Comparison of perioperative adverse events following suburethral sling placement using synthetic mesh, autologous rectus fascia, and autologous fascia lata in a national surgical registry

AIMS

To assess and compare 30-day perioperative adverse events following suburethral sling surgery using synthetic mesh, autologous rectus fascia, and autologous fascia lata in women.

METHODS

This was a retrospective cohort study of patients who underwent fascial or synthetic sling placement for stress urinary incontinence between 2008 and 2021 using the American College of Surgeons' National Surgical Quality Improvement Program database. Current Procedural Terminology codes were used to identify patients undergoing each type of sling procedure. Multivariable regression analysis with stepwise regression was used to assess the odds of composite adverse events (e.g., urinary tract infection, surgical site infection, pulmonary embolism, and other reportable events) between cohorts.

RESULTS

Of the 41 533 female patients who underwent isolated suburethral sling placement without concurrent procedures, 41 292 (99.4%) received a synthetic mesh sling, and 241 (0.6%) received an autologous facial sling. In the fascial sling cohort, 160 (66.4%) underwent rectus fascia harvest and 81 (33.6%) underwent fascia lata harvest. Sling surgeries involving autologous fascia were associated with increased odds of adverse events compared to those involving synthetic mesh, even after adjusting for confounders (adjusted odds ratio [aOR]: 3.63, 95% confidence interval [CI]: 2.56-5.15). Compared to fascial slings from rectus fascia, slings from fascia lata were associated with increased odds of composite adverse events (aOR: 2.11, 95% CI: 1.03-4.04). However, with the exclusion of urinary tract infections, the adverse event rate was similar between slings using the two fascial harvest techniques (aOR: 1.93, 95% CI: 0.81-4.63).

CONCLUSIONS

In this retrospective database study, suburethral sling surgeries using autologous fascia were independently associated with a 3.6-fold increase in odds of 30-day perioperative adverse events compared to sling surgeries using synthetic mesh.

Restrictive opioid prescribing after surgery for prolapse and incontinence: a randomized, noninferiority trial

BACKGROUND

Opioids are routinely prescribed for postoperative pain control after gynecologic surgery with growing evidence showing that most prescribed opioids go unused. Restrictive opioid prescribing has been implemented in other surgical specialties to combat the risk for opioid misuse and diversion. The impact of this practice in the urogynecologic patient population is unknown.

OBJECTIVE

This study aimed to determine if a restrictive opioid prescription protocol is noninferior to routine opioid prescribing in terms of patient satisfaction with pain control after minor and major surgeries for prolapse and incontinence.

STUDY DESIGN

This was a single-center, randomized, noninferiority trial of opioid-naïve patients who underwent minor (eg, colporrhaphy or mid-urethral sling) or major (eg, vaginal or minimally invasive abdominal prolapse repair) urogynecologic surgery. Patients were excluded if they had contraindications to all multimodal analgesia and if they scored ≥30 on the Pain Catastrophizing Scale. Subjects were randomized on the day of surgery to the standard opioid prescription protocol (wherein patients routinely received an opioid prescription upon discharge [ie, 3-10 tablets of 5 mg oxycodone]) or to the restrictive protocol (no opioid prescription unless the patient requested one). All patients received multimodal pain medications. Participants and caregivers were not blinded. Subjects were asked to record their pain medication use and pain levels for 7 days. The primary outcome was satisfaction with pain control reported at the 6-week postoperative visit. We hypothesized that patient satisfaction with the restrictive protocol would be noninferior to those randomized to the standard protocol. The noninferiority margin was 15 percentage points. Pain level scores, opioid usage, opioid prescription refills, and healthcare use were secondary outcomes assessed for superiority.

RESULTS

A total of 133 patients were randomized, and 127 (64 in the standard arm and 63 in the restrictive arm) completed the primary outcome evaluation and were included in the analysis. There were no statistically significant differences between the study groups, and this remained after adjusting for the surgery type. Major urogynecologic surgery was performed in 73.6% of the study population, and minor surgery was performed in 26.4% of the population. Same-day discharge occurred for 87.6% of all subjects. Patient satisfaction was 92.2% in the standard protocol arm and 92.1% in the restrictive protocol arm (difference, -0.1%; P=.004), which met the criterion for noninferiority. No opioid usage in the first 7 days after hospital discharge was reported by 48.4% of the patients in the standard protocol arm and by 70.8% in the restrictive protocol arm (P=.009). Opioid prescription refills occurred in 8.5% of patients with no difference between the study groups (9.4% in the standard arm vs 6.7% in the restrictive arm; P=.661). No difference was seen in the rate of telephone calls and urgent visits for pain control between the study arms.

CONCLUSION

Among women who underwent minor and major surgery for prolapse and incontinence, patient satisfaction rates were noninferior after restrictive opioid prescribing when compared with routine opioid prescribing.

Feasibility of Using a GENEActiv Accelerometer with Triaxial Acceleration and Temperature Sensors to Monitor Adherence to Shoulder Sling Wear Following Surgery

BACKGROUND

Self-reported adherence to sling wear is unreliable due to recall bias. We aim to assess the feasibility and accuracy of quantifying sling wear and non-wear utilising slings pre-fitted with a GENEActiv accelerometer that houses triaxial acceleration and temperature sensors.

METHODS

Ten participants were asked to wear slings for 480 min (8 h) incorporating 180 min of non-wear time in durations varying from 5-120 min. GENEActiv devices were fitted in sutured inner sling pockets and participants logged sling donning and doffing times. An algorithm based on variability in acceleration in three axes and temperature change was developed to identify sling wear and non-wear and compared to participants' logs.

RESULTS

There was no significant difference between algorithm detected non-wear duration (mean ± standard deviation = 172.0 ± 6.8 min/participant) and actual non-wear (179.7 ± 1.0 min/participant). Minute-by-minute agreement of sensor-detected wear and non-wear with participant reported wear was 97.3 ± 1.5% (range = 93.9-99.0), with mean sensitivity 94.3 ± 3.5% (range = 86.1-98.3) and specificity 99.1 ± 0.8% (range = 93.7-100).

CONCLUSION

An algorithm based on accelerometer-assessed acceleration and temperature can accurately identify shoulder sling wear/non-wear times. This method may have potential for assessing whether sling wear adherence after shoulder surgeries have any bearing on patient functional outcomes.

Surgical Treatment of Hemifacial Spasm via Microvascular Decompression of a Large, Ectatic Vertebral Artery

Hemifacial spasm is a neuromuscular disorder caused by compression of the facial nerve at the nerve root entry zone, often due to ectatic or aberrant vasculature. Pathologic compression of the nerve-brainstem interface results in involuntary, paroxysmal contractions of ipsilateral facial muscles that may cause considerable impairments in quality of life. For those with severe symptoms, have positive imaging demonstrating vascular compression, or who fail other management modalities, 1 2 3 4 microvascular decompression offers potential definitive treatment. 5 6 Traditionally, nonabsorbable packing agent is used to pack between the nerve and offending vascular structure. However, for large and more complex arterial structures, simple nonabsorbable padding is often not sufficient. In this operative video, we demonstrate microvascular decompression for intractable hemifacial spasm in a 52-year-old female using a specialized sling tacked to the petrous dura for management of a large, ectatic vertebral artery. Following a standard left retrosigmoid craniotomy, an atheromatous ectatic vertebral artery was identified. We fashioned a bovine pericardium sling around the vessel and used a permanent aneurysm clip to secure it to an incision portion of petrous dura. We subsequently identified potential additional facial nerve root compression by anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) branches, which were elevated and secured using Teflon felt packing. Following elevation of all three vessels, the lateral spread response resolved. At 2 weeks postoperatively, the patient reported substantial relief in her hemifacial spasms and endorsed highly improved quality of life.

Ultrasound in Female Urinary Incontinence

Urinary incontinence (UI) is a common health condition that may interfere with the quality of life. A comprehensive evaluation of female UI helps with effective and safe treatments. Ultrasound has gained popularity to explore UI recently because it can collect crucial information for treatment planning and counseling. Translabial and introital approaches are commonly and reliably applied to ultrasound. The images can be obtained using two-dimensional and three-dimensional ultrasounds. Ultrasound is the only modality capable of confirming the presence or absence of a mid-urethral sling (MUS) and is able to demonstrate bulking agents as well. Although some of the ultrasound findings may only be incidental or supplementary to the patient's symptoms, ultrasound benefits for investigating the pathophysiology of UI and surgical outcomes of MUS procedures. It is anticipated that standardization in terminology, measurement techniques, and reporting can be established in the near future.

