Complications and their treatment after midurethral tape implantation using retropubic and transobturator approaches for treatment of female stress urinary incontinence

Management of iatrogenic urethral foreign body after mid-urethral sling A literature review

INTRODUCTION

Urethral mesh perforation is a rare complication of mid-urethral sling resulting in a lack of clear management guidelines. Thus, we aimed to determine management options and their respective outcomes in terms of erosion resolution and continence.

METHODS

A literature review was performed by extracting studies from the PubMed, Cochrane, and Google Scholar from January 1996 to December 1, 2022. Only French and English language studies were included. A total of 227 papers were screened and assessed for eligibility.

RESULTS

Forty-eight studies were included in the final analysis, for a total of 224 patients. Treatment options consisted of conservative, endoscopic, transurethral, and transvaginal approaches. Conservative treatment was associated with a 100% risk of persistence or recurrence of urethral perforation, while the failure rates for endoscopic, transurethral, and transvaginal approaches were 33%, 7.5%, and 7%, respectively. Most patients suffered from stress urinary incontinence after reconstructive management. The most common symptoms at the time of presentation were overactive bladder and pain. The mean time between the onset of symptoms and diagnosis was 10 months. About half of the urethral mesh perforations were diagnosed within the first years after the initial sling insertion.

CONCLUSIONS

Multiple management options for sling penetration of the urethra have been described in the literature. Transvaginal sling resection with consecutive tissue interposition seems to carry the lowest risk of erosion recurrence; however, all treatment options are associated with a high relapse rate for stress urinary incontinence.

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

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

The Clinical Effects of Pixel CO2 Laser on Bladder Neck and Stress Urinary Incontinence

Background: Our study aims to assess Pixel CO2 laser efficacy for female stress urinary incontinence (SUI). Methods: In the study, 25 women with SUI were included and scheduled for vaginal Pixel CO2 Laser (FemiLift™, Alma Lasers, Israel) treatment. All subjects had a baseline and 6-month post-treatment assessment that included three-dimensional perineal ultrasound and validated questionnaires. Results: Data showed that monthly three-session vaginal Pixel CO2 Laser treatment significantly improved SUI symptoms, as evidenced by validated questionnaires, including UDI-6, IIQ-7, ICIQ, and vaginal laxity questionnaire (p < 0.05). The Pixel CO2 Laser efficacy in vaginal treatment was 20/25 (80%), and the perineal sonography showed that laser treatment significantly decreased bladder neck mobility and middle urethral area (during resting and straining). Permanent adverse events were not found. Conclusions: The results of our study suggested that for the treatment of mild to moderate SUI symptoms, Pixel CO2 Laser is effective and safe; however, more studies and a longer follow-up should be conducted to confirm its efficacy and durability.

A retrospective analysis of perioperative complications associated with retropubic tension-free vaginal tape in 960 women

Purpose

The purpose is to analyse perioperative complications associated with the retropubic tension-free vaginal tape (TVT) procedure and their management.

Methods

This retrospective, monocentric cohort study included 960 women after retropubic TVT procedure performed by one surgeon from 2011 to 2016. Complications were identified up to 6 weeks after the procedure, divided into specific and general complications and classified based on the Clavien–Dindo (CD) Classification. A visit 6 weeks after the surgical procedure was attended by all patients.

Results

77 complications, of which 74 occurred postoperatively and 3 intraoperatively, affecting 72 (7.5%) out of 960 women. Urinary retention and voiding problems were the most common complication. The mean age of women suffering complications was 3.4 years higher in comparison to the mean age of women without complications (p = 0.036). The Body Mass Index (BMI) of the group of women with perioperative complications had an average BMI which was 0.5 kg/m² lower than the average BMI of the women without complications. 22 (12.8%) out of 172 women with recurrent stress incontinence had postoperative complications, of which 21 were related to the TVT.

Conclusion

The retropubic TVT is a surgical procedure associated with a low number of perioperative complications, even in the group of elderly and overweight women, as well as in cases of recurrent stress incontinence.

ANO1 in urethral SMCs contributes to sex differences in urethral spontaneous tone

Stress urinary incontinence (SUI) is more common in women than in men, and sex differences in anatomic structure and physiology have been suggested as causes; however, the underlying cellular and molecular mechanisms remain unclear. The spontaneous tone (STT) of the urethra has been shown to have a fundamental effect on preventing the occurrence of SUI. Here, we investigated whether the urethral STT exhibited sex differences. First, we isolated urethral smooth muscle (USM) and detected STT in female mice and women. No STT was found in male mice or men. Furthermore, caffeine induced increased contractility and intracellular Ca²⁺ concentration in urethrae from female mice compared with male mice. EACT [an N-aroylaminothiazole, anoctamin-1 (ANO1) activator] elicited increased intracellular Ca²⁺ concentration and stronger currents in female mice than in male mice. Moreover, ANO1 expression in single USM cells from women and female mice was almost twofold higher than that found in cells from men and male mice. In summary, ANO1 in USM contributes to sex differences in urethral spontaneous tone. This finding may provide new guidance for the treatment of SUI in women and men.

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

Introduction

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

Aim

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

Material and methods

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

Results

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

Conclusions

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