at 10 years, respectively. There were no significant complications at the end of the study period.

CONCLUSIONS

Treatment of stress urinary incontinence with the TVA mesh presented a high degree of objective healing and satisfaction at 10 years, with no severe adverse effects. The study showed that satisfaction does not always mean total continence but rather it reflects the improvement of symptoms and consequent quality of life.

Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review

We reviewed the incidence, predisposing factors, presentation and management of complications related to the use of synthetic mesh in the management of stress urinary incontinence and pelvic organ prolapse repair. Immediate complications, such as bleeding, hematoma, injury to adjacent organs during placement of mesh and complication of voiding dysfunction are not discussed in this review, since they are primarily related to technique. A PubMed search of related articles published in English was done from April 2008 to March 2011. Key words used were urinary incontinence, mesh, complications, midurethral sling, anterior prolapse, anterior vaginal repair, pelvic organ prolapse, transvaginal mesh, vault prolapse, midurethral slings, female stress urinary incontinence, mesh erosion, vaginal mesh complications, and posterior vaginal wall prolapse. Since there were very few articles dealing with the management of mesh-related complications in the period covered in the search we extended the search from January 2005 onwards. Articles were selected to fit the scope of the topic. In addition, landmark publications and Manufacturer and User Facility Device Experience (MAUDE) data (FDA website) were included on the present topic. A total of 170 articles were identified. The use of synthetic mesh in sub-urethral sling procedures is now considered the standard for the surgical management of stress urinary incontinence. Synthetic mesh is being increasingly used in the management of pelvic organ prolapse. While the incidence of extrusion and erosion with mid-urethral sling is low, the extrusion rate in prolapse repair is somewhat higher and the use in posterior compartment remains controversial. When used through the abdominal approach the extrusion and erosion rates are lower. The management of mesh complication is an individualized approach. The choice of the technique should be based on the type of mesh complication, location of the extrusion and/or erosion, its magnitude, severity and potential recurrence of pelvic floor defect.

Management of Recurrent or Persistent Stress Urinary Incontinence after Mid-urethral Sling

The mid-urethral sling (MUS) procedure is the most common treatment modality for women with stress urinary incontinence (SUI). Although this procedure is highly successful, 5-20% of patients undergoing MUS experience persistent or recurrent SUI, regarded as surgical failure. However, little is known about methods to evaluate and manage patients who fail MUS procedures. The surgical options in these patients include bulking agent injection, shortening of pre-implanted tape, pubovaginal sling and repeat MUS. Of these secondary procedures, repeat MUS is the most widely studied, although this has been limited to small case series without long-term follow-up. Repeat MUS for prior MUS failure has shown relatively good success rates, ranging from 55 to 90%, with better outcomes obtained using the retropubic rather than the transobturator route. Persistent or recurrent SUI may also be successfully managed with less invasive techniques, such as tape shortening and periurethral injection of a bulking agent. Transurethral injection therapy for primary SUI has shown success rates of more than 65% at 1 year; however, these decreased significantly thereafter to around 30% at long-term follow-up. Since the optimal management of recurrent or persistent SUI after MUS has not yet been established, long-term, prospective, randomized trials are warranted.

A Comparison of the Clinical Efficacy of the Transobturator Adjustable Tape (TOA) and Transobturator Tape (TOT) for Treating Female Stress Urinary Incontinence with Intrinsic Sphincter Deficiency: Short-term Results

PURPOSE

The transobturator adjustable tape (TOA) allows adjustment of tension after surgical intervention, thus permitting correction of postoperative incontinence or obstruction. The aim of this study was to compare the efficacy and safety of TOA versus transobturator tape (TOT) for the treatment of stress urinary incontinence with intrinsic sphincter deficiency (ISD).

MATERIALS AND METHODS

Patients underwent TOA (n=33 with ISD) or TOT (n=47 with ISD) insertion by one experienced surgeon. The patients were considered to have ISD on the basis of a Valsalva leak point pressure <60 cmH(2)O or a maximum urethral closure pressure <20 cmH(2)O. The preoperative evaluation included history taking, physical examination, voiding diary, stress and 1-hour pad tests, and a comprehensive urodynamic examination. Postoperative evaluation included a stress test, 1-hour pad test, questionnaire, and uroflowmetry with postvoid residuals.

RESULTS

After 6 months of follow-up, the rate of cure (TOA, 75.6% vs. TOT, 72.3%) was similar between the two groups. The rate of satisfaction was not significantly higher in the TOA group than in the TOT group (84.8% vs. 78.7%; p=0.05). Four patients in the TOA group (12.1%) needed a reduction in tension because of urinary obstruction (flow <10 ml/sec and/or residual urine >50 ml). The tension of the mesh was tightened in 5 patients (15.2%) because of the persistence of a certain degree of incontinence. The residual urine volume at postoperative 7 days was significantly lower in the TOA group than in the TOT group (19.5 ml vs. 41 ml; p=0.016, repeated-measures analysis of variance test).

CONCLUSIONS

The TOA allows postoperative readjustment of the suburethral sling pressure for a number of days after surgical intervention, which allows for the achievement of good short-term results. These data suggest that better lower obstructive voiding symptoms than those achieved with the traditional nonadjustable mesh can be obtained with the TOA.

Proper Mesh Placement Using the Outer Cylinder of a Ballpoint Pen in the Transobturator Adjustable Tape Sling Procedure for Female Stress Urinary Incontinence

Purpose

The transobturator adjustable tape (TOA) sling operation is an effective procedure that allows for correction of postoperative incontinence or obstruction through adjustment of the mesh tension. During the operation, the outer cylinder of a ballpoint pen was used for proper mesh placement with less dissection. We evaluated the efficacy and safety of the TOA sling operation with the use of the outer cylinder of a ballpoint pen.

Materials and Methods

A total of 127 consecutive women with stress urinary incontinence underwent the TOA sling operation with the use of the outer cylinder of a ballpoint pen. The preoperative evaluations included a stress cough test, urodynamic study, and questionnaires related to quality of life. The mesh tension was adjusted 1 day after the operation. Postoperative evaluation was done at 1 month and included a stress cough test, uroflowmetry, questionnaires, and asking about satisfaction. At 1 year, we evaluated the patients with a stress cough test and by asking about their satisfaction with the procedure.

Results

The overall cure rate was 95.3% at 1 month and 96.8% at the 1-year follow-up. Postoperative adjustment of the mesh tension was done for 22 patients (17.3%). Eight patients needed increased tension for remaining stress urinary incontinence, and 14 patients needed reduced tension for urinary obstruction. The maximal flow rate was decreased significantly. However, the residual urine volume was not increased significantly. The total score on the questionnaires increased significantly.

Conclusions

Results were excellent compared with outcomes of the traditional TOA sling procedure. Proper mesh placement by use of the outer cylinder of a ballpoint pen with less dissection and tension adjustment could improve the success rate of the TOA sling operation.