The N-brace trial: Does arm position during immobilisation of proximal humerus fractures influence outcome - A preliminary study

Background

Traditional initial management of proximal humerus fractures (PHF) involves arm immobilisation in a simple sling (SS) in an internally rotated position. We believe this risks fracture displacement and imbalance of soft tissues, encouraging malunion and stiffness. A neutral-rotation brace (NRB) maintains an arm position which may prevent this, leading to quicker and superior recovery.

Methods

We randomised patients with two- to four-part PHF into 4 weeks of immobilisation with either a SS or NRB, independent of surgery. Range of motion (ROM), subjective shoulder value (SSV), DASH, Constant-Murley (CMS) and Oxford Shoulder (OSS) scores were assessed at 6-weeks, 3-months and 1-year post-injury.

Results

The SS group included 11 patients vs 9 in the NRB group. At final follow-up, the SS and NRB groups had mean DASH scores of 42 vs 35, OSS 42 vs 46, CMS 71 vs 86, SSV 84% vs 92%, respectively. ROM was superior with the NRB (elevation 159°, ER 47° and IR score 8 vs 140°, 37° and 7 with SS).

Conclusions

Despite being a small series, our results demonstrate a trend towards NRB providing better outcomes. This feasibility study supports the need for a larger multi-centre randomised controlled trial comparing these immobilisation methods for PHF.

Mostafa Maged sling technique to treat prolapsed uterus in an easy way (New Technique)

Background

In the female population, pelvic organ prolapse is a common problem that lowers people's quality of life in terms of their health. Depending on the severity of the prolapse and the symptoms, there are many treatment options. Simple observation, vaginal pessaries, or surgical management are all possible treatments. Reconstructive pelvic surgery with or without mesh augmentation and obliterative surgery are two surgical treatments that are available. Due to the contentious concerns surrounding the use of mesh and the rising demand for uterine preservation, surgical practices are currently shifting.

Methods

Just two cases are included in this study due to the rarity of this condition. In this study, I introduce a new technique to the literature (Mostafa Maged sling technique) which will be challenging. This technique depends on round ligaments and ovarian ligament to hitch up the whole uterus.

Results

There were no difficulties following the procedure. None of the patients required blood transfusions, and there were no signs of dehiscence or incision infection. Non-steroidal antiinflammatory medications were administered to both patients as analgesia. On the first postoperative day, the foley catheters were removed from both patients.

Conclusion

A simple and new manueuver is applied in the literature to treat the uterine prolapse. It is easy to learn and easy to perform. We need further studies to compare different techniques including Mostafa Maged sling operation to manage uterine prolapse.

Sling Versus Abduction Brace Shoulder Immobilization After Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background

The optimal immobilization position of the shoulder after rotator cuff repair is controversial.

Purpose

To compare the clinical outcomes and incidence of retears after arthroscopic rotator cuff repair between patients who used an abduction brace versus a sling for postoperative shoulder immobilization.

Study Design

Systematic review; Level of evidence, 1.

Methods

This systematic review and meta-analysis was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, MEDLINE, and Embase electronic databases for randomized controlled trials (RCTs) that compared abduction brace and sling immobilization after arthroscopic rotator cuff repair using single-row, double-row, or suture-bridge fixation. Clinical scores, pain severity, and retear rates were compared between patients with abduction brace versus sling immobilization.

Results

Of 1572 retrieved studies, 4 RCTs with a total of 224 patients (112 patients with abduction brace and 112 patients with sling) were included in the qualitative analysis, and 3 of the RCTs were included in the quantitative analysis (meta-analysis). There were no significant differences between the abduction brace and sling immobilization groups in the Constant-Murley score at 3 months (weighted mean difference [WMD], 0.26 [95% CI, -1.30 to 1.83]; P = .74; I 2 = 84%), 6 months (WMD, 1.91 [95% CI, -0.17 to 4.00]; P = .07; I 2 = 85%), and 12 months (WMD, 0.55 [95% CI, -1.37 to 2.47]; P = .57; I 2 = 0%); the visual analog scale score for pain at 1 week (WMD, 0.10 [95% CI, -0.20 to 0.41]; P = .51; I 2 = 0%), 3 weeks (WMD, -0.12 [95% CI, -0.34 to 1.00]; P = .29; I 2 = 0%), 6 weeks (WMD, -0.12 [95% CI, -0.30 to 0.06]; P = .20; I 2 = 0%), and 12 weeks (WMD, -0.13 [95% CI, -0.27 to 0.02]; P = .09; I 2 = 18%); or the retear rate at 3 months (risk ratio, 0.63 [95% CI, 0.09 to 4.23]; P = .64; Z = 0.47%) postoperatively.

Conclusion

Our systematic review demonstrated a lack of significant differences between the abduction brace and sling immobilization groups regarding postoperative clinical scores, pain severity, and tendon healing.

The Effect of Upper Extremity Slings (UESs) on Balance in Young Adults

INTRODUCTION

Upper extremity slings (UESs) are frequently provided for patients with a hand or forearm injury. However, their effect on balance has not been well explored. We sought to characterize the effect of a UES on balance in young adults.

METHODS

Healthy young adult participants with no injuries acting as a proxy for the general young adult patient population using UESs balanced on a BioDex Balance System platform: once while wearing a UES and once without wearing it, to serve as their own control. Participant weight, height, gender, hand dominance, overall stability index, anterior/posterior stability index, and medial/lateral stability index were recorded. Comparisons were analyzed with paired t-tests and linear regression analysis.  Results: No significant difference in the three stability index scores were found between UES and no UES usage. Height and weight were found to have positive significant relationships with the overall stability index during UES usage.  Conclusions: Our study demonstrates the feasibility of assessing balance discrepancies between the sling and nonsling usage in a broader patient population and suggests that height and weight may impact balance negatively during UES use.

Medium-Term Outcomes of Conservative and Surgical Treatments for Stress Urinary Incontinence: A Medicare Claims Analysis: Developed by the AUGS Payment Reform Committee

OBJECTIVE

This study aimed to evaluate the 3- to 5-year retreatment outcomes for conservatively and surgically treated urinary incontinence (UI) in a population of women 66 years and older.

METHODS

This retrospective cohort study used 5% Medicare data to evaluate UI retreatment outcomes of women undergoing physical therapy (PT), pessary treatment, or sling surgery. The data set used inpatient, outpatient, and carrier claims from 2008 to 2016 in women 66 years and older with fee-for-service coverage. Treatment failure was defined as receiving another UI treatment (pessary, PT, sling, Burch urethropexy, or urethral bulking) or repeat sling. A secondary analysis was performed where additional treatment courses of PT or pessary were also considered a treatment failure. Survival analysis was used to evaluate the time from treatment initiation to retreatment.

RESULTS

Between 2008 and 2013, 13,417 women were included with an index UI treatment, and follow-up continued through 2016. In this cohort, 41.4% received pessary treatment, 31.8% received PT, and 26.8% underwent sling surgery. In the primary analysis, pessaries had the lowest treatment failure rate compared with PT (P<0.001) and sling surgery (P<0.001; survival probability, 0.94 [pessary], 0.90 [PT], 0.88 [sling]). In the analysis where retreatment with PT or a pessary was considered a failure, sling surgery had the lowest retreatment rate (survival probability, 0.58 [pessary], 0.81 [PT], 0.88 [sling]; P<0.001 for all comparisons).

CONCLUSIONS

In this administrative database analysis, there was a small but statistically significant difference in treatment failure among women undergoing sling surgery, PT, or pessary treatment, but pessary use was commonly associated with the need for repeat pessary fittings.

Patient decision-making for surgical treatment of post-prostatectomy stress urinary incontinence: a mixed-methods exploratory pilot study

Background

Male stress urinary incontinence (SUI) is a known complication following surgical intervention on the prostate, particularly following surgery for prostate cancer. Effective surgical treatments for SUI include artificial urinary sphincter (AUS) and male urethral sling. Prior data suggest that men may forego available treatment despite bothersome symptoms. The objective was to explore how men who underwent surgical correction for post-prostatectomy SUI navigated SUI treatment decisions.

Methods

Mixed method study was employed. Semi-structured interviews, participant surveys and objective clinical assessment of SUI were performed among a group of men living with incontinence after prostate cancer surgery who underwent surgery for SUI at the University of California in 2017.

Results

Eleven men were interviewed after consultation for SUI and all had complete quantitative clinical data. Surgery for SUI included AUS (n=8) and sling (n=3). There was a decrease in pads per day from 3.2 to 0.9 and no major complications. Most patients found that the impact on activities and their treating urologist were of great importance. Sexual and relationships played a variable role with some participants ranking these as "great deal of influence" and others "little or no influence". Participants who underwent AUS were more likely to cite a higher importance on "being very dry" in choosing that surgery while sling patients had more variable ranking of important factors. Participants found a variety of inputs helpful in hearing information about SUI treatment options.

Conclusions

Among a group of 11 men who underwent surgical correction for post-prostatectomy SUI, there were identifiable themes on how men make decisions, evaluate quality of life (QoL) changes and approach treatment options. Men value more than being dry with measures of individual success that can include sexual and relationship health. Furthermore the role of the Urologist remains crucial as patients relied heavily on input and discussion with their Urologist to assist in treatment decisions. These findings can be used to inform future studies of the experience of men with SUI.

The transvaginal mesh: an overview of indications and contraindications for its use

INTRODUCTION

In recent decades, concerns about safety of synthetic non-absorbable materials transvaginally implanted emerged. We aim to define the actual role of synthetic non-absorbable transvaginal mesh (TVM) for pelvic organ prolapse (POP) and mid-urethral sling (MUS) for stress urinary incontinence (SUI), in relation with the worldwide legislative evolution.

AREAS COVERED

While in the United Kingdom MUS is not considered the first-line surgical option, other countries adopt MUS as the main procedure. United States, United Kingdom, Australia, New Zealand, France banned or paused TVM use for POP repair. At the same time, Germany, Asian and South American countries adopt TVM after adequate counseling for selected populations such as women affected by or at high risk of POP relapse and contraindication for other surgical routes.

EXPERT OPINION

The worldwide evolution of recommendations determined deep modification of clinical practice, with native tissue repair returning to forefront when the vaginal route is indicated. A more careful evaluation of the safety and efficacy profile of meshes' materials and the assessment of the minimal surgeon's expertise in performing TVM procedures became crucial. A multidisciplinary approach and a high specialization of the hospitals both in performing mesh procedures and in managing complications is mandatory.

Shoulder Surgery Postoperative Immobilization: An International Survey of Shoulder Surgeons

BACKGROUND

There is currently no consensus on immobilization protocols following shoulder surgery. The aim of this study was to establish patterns and types of sling use for various surgical procedures in the United States (US) and Europe, and to identify factors associated with the variations.

METHODS

An online survey was sent to all members of the American Shoulder and Elbow Society (ASES) and European Society for Surgery of the Shoulder and Elbow (ESSSE). The survey gathered member data, including practice location and years in practice. It also obtained preferences for the type and duration of sling use after the following surgical procedures: arthroscopic Bankart repair, Latarjet, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears <3 cm and >3 cm, anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA), and isolated biceps tenodesis (BT). Relationships between physician location and sling type for each procedure were analyzed using Fisher's exact tests and post-hoc tests using Bonferroni-adjusted p-values. Relationships looking at years in practice and sling duration preferred were analyzed using Spearman's correlation tests.

RESULTS

In total, 499 surgeons with a median of 15 years of experience (IQR = 9-25) responded, with 54.7% from the US and 45.3% from Europe. US respondents reported higher abduction pillow sling use than European respondents for the following: Bankart repair (62% vs. 15%, p < 0.0001), Latarjet (53% vs. 12%, p < 0.001), ARCR < 3 cm (80% vs. 42%, p < 0.001) and >3 cm (84% vs. 61%, p < 0.001), aTSA (50% vs. 21%, p < 0.001) and rTSA with subscapularis repair (61% vs. 22%, p < 0.001) and without subscapularis repair (57% vs. 17%, p < 0.001), and isolated BT (18% vs. 7%, p = 0.006). European respondents reported higher simple sling use than US respondents for the following: Bankart repair (74% vs. 31%, p < 0.001), Latarjet (78% vs. 44%, p < 0.001), ARCR < 3 cm (50% vs. 17%, p < 0.001) and >3 cm (34% vs. 13%, p < 0.001), and aTSA (69% vs. 41%, p < 0.001) and rTSA with subscapularis repair (70% vs. 35%, p < 0.001) and without subscapularis repair (73% vs. 39%, p < 0.001). Increasing years of experience demonstrated a negative correlation with the duration of sling use after Bankart repair (r = -0.20, p < 0.001), Latarjet (r = -0.25, p < 0.001), ARCR < 3 cm (r = -0.14, p = 0.014) and >3 cm (r = -0.20, p < 0.002), and aTSA (r = -0.37, p < 0.001), and rTSA with subscapularis repair (r = -0.10, p = 0.049) and without subscapularis repair (r = -0.19, p = 0.022. Thus, the more experienced surgeons tended to recommend shorter durations of post-operative sling use. US surgeons reported longer post-operative sling durations for Bankart repair (4.8 vs. 4.1 weeks, p < 0.001), Latarjet (4.6 vs. 3.6 weeks, p < 0.001), ARCR < 3 cm (5.2 vs. 4.5 weeks p < 0.001) and >3 cm (5.9 vs. 5.1 weeks, p < 0.001), aTSA (4.9 vs. 4.3 weeks, p < 0.001), rTSR without subscapularis repair (4.0 vs. 3.6 weeks, p = 0.031), and isolated BT (3.7 vs. 3.3 weeks, p = 0.012) than Europe respondents. No significant differences between regions within the US and Europe were demonstrated.

CONCLUSIONS

There is considerable variation in the immobilization advocated by surgeons, with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery.

LEVEL OF EVIDENCE

Level IV.

The Effect of Patients' Understanding of Sling Necessity and Home Assistance on Sling Wear After Shoulder Surgery

BACKGROUND

Perioperative education and socioeconomic factors influence patient behavior. Recent evidence has suggested that sling compliance is associated with improved outcomes after shoulder surgery; it is important to investigate factors that influence sling compliance.

PURPOSE

To determine the associations between postoperative sling wear and patients' understanding of sling necessity, postoperative home assistance, and social deprivation.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 66 patients were prospectively enrolled from 2018 to 2020 if they were ≥18 years of age and undergoing shoulder surgery requiring a sling for at least 1 month postoperatively. Sling wear was measured using a temperature-sensing device. At 6 weeks postoperatively, patients' understanding for sling necessity was determined by their response to a question on the Medical Adherence Measure questionnaire, "Why did you have to wear a shoulder sling?" The Patient Understanding Grading Scale (PUGS) was developed to quantify patient responses. PUGS was graded 1 to 3, with grade 1 corresponding to the least technical knowledge. Patient characteristics, social deprivation (Area Deprivation Index [ADI]), and home assistance were additionally analyzed.

RESULTS

There were no significant differences in baseline characteristics between patients when stratified by PUGS grade. Multivariable linear regression analysis for total hours of sling wear per week showed that patients with PUGS grade 2 (β, 48.2 hours; P = .007) and grade 3 (β, 59.5 hours; P = .003) wore their slings significantly more than grade 1 patients. Patients with home assistance had significantly greater day hours (73.5 ± 33.0 vs 44.0 ± 24.5 hours; P = .037) of sling wear per week, but there was no difference in night sling hours. Patients older than 60 years wore their slings significantly more, while men and those with a higher body mass index (BMI) wore their slings significantly less. ADI was not significantly associated with sling wear.

CONCLUSION

This study demonstrates that patients with greater understanding for sling necessity, those with home assistance, and patients >60 years have greater sling wear, while male patients and those with a higher BMI have lower sling compliance. ADI was not a significant contributor.

The Correlation Between the Sonographic Course of Transobturator Slings and Sling-Related Pain

OBJECTIVES

To determine whether transobturator slings follow a consistent path and whether there is an association between ultrasonographically visualized sling pattern or position with sling-related pain.

METHODS

This was a cross-sectional retrospective pilot study. We evaluated women who were presented to our clinic for pain or other urogynecologic symptoms following transobturator sling placement between 2009 and 2014. Patients had undergone a 3-dimensional endovaginal pelvic floor ultrasound, assessing minimal levator hiatus, antero-posterior diameter, left-right diameter, and the hiatal shape. The mesh patterns were categorized as seagull patterns (normal), lopsided, flat, and convoluted.

RESULTS

A total of 68 cases were reviewed. Fifty patients reported pain, and 18 did not. There were wide variations in the course of the slings. The sling center- minimal levator hiatus position ranged 14.8 mm below and 17.9 mm above the minimal levator hiatus. The lateral arm insertion points ranged between 17.1 mm below and 16.6 mm above the minimal levator hiatus. The right arm insertion points ranged between 9.6 mm below and 18.8 mm above the minimal levator hiatus. Thirty-five of 68 (70%) patients with pain and 13 of 18 (72.2%) without had abnormal sling patterns. The abnormal sling shape was not correlated with pain (P = 1). The levator shape trended toward a statistical significant correlation with sling shape abnormality (P = .084).

CONCLUSIONS

This population of women with transobturator sling complications demonstrated wide variations in anatomic paths. Neither the abnormal sling shape nor the distance of the center of the tape from the minimal levator hiatus level were correlated with pain.

A preliminary evaluation of in vivo response to a filament-wound macroporous collagen midurethral sling in an ovine model

Stress urinary incontinence (SUI) impacts ~1/3 of women over age 50. Negative publicity around PP meshes used in pelvic prolapse repair drives the need for identifying alternative biomaterials for SUI repair. Our study evaluated in vivo response to collagen sling implanted in an ovine model. Electrocompacted collagen threads were filament wound as slings and crosslinked in genipin. Collagen slings were implanted suburethrally mimicking the transvaginal tape technique. Main study groups were: Collagen sling (n = 3, 6 months) and PP sling (n = 3, 6 months). Collagen sling was also tested at 3-weeks (n = 1) to observe early-stage tissue response and 1-year (n = 2) to assess biomaterial longevity in a preliminary capacity. Collagen slings healed to a fibrous ligament texture at 6 months and maintained such texture to 1 year. Histological scoring indicated biocompatible responses to collagen slings with no adverse events. All study groups exhibited complete tissue ingrowth and interstitial de novo collagen deposition at all time points. Collagen threads induced orderly de novo collagen deposition that was aligned along long axes of threads. Tissue infiltrated collagen slings that were explanted at 6 and 12 months presented similar structural strength with native tissues such as vagina and fascia, and PP (Lynx) slings (p > .05). With the limitation of low number of animals per time point in hindsight, this preliminary study justifies evaluation of collagen slings in a larger sample size of animals, particularly to assess persistence of ligamentous tissue response over longer durations than 1-year.

Comparison among low intensity bridge exercises using suspension devices based on muscle activity and subjective difficulty

BACKGROUND

Recent clinical studies have revealed the advantages of using suspension devices. Although the supine, lateral, and forward leaning bridge exercises are low-intensity exercises with suspension devices, there is a lack of studies directly comparing exercise progression by measuring muscular activity and subjective difficulty.

OBJECTIVE

To identify how the variations in the bridge exercise affects trunk muscle activity, the present study investigated changes in neuromuscular activation during low-intensity bridge exercises. We furthermore explored whether the height of the suspension point affects muscle activation and subjective difficulty.

METHODS

Nineteen asymptomatic male participants were included. Three bridge exercise positions, supine bridge (SB), lateral bridge (LB), forward leaning (FL), and two exercise angles (15 and 30 degrees) were administered, thereby comparing six bridge exercise conditions with suspension devices. Surface electromyography and subjective difficulty data were collected.

RESULTS

The rectus abdominis activity was significantly higher with the LB and FL exercises compared with the SB exercise (p< 0.05). The erector spinae muscle activity was significantly higher with the SB and LB exercises, compared with the FL exercise (p< 0.05). The LB exercise significantly increased the internal oblique muscle activity, compared with other exercise variations (p< 0.05). The inclination angle of the exercise only affected the internal oblique muscle and subjective difficulty, which were significantly higher at 30 degrees compared with 15 degrees (p< 0.05).

CONCLUSIONS

Relatively higher inclination angle was not effective in overall activation of the trunk muscles; however, different bridge-type exercises could selectively activate the trunk muscles. The LB and SB exercises could be good options for stimulating the internal oblique abdominis, and the erector spinae muscle, while the FL exercise could minimize the erector spinae activity and activate the abdominal muscles.

A fresh "slant" on modified Mitchell bladder neck reconstruction: A contemporary single-institution experience

INTRODUCTION

Patients with neurogenic urinary incontinence due to an incompetent outlet may be offered bladder neck reconstruction, but the quest for the perfect surgical-outlet procedure continues. Our aim was to characterize continence and complications after modified Mitchell urethral lengthening/bladder neck reconstruction (MMBNR) with sling and to introduce a modification of exposure that facilitates subsequent steps of MMBNR.

METHODS

A single-institution, retrospective cohort study of patients who underwent primary MMBNR between May 2011 and July 2019 was performed. Data on demographics, urodynamic testing, operative details, unanticipated events, continence, bladder changes, and additional procedures were collected. A 2013 modification that permits identification of the incompetent bladder neck prior to urethral unroofing was applied to the last 17 patients. The trigone and bladder neck are exposed via an oblique low anterolateral incision on the bladder. Ureteral reimplantation is not routinely performed. Focal incision of the endopelvic fascia after posterior plate creation limits breadth of blunt dissection for sling placement. Descriptive statistics were utilized.

RESULTS

A total of 25 patients (13 females) had MMBNR with sling at a median age of 10 years [interquartile range (IQR) 8-11]. Bladder augmentation was performed concurrently in 14/25 (56%) patients. At a median of 5.0 (IQR 3.9-7.5) years follow-up after MMBNR, 9/11 (82%) without bladder augmentation and 13/14 (93%) with bladder augmentation had no leakage per urethra during the day without further continence procedures. Of the three patients with persistent incontinence, two achieved continence with bladder wall Botox injection (overall continence 24/25, 96%). New and recurrent vesicoureteral reflux was noted in five patients and one patient, respectively. Two patients required subsequent bladder augmentation for pressures and one other will likely require it. None have required bladder neck closure or revision.

CONCLUSION

MMBNR with sling provides promising continence per urethra in neurogenic bladder with low need for secondary continence procedures. Ongoing modifications may achieve elusive total continence.

An accurate method of measuring shoulder sling compliance: a validation study

Background

The effect of postoperative shoulder sling compliance on surgical outcomes is unknown. The goal was to determine an accurate method to measure sling compliance. We compared volunteer recorded sling wear time with temperature-based sensors to monitor sling compliance.

Methods

Data loggers sutured at three locations measured heat generated in 15-minute intervals. Slings wearers logged sling wear to accurately cross-reference with temperature sensors. Secondary experiments analyzed whether surrounding ambient temperature can be discerned from actual sling wear. We created an algorithm to describe actual sling wear time as a function of heat recorded and calculated percent wear accuracy.

Results

The modified sling was worn for 172 h. The algorithm modeled sling on/off times by analyzing cutoff temperatures. Diagnostic accuracy was >99 % for the three locations, with no statistically significant differences among them. Compared with sling wear, ambient temperature took longer to reach critical temperature values determined by the algorithm, helping distinguish compliance from false positives.

Conclusions

The described algorithm can effectively quantify shoulder sling wear time based on heat-generated sensor readings. False positives from ambient temperature are minimal. This measurement method could be used to study the relationship between postoperative sling use and functional outcomes after shoulder surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04396-1.

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study

BACKGROUND

There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making.

OBJECTIVE

This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling.

STUDY DESIGN

A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding.

RESULTS

The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00).

CONCLUSION

This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Clinical Outcome of a Modified Coracoid Tunnel-Free Coracoclavicular Sling Technique With Remnant Preservation for the Treatment of High-Grade Acromioclavicular Joint Separation: A Report of 48 Cases With 2 to 5 Years of Follow-up

BACKGROUND

High-grade acromioclavicular (AC) joint separation injuries (Rockwood type IV or V) are surgically indicated because of complete disruption of the AC and coracoclavicular (CC) ligaments, leading to instability and pain. In surgical techniques that require a suspensory system, coracoid tunnel-related complications are not uncommon.

PURPOSE

To report subjective and objective clinical outcomes and complication rates of a modified coracoid tunnel-free CC sling technique combined with CC ligament remnant preservation for a minimum 2-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2014 and January 2017, we prospectively enrolled patients who underwent a modified CC sling technique performed by 1 senior surgeon using the AC TightRope System in a coracoid tunnel-free fashion. The CC distance (CCD) and Rockwood AC joint classification were evaluated on radiographs preoperatively, immediately postoperatively, and at the final follow-up. The visual analog pain score, range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and University of California Los Angeles score were recorded preoperatively and at the final follow-up.

RESULTS

In total, 48 of 54 patients (88.9%) were included for the evaluation with a mean ± SD follow-up of 39.3 ± 8.9 months (range, 24.7-64.3 months). The CCD was significantly decreased from 22.7 ± 4.2 to 9.8 ± 2.3 mm (P < .01) immediately after surgery and to 11.2 ± 1.8 mm (P < .01) at final follow-up. At the final follow-up, the side-to-side difference of CCD was 3.5 ± 0.6 mm. Compared with the preoperative level, all subjective evaluations were significantly improved at the final follow-up. We observed that 4 of the 48 patients (8.3%) had a loss of reduction at the final follow-up, but no pain or instability was documented. Further, no coracoid-related complication or other complications were recorded.

CONCLUSION

The coracoid tunnel-free CC sling technique using the AC TightRope System combined with CC ligament remnant preservation demonstrated significant improvement regarding both clinical and radiological outcomes, with a reduction loss rate of 8.3%. It is a safe method that could achieve satisfactory result without any coracoid drilling-related complications.

Hybrid Sling for the Treatment of Concomitant Female Urethral Complex Diverticula and Stress Urinary Incontinence

This study aims to present an alternative technique with the use of a transobturator hybrid sling (autologous fascia lata with a synthetic sling) in two patients with complex urethral diverticulum (CUD), urinary stress incontinence (SUI) and a large incisional infraumbilical hernia. Staged procedures could be performed, but considering the risk of persistence or worsening SUI, and no standard management strategy of SUI associated with CUD; simultaneous treatment was proposed. It is preferable to use autologous materials in such cases. However, the presence of incisional hernia protruded with its content covering the suprapubic area prohibits the retropubic sling technique due to visceral lesion risk. The diverticulum and SUI were repairs in the same surgery using a hybrid transobturator. The technique used for obtaining the fascia lata followed the literature, and a 6 cm segment was acquired. The patients were re-prepared in a lithotomy fashion, and diverticulectomy was performed. The segment of fascia lata was fixed to the mesh and sling was manipulated so that its middle part (fascia) rested directly below the urethra. After 6 months post-operatively, patients referred significant improvement in urinary symptoms. Patients have not had any storage symptoms, International Consultation on Incontinence Questionnaire – Short Form = zero, no SUI, and have not had any mesh-related complications. In conclusion, the present study evaluated a new technique for the treatment of CUD with SUI in a particular clinical scenario. Other studies with extended follow-up periods and larger sample sizes should be performed in this subset of patients.

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.

A national study of artificial urinary sphincter and male sling implantation after radical prostatectomy in England

OBJECTIVES

To consider the provision of post-radical prostatectomy (RP) continence surgery in England.

MATERIALS AND METHODS

Patients with an Office of Population Census and Surveys Classification of Interventions and Procedures, version 4 code for an artificial urinary sphincter (AUS) or male sling between 1 January 2010 and 31 March 2018 were searched for within the Hospital Episode Statistics (HES) dataset. Those without previous RP were excluded. Multivariable logistic regressions for repeat AUS and sling procedures were built in stata. Further descriptive analysis of provision of procedures was performed.

RESULTS

A total of 1414 patients had received index AUS, 10.3% of whom had undergone prior radiotherapy; their median follow-up was 3.55 years. The sling cohort contained 816 patients; 6.7% of these had received prior radiotherapy and the median follow-up was 3.23 years. Whilst the number of AUS devices implanted had increased each year, male slings peaked in 2014/2015. AUS redo/removal was performed in 11.2% of patients. Patients in low-volume centres were more likely to require redo/removal (odds ratio [OR] 2.23 95% confidence interval [CI] 1.02-4.86; P = 0.045). A total of 12.0% patients with a sling progressed to AUS implantation and 1.3% had a second sling. Patients with previous radiotherapy were more likely to require a second operation (OR 2.03 95% CI 1.01-4.06; P = 0.046). Emergency re-admissions within 30 days of index operation were 3.9% and 3.6% fewer in high-volume centres, for AUS and slings respectively. The median time to initial continence surgery from RP was 2.8 years. Increased time from RP conferred no reduced risk of redo surgery for either procedure.

CONCLUSION

There is a volume effect for outcomes of AUS procedures, suggesting that they should only be performed in high-volume centres. Given the known impact of incontinence on quality of life, patients should be referred sooner for post-prostatectomy continence surgery.

Strong correlation between standing cough test and 24-hour pad weights in the evaluation of male stress urinary incontinence

AIMS

We sought to compare in-office physical exam findings via standing cough test (SCT) versus 24-hour pad weights among men seeking treatment for postprostatectomy stress urinary incontinence (SUI).

METHODS

A retrospective review of a single surgeon database of incontinence procedures was performed. Documentation of SUI severity (grades 0-4) was completed by SCT preoperatively utilizing the Male Stress Incontinence Grading Scale (MSIGS). All patients had pads per day (PPD) and 24-hour pad weights obtained. We determined the Spearman's correlation coefficient between these variables.

RESULTS

We identified 104 men who underwent anti-incontinence surgery (AdVance Sling or artificial urinary sphincter [AUS]). In the sling group (65 patients), nearly all (97%) had minimal incontinence with SCT (MSIGS = 0-2). In the AUS group (39 patients), most patients (69%) had an MSIGS 3 or 4 with SCT. Spearman's coefficient between quantification of SCT and pad weight for the overall group was ρ = .68 (P < .0001) demonstrating a strong positive correlation. PPD was also strongly correlated with pad weight (ρ = .55, P < .0001). As seen previously, SCT and PPD were correlated (ρ = .47, P < .0001). In a multivariable model predicting pad weight, the effect of SCT was greater than PPD (β = 83 [54-111], P < .0001 vs 45 [2169], P = .0004).

CONCLUSIONS

SCT findings strongly correlate to 24-hour pad weights in the evaluation of male SUI. The SCT shows promise as a rapid, reliable, noninvasive measure of SUI severity before anti-incontinence surgery.

Effectiveness of surgical management with an adjustable sling versus an artificial urinary sphincter in patients with severe urinary postprostatectomy incontinence: a systematic review and network meta-analysis

Background:

The purpose of this study was to determine the effectiveness of an adjustable sling compared with an artificial urinary sphincter (AUS) in patients with severe urinary incontinence (SUI) postprostatectomy (PP).

Methods:

This review was carried out following the Cochrane Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. We searched Medline, Embase, LILACS, and CENTRAL databases. Studies with patients older than 18 years of age with SUI PP who underwent sling or AUS intervention and had been monitored for longer than 12 months were included.

Results:

Seven studies were included, yielding a sample size of 420. Pads were reportedly dry or improved in 70% of the sling group compared with 74% in the AUS group. The Incontinence Impact Questionnaire, Short Form (IIQ-7) was the most frequently used scale and showed improvement, with a score of 82.8% in the AUS group compared with 86.1% in the sling group. When comparing interventions with nonintervention, relative risks (RRs) of 35.37 (95% confidence interval [CI]: 7.17–174.35) and 45.14 (95% CI: 11.09–183.70) were found for the adjustable sling and AUS, respectively, which were statistically significant. No significant differences were found when AUS versus adjustable sling were compared, with an RR of 0.78 (95% CI: 0.09–6.56). We found a low risk of bias in most studies.

Conclusions:

Both interventions can reduce incontinence and improve the quality of life of patients with SUI PP. The published literature is substantially limited as no randomized clinical trials are available, no consensus has been reached regarding the definition of severity of incontinence, and considerable heterogeneity exists across the outcome variables measured.

Immediate effects of isometric trunk stabilization exercises with suspension device on flexion extension ratio and strength in chronic low back pain patientss

BACKGROUND

Recent clinical research has supported the use of suspension devices in rehabilitation procedures both in practice and in theory. Although a longitudinal study has reported on the use of suspension devices among asymptomatic subjects, it is necessary to investigate the immediate effects of suspension exercises in patients with CLBP.

OBJECTIVE

The present study aims to investigate changes in neuromuscular activation after the prescription of suspension exercises in patients with CLBP. A secondary aim was to determine whether practical flexion and extension strength can be effectively enhanced.

METHODS

Before and after suspension exercise, flexion extension (FE) ratio and trunk strength of flexion and extension were measured. Patients performed two types of suspension exercises: supine bridge and forward leaning exercises. The paired t-test was used to compare the FE ratio and strength data. Pearson correlation coefficient was performed to study the correlation between measured variables.

RESULTS

Compared to the pre-exercise measurements, the flexion-extension ratio and trunk extension strength was significantly increased at the post-exercise measurement (p< 0.05). The FE ratio in the right lumbar erector spine muscle was significantly correlated with post-exercise trunk extension strength (p< 0.05).

CONCLUSIONS

For patients with chronic lower back pain, stimulation of the lumbar extensor muscle and of proprioception is effective both for strengthening lumbar extensors and for improving the flexion-extension ratio. Consequently, forward leaning and supine bridge exercises with a suspension device are beneficial for normalising neuromuscular control of the erector spinae muscles.

The autologous pubovaginal fascial sling: An update in 2019

The contemporary management of stress urinary incontinence (SUI) has seen renewed interest in the use of autologous fascia for the formation of a retropubic suburethral sling. Traditionally, it has been used in only the most severe of incontinence cases, such as those women with intrinsic sphincter deficiency, or in patients requiring concomitant reconstructive procedures. In the current climate surrounding transvaginal mesh, many doctors and patients are shying away from the less morbid synthetic midurethral sling. International literature has demonstrated that the fascial sling is a safe and efficacious procedure for all patients with SUI, adequately treating both urethral hypermobility and intrinsic sphincter deficiency. This paper will discuss the indications, technique, and outcomes of autologous fascial slings. We will explore the use of fascial slings following failed synthetic slings and also the troubleshooting of commonly encountered issues intra- and postoperatively.

Temporalis Muscle Transfer with Fascia Lata Sling: A Novel Technique for Facial Reanimation

Bell's palsy is an idiopathic facial paralysis which is a lower motor neuron disorder. The ultimate goal of treatment is normalization of paralyzed hemi -face with symmetrical smile and face along with corneal protection. The aim of this article is to revisit all the current options available for management of facial nerve paralysis with main concentration on best surgical management in long-standing cases i.e. regional muscle transfer using temporalis tendon with fascia lata. A Case Report of a 38 year old Indian male is reported with chronic facial palsy. Static Facial paralysis reanimation with fascia lata and tarsorrhaphy is explained step by step. Others Treatment modalities are explained. This present case report adds one more case to the scanty number of publications.

Stress Urinary Incontinence and Pelvic Organ Prolapse Correction by Single Incision and Using Monoprosthesis: Three-year Follow-up

Background:

The aim was to study the effectiveness and safety of a modified technique that employs a four-arm polypropylene (PP) mesh (NAZCA-TC) to treat pelvic organ prolapse (POP) and concurrent stress urinary incontinence (SUI) simultaneously.

Materials and Methods:

This prospective follow-up study was conducted on fifty SUI women with concurrent high-grade (greater than Stage 2) anterior vaginal wall and/or uterine prolapse who were referred to Al-Zahra and Noor Hospitals in Isfahan and underwent surgery using the NAZCA-TC, Promedon, Argantina kit. The POP-Quantification system was employed for staging POP before and after surgery. To evaluate lower urinary tract symptoms (LUTS) and patients’ quality of life, a stress test and the short form of International Consultation on Incontinence Questionnaire of Female Lower Urinary Tract Symptom were used. Patients were followed up and assessed at 6 weeks, 6 months, and 1, 2, and 3 years after surgery.

Results:

The mean age of patients was 58.2 ± 10.2 years. There was a great reduction (88.6%) in POP staging after surgery. The success rate of SUI treatment was significantly high (83.5%). During 3 years of postoperative follow-up, mesh erosion occurred in 18%, 5 patients (10%) presented with mesh erosion in the first years after operation, 16% reported significant groin or pelvic pain, and 10% required sling release.

Conclusion:

A single vaginal incision and using two less percutaneous access sites with the PP meshes were effective for treating patients with concurrent POP and SUI but have a high rate of postsurgery erosion rate.

The position of sling immobilization influences the outcomes of anatomic total shoulder arthroplasty: a randomized, single-blind, prospective study

BACKGROUND

To date, no studies have been published that have assessed the optimal position of sling immobilization after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis.

METHODS

Thirty-six patients undergoing anatomic total shoulder arthroplasty for osteoarthritis were randomized to a neutral rotation sling versus an internal rotation sling. The primary outcomes assessed included the Disabilities of the Arm, Shoulder and Hand score; Western Ontario Osteoarthritis of the Shoulder score; Single Assessment Numeric Evaluation score; visual analog scale (VAS) scores for pain and satisfaction; compliance ratings; and radiographic and range-of-motion measurements. Primary outcomes were assessed at baseline and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year.

RESULTS

All patient-determined outcome scores for both groups revealed statistically significant improvements (P < .0001) from enrollment to final follow-up. There were statistically significant advantages to the neutral rotation sling group compared with the internal rotation sling group when we evaluated the improvements in (1) active external rotation (42° vs 25°, P = .03), (2) passive external rotation (44° vs 26°, P = .02), (3) passive horizontal adduction (7.7 cm vs 3.7 cm, P = .05), and (4) pain relief with passive adduction (VAS score, 6.2 cm vs 3.5 cm; P = .002). There was a trend toward greater improvements in the neutral rotation sling group when we measured (1) active horizontal adduction (8.3 cm vs 2.9 cm, P = .06) and (2) active internal rotation behind the back (18 cm vs 11.1 cm, P = .09). At 2 weeks, the neutral rotation sling group had significantly less night pain than the internal rotation sling group (mean VAS score, 18 mm vs 34 mm; P = .047).

CONCLUSIONS

Neutral rotation sling use after anatomic total shoulder arthroplasty resulted in statistically significant improvements in external rotation and adduction, as well as decreased night pain, compared with an internal rotation sling.

Major postoperative complications following surgical procedures for pelvic organ prolapse: a secondary database analysis of the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Surgical approaches to the correction of pelvic organ prolapse include abdominal, vaginal, and obliterative approaches. These approaches require vastly different anatomical dissections, surgical techniques, and operative times and are often selected by the patient and surgeon to match preoperative multimorbidity and ability of the patient to tolerate the stress of surgery.

OBJECTIVE

We sought to describe the occurrence of postoperative complications occurring after 3 different surgical approaches to treat pelvic organ prolapse: vaginal, abdominal, and obliterative.

STUDY DESIGN

We conducted a secondary database analysis of the 2006 through 2014 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze patients undergoing procedures for pelvic organ prolapse based on Current Procedural Terminology codes. Women were categorized into 3 surgical approaches to prolapse: vaginal, abdominal, and obliterative. Concomitant hysterectomy and sling were also examined. The primary outcome was a composite of 30-day major postoperative complications.

RESULTS

A total of 33,416 women were included in our final analysis: 24,928 vaginal procedures, 6834 abdominal (4461 minimally invasive) procedures, and 1654 obliterative procedures. Concomitant hysterectomies and slings were performed in 17,380 (52.0%) and 10,896 (32.6%) of prolapse procedures. The overall prevalence of composite 30-day major postoperative complications was 3.1% (n/N = 1028/33,416). There were 13 perioperative deaths (0.04%) with no difference in the surgical approaches (P = .55). There were no differences in major postoperative complications between vaginal and abdominal procedures (3.0% vs 3.0%; P = .71). Women undergoing obliterative procedures had an occurrence of major postoperative complications of 5.0% (n/N = 83/1654), P < .001.

CONCLUSION

The occurrence of major postoperative complications after prolapse surgery is rare. We did not find a significant difference in major postoperative complications between vaginal and abdominal surgeries for pelvic organ prolapse. In this well-characterized cohort of patients who self-selected surgical approach, women undergoing obliterative surgery had more postoperative complications, likely attributed to increased age and multimorbidity.

Tissue-engineered sling with adipose-derived stem cells under static mechanical strain

The implantation of a suburethral sling is an important treatment for stress urinary incontinence (SUI). However, the slings used current have a number of inherent limitations, such as tissue rejection and infection. The present study investigated the potential of engineering sling tissue in vitro using adipose-derived stem cells (ADSCs). The ADSCs were obtained from Sprague-Dawley rats and were characterized in vitro. The ADSCs were seeded on polyglycolic acid (PGA) fibers that formed a scaffold with a shape mimicking a sling complex. The results demonstrated that following in vitro culture for 12 weeks under static strain, neo-sling tissue could be generated using ADSCs. With increasing culture time, the engineered neo-sling tissue exhibited a significant improvement in biomechanical properties, including maximal load and Young's modulus (P<0.05), and the tissue and collagen structures matured. Furthermore, differentiated ADSCs cultured under static strain were maintained their myoblast phenotype within the PGA scaffolds. These results indicate that ADSCs may serve as a novel cell source for tissue sling engineering and could improve treatment for patients with SUI.

How neutrophils resist shear stress at blood vessel walls: molecular mechanisms, subcellular structures, and cell-cell interactions

Neutrophils are the first cells arriving at sites of tissue injury or infection to combat invading pathogens. Successful neutrophil recruitment to sites of inflammation highly depends on specific molecular mechanisms, fine-tuning the received information into signaling pathways and converting them into well-described recruitment steps. This review highlights the impact of vascular flow conditions on neutrophil recruitment and the multitude of mechanisms developed to enable this sophisticated process under wall shear stress conditions. The recruitment process underlies a complex interplay between adhesion and signaling molecules, as well as chemokines, in which neutrophils developed specific mechanisms to travel to sites of lesion in low and high shear stress conditions. Rolling, as the first step in the recruitment process, highly depends on endothelial selectins and their ligands on neutrophils, inducting of intracellular signaling and subsequently activating β₂ integrins, enabling adhesion and postadhesion events. In addition, subcellular structures, such as microvilli, tethers, and slings allow the cell to arrest, even under high wall shear stress. Thereby, microvilli that are pulled out from the cell body form tethers that develop into slings upon their detachment from the substrate. In addition to the above-described primary capture, secondary capture of neutrophils via neutrophil-neutrophil or neutrophil-platelet interaction promotes the process of neutrophil recruitment to sites of lesion. Thus, precise mechanisms based on a complex molecular interplay, subcellular structures, and cell-cell interactions turn the delicate process of neutrophil trafficking during flow into a robust response allowing effective neutrophil accumulation at sites of injury.

Effect of Preoperative Low Maximal Flow Rate on Postoperative Voiding Trials after the Midurethral Sling Procedure in Women with Stress Urinary Incontinence

OBJECTIVES

To evaluate the effects of preoperative low maximal flow rate (Qmax) on voiding trials after the midurethral sling (MUS) procedure in women with stress urinary incontinence (SUI).

METHODS

One hundred and sixty-eight women who underwent MUS procedure were enrolled. Preoperative free uroflowmetry was performed and patients were divided by Qmax. Low Qmax was defined as a Qmax under 15 mL/sec with voided volume at least 150 mL. Surgical results, failure of voiding trial, and postoperative uroflowmetry parameters were compared between the groups. Failure of voiding trial was defined by a PVR more than 100 mL on postoperative uroflowmetry.

RESULTS

At the discharge day, there were 42 cases showing failure of voiding trial and 33 cases requiring CIC, but only one patient showed failure of voiding trial at 12 months postoperatively. Overall, 48 patients had preoperative low Qmax. Low Qmax group showed lower Qmax in all of postoperative uroflowmetry, but there were no significant differences in the rate of postoperative voiding trial failure or CIC. The low Qmax group was then divided into two groups according to the preoperative detrusor pressure at Qmax over and under 20 cmH₂ O in pressure flow study. Comparing the two groups, no significant differences were observed in the cure rate, voiding trial failure or CIC.

CONCLUSIONS

Our results suggest that women with preoperative low Qmax experienced no definite unfavorable voiding problem from the MUS procedure compared to those with normal voiding function. MUS procedure may be regarded as a safe and successful procedure in SUI women with low Qmax.

Stress urinary incontinence surgery trends in academic female pelvic medicine and reconstructive surgery urology practice in the setting of the food and drug administration public health notifications

AIMS

To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States.

METHODS

Surgical volume for procedures performed primarily by FPMRS surgeons at eight academic institutions across the US was collected using Current Procedural Terminology (CPT) codes for stress urinary incontinence repair and revision surgeries from 2007 to 2013. SAS statistical software was used to assess for trends in the data.

RESULTS

There was a decrease in the use of synthetic mesh sling for the treatment of SUI at academic tertiary care centers over the past 7 years; however, this was not statistically significant. While the total number of surgical interventions for SUI remained stable, there was an increase in the utilization of autologous fascia pubovaginal slings (AFPVS). The number of mesh sling revision surgeries, including urethrolysis and removal or revision of slings, increased almost three-fold at these centers.

CONCLUSIONS

These observed trends suggest a possible effect of the FDA Public Health Notifications regarding TVM on surgical practice for SUI in academic centers, even though they did not specifically warn against the use of synthetic mesh for this indication. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study. However, such data may provide alternative insights into reasons for the observed trends. Neurourol. Urodynam. 36:1155-1160, 2017. © 2016 Wiley Periodicals, Inc.

Did Emperor Moctezuma II's head injury and subsequent death hasten the fall of the Aztec nation?

This article analyzes the head injury of Emperor Moctezuma as one of those injuries that affected the course of history. The Emperor's death arguably changed the fate of an entire nation and led to the destruction of the Aztec civilization. Moctezuma died in the evening hours of June 30, 1520, in his palace in the Aztec capital, Tenochtitlan, while a prisoner of the Spanish conquistadors. The Emperor had been speaking to his people in an effort to persuade them to cease hostilities against Hernán Cortés, his Spanish soldiers, and Indian allies. Both Spanish and Indian contemporary sources document that he sustained a severe head injury when one of his own warriors hit him with a rock thrown from a sling. However, after the Conquest of Mexico some of the information collected by Spanish friars from Indian stories, songs, and pictorial representations raised the possibility that Moctezuma died of strangulation or stabbing at the hands of the Spaniards. There is even a suggestion of suicide. This issue remains unresolved and emotionally charged. The historical and clinical analysis of the events surrounding Moctezuma's death indicates that the Emperor most likely died as a consequence of head injury. The author has attempted to present a neutral analysis but agrees with Benjamin Keen that neutrality may be unattainable, no matter how remote the subject of historical inquiry is from the present.

Vaginal excision of the sub-urethral sling: analysis of indications, safety and outcome

INTRODUCTION

Sling techniques are the method of choice in stress urinary incontinence management, despite the high rates of complications leading sometimes to the necessity of re-operation, and the tape transection and resection are of the greatest importance. The study was aimed at analyzing the indications, technique and effects of transvaginal tape excision.

MATERIAL AND METHODS

A retrospective study including 100 patients who underwent surgical removal of the sub-urethral sling in Evangelisches Krankenhaus Hagen-Haspe was conducted. The analyzed measures were: sling type, onset of symptoms, rates of particular complications, safety and outcome of the operative procedure.

RESULTS

Most complications occurred in the first 2 years after surgery. The most common indications for re-operation were: overactive bladder (OAB) (64%), persistent stress urinary incontinence (SUI) (59%), pain (40%), urinary retention (40%), and erosion (29%). Some of the complications co-existed (i.e. vaginal erosion with postoperative pain, infections with urinary retention). During the procedure 1 bladder was injured and 1 patient had a hematoma. In women with OAB, 24-hour frequency decreased from 13.3 to 8.5 (p < 0.001), the mean voiding volume increased from 131.7 to 216.4 ml (p < 0.001), and nocturia increased from 3.28 to 1.19 (p < 0.001). Intensity of urgency decreased from 8.78 to 0.92 in the 10-point visual score (p < 0.001). Pain and urinary retention resolved in 39 out of 40 patients (p < 0.0001). The rate of SUI increased from 59% to 83% (p < 0.001).

CONCLUSIONS

Sling removal is safe and associated with a minimal rate of complications. Removing the tape causes resolution of most of the complications, but SUI recurs or worsens.

The use of sling vs sphincter in post-prostatectomy urinary incontinence

The artificial urinary sphincter (AUS) is considered the 'gold standard' in post-prostatectomy urinary incontinence. However, in recent years, male slings have gained much popularity due to the ease of surgery, good functional results and low complications rates. This review systematically shows the evidence for the different sling systems, describes the working mechanism, and compares their efficacy against that of the AUS. Furthermore subgroups of patients are defined who are not suited to undergo sling surgery.

Retropubic bulbourethral sling in incontinence post-exstrophy repair: 2-year minimal follow up of a salvage procedure

AIMS

Post-exstrophy incontinence is a challenge because continence is difficult to achieve and more difficult to maintain. Feasibility and outcomes of a bulbourethral sling to treat post-exstrophy incontinence is shown in this report.

METHODS

A retropubic bulbourethral sling was applied to male patients with incontinence post-exstrophy-epispadius repair. The study included children with total (continuous) incontinence who underwent multiple previous anti-incontinence procedures, ranging from bladder neck injection to bladder neck reconstruction. Preoperative assessment includes urinalysis, renal US, VCUG, 1-hr pad test and urodynamics. The bulbourethral sling applied is made of polypropylene and is suspended by 4 pairs of nylon sutures, to support the bulbar urethra within its covering muscles with the sutures tied on the rectus muscles. Continence was evaluated as well as adverse events.

RESULTS

Seventeen children, (median age 8.7 years) completed 24-month of follow up. All had CPRE. Five children (29.27%) were dry. Four micturated through the urethra and one by catheterizing his cutaneous stoma every 3-4 hr. In none, PVR exceeded 10% of expected capacity. Four children underwent re-tightening 1-4 weeks after removal of urethral catheter. Perineal wound dehiscence occurred in one, perineal/suprapubic pain in seven and epididymo-orchitis in one child.

CONCLUSION

The current technique is promising for difficult cases of incontinence after CPRE. It is safe, as no serious adverse events occurred during follow up period. It is economic and re-tightening is easy to perform. Neurourol. Urodynam. 35:497-502, 2016. © 2015 Wiley Periodicals, Inc.

The effect of shoulder immobilization on driving performance

BACKGROUND

The purpose of this study was to evaluate the effect of sling immobilization on driving performance with use of a driving simulator.

METHODS

This is a prospective trial with a cohort of 21 healthy volunteers comparing their driving ability with and without sling immobilization on their dominant (driving) extremity. Multiple variables, including number of collisions, off-road excursions, and centerline crossings, were measured with a validated driving simulator. Trials were separated by 2 weeks to control for "adaptations" to the simulator. Statistical significance was found in collisions between sling and no-sling tests.

RESULTS

The total number of collisions for trial 1 (no sling) was 36 (mean, 1.7 ± 1.2) compared with 73 (3.7 ± 1.6) (P < .01) for trial 2 (sling immobilization). Approximately 70% of participants with upper extremity immobilization were involved in ≥3 collisions; approximately 70% of no-sling participants were involved in ≤2 collisions. There was no statistically significant difference between groups with respect to overall vehicle road position and control.

CONCLUSION

Sling immobilization of the dominant driving arm results in a decrease in driving performance and safety with respect to the number of collisions in a simulated driving circuit (P < .01). There were no significant differences in driving parameters that are indicative of overall vehicle position and control. The decrease in driving performance with respect to the number of collisions is likely to be related to the effect the immobilized arm has on effectively performing evasive maneuvers during hazardous driving conditions.

Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study

OBJECTIVE

The purpose of this study was to describe the evaluation and management of synthetic mesh-related complications after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP).

STUDY DESIGN

We conducted a multicenter, retrospective analysis of women who attended 4 US tertiary referral centers for evaluation of mesh-related complications after surgery for SUI and/or POP from January 2006 to December 2010. Demographic, clinical, and surgical data were abstracted from the medical record, and complications were classified according to the Expanded Accordion Severity Classification.

RESULTS

Three hundred forty-seven patients sought management of synthetic mesh-related complications over the study period. Index surgeries were performed for the following indications: SUI (sling only), 49.9%; POP (transvaginal mesh [TVM] or sacrocolpopexy only), 25.6%; and SUI + POP (sling + TVM or sacrocolpopexy), 24.2%. Median time to evaluation was 5.8 months (range, 0-65.2). Thirty percent of the patients had dyspareunia; 42.7% of the patients had mesh erosion; and 34.6% of the patients had pelvic pain. Seventy-seven percent of the patients had a grade 3 or 4 (severe) complication. Patients with TVM or sacrocolpopexy were more likely to have mesh erosion and vaginal symptoms compared with sling only. The median number of treatments for mesh complications was 2 (range, 1-9); 60% of the women required ≥2 interventions. Initial treatment intervention was surgical for 49% of subjects. Of those treatments that initially were managed nonsurgically, 59.3% went on to surgical intervention.

CONCLUSION

Most of the women who seek management of synthetic mesh complication after POP or SUI surgery have severe complications that require surgical intervention; a significant proportion require >1 surgical procedure. The pattern of complaints differs by index procedure.

Factors associated with survival in 148 recumbent horses

REASONS FOR PERFORMING STUDY

There are currently few data available on the prognosis and outcome of recumbent horses.

OBJECTIVES

To investigate the outcome of hospitalised horses that had been recumbent in the field or hospital and factors affecting their survival within the first 3 days of hospitalisation and survival after 3 days to hospital discharge.

STUDY DESIGN

Retrospective analysis of clinical records.

METHODS

Records of 148 horses admitted to the William R. Pritchard Veterinary Medical Teaching Hospital, University of California Davis from January 1995 to December 2010 with a history of recumbency or horses that became recumbent while hospitalised were evaluated. Exact logistic regression was used to assess the association between clinical parameters and survival within the first 3 days of hospitalisation and survival to hospital discharge after 3 days.

RESULTS

There were 109 nonsurvivors and 39 survivors. Multivariate analysis showed variables associated with an increased odds of death within the first 3 days of hospitalisation included duration of clinical signs prior to presentation, with horses showing clinical signs for over 24 h having increased odds of death (P = 0.043, odds ratio [OR] 4.16, 95% confidence interval [95% CI] 1.04-16.59), the presence of band neutrophils (P = 0.02, OR 7.94, 95% CI 1.39-45.46), the horse not using the sling (P = 0.031, OR 4.22, 95% confidence interval 1.14-15.68) and horses that were unable to stand after treatment (P<0.0001, OR 231.15, 95% CI 22.82-2341.33). Increasing cost was associated with lower odds of death (P = 0.017, OR 0.96, for each additional $100 billed, 95% CI 0.93-0.99).

CONCLUSIONS

This study demonstrates that the duration of clinical signs, response to treatment and the ability of horses to use a sling are associated with survival to hospital discharge for recumbent horses.

Sling revision/removal for mesh erosion and urinary retention: long-term risk and predictors

OBJECTIVE

The objective of the study was to estimate the long-term risk of sling revision/removal after an initial sling and to assess indications (mesh erosion and urinary retention) and predictors of sling revision/removal.

STUDY DESIGN

Using a population-based cohort of commercially insured individuals, we identified women 18 years old or older who underwent a sling (Current Procedural Terminology code 57288) between 2001 and 2010 and any subsequent sling revision/removal (Current Procedural Terminology code 57287). We estimated the cumulative risk of revision/removal annually and evaluated predictors of sling revision/removal using Kaplan-Meier survival curves and Cox proportional hazards models, respectively.

RESULTS

We identified 188,454 eligible women who underwent an index sling. The 9 year cumulative risk of sling revision/removal was 3.7% (95% confidence interval [CI], 3.5-3.9). At 1 year, this risk was already 2.2% and then increased to 3.2% at 4 years before plateauing. With regard to the indication for the sling revision/removal, a greater proportion was due to mesh erosion compared with urinary retention, with a 9 year risk of 2.5% (95% CI, 2.3-2.6) for mesh erosion vs 1.3% (95% CI, 1.2-1.4) for urinary retention. Age had an effect on the revision/removal rates for both mesh erosion and urinary retention, with the higher risks among those aged 18-29 years. The risk of revision/removal for mesh erosion and urinary retention was also elevated among women who had a concomitant anterior or apical prolapse procedure.

CONCLUSION

In this population-based analysis, the 9 year risk of sling revision/removal was relatively low at 3.7%, with 60% of revisions/removals caused by mesh erosion.

Transobturator Tape in Treatment of Stress Urinary Incontinence: It is Time for a New Gold Standard

Background:

Stress urinary incontinence (SUI) can significantly impair the quality of life. A variety of treatments, both medical and surgical, have been used to manage it. The transobturator sling, which is a subfascial sling, is relatively a new surgical technique with minimal access.

Aim:

The objective of this study was to evaluate the effectiveness of transobturator tape (TOT) in the treatment of female SUI and to analyze functional results.

Materials and Methods:

A total of 59 patients were applied TOT by outside-in technique and various outcome parameters recorded. These patients were followed up 6 months after surgery.

Results:

Success rate of TOT was 93.2% (95% CI: 86.4–99.5). A total of 51 patients (86.4%) were completely satisfied, whereas 4 (6.8%) were partially satisfied and 4 were unsatisfied with surgical outcome. The procedure-related complications were few and could be managed in the same sitting.

Conclusion:

The transobturator approach is an effective treatment of SUI with low morbidity, and it has all the potential to be the new Gold Standard in the treatment of female SUI.

The effect of a bioactive tissue-engineered sling in a rat of stress incontinence model

In this study, we attempt to examine the feasibility of the bioactive tissue-engineered sling by using muscle precursor cells (MPCs)-seeded Poly(ε-caprolactone) (PCL) nanofiber sheet in a rat model of stress urinary incontinence (SUI). In vitro, MPCs were cultured on a PCL nanofiber sheet for one week, where the MPCs-seeded PCL nanofiber sheet showed constant twitching contraction by electrical field stimulation in an organ bath. In vivo, MPCs-seeded PCL nanofiber sheet was placed under the female rat's urethra after pudendal nerve denervation (animal model of SUI). The leak point pressure (LPP) was evaluated with the vertical tilt table after the operation for four weeks. The resulting LPP of MPCs-seeded PCL nanofiber sheet group was observed to be significantly higher than the denervation-only group's. Furthermore, PKH-26-labeled MPCs were observed under the urethral sphincter by immunohistochemistry. These results indicated that, the MPCs-seeded PCL nanofiber sheet have not only provided support for the deficient sphincter, but also actively improved the sphincter's function overall. In conclusion, this bioactive tissue-engineered sling could be used as an ideal material for the treatment of SUI.