Complications of mid urethral slings: important outcomes for future clinical trials

Prevalence and risk factors for urinary tract infection up to one year following midurethral sling incontinence surgery

OBJECTIVE

To investigate the prevalence and risk factors of urinary tract infection (UTI) one year following sub-midurethral sling (SMUS) incontinence surgery in a university affiliated medical center in southern Israel.

METHODS

A retrospective cohort study was conducted to identify and characterize patients who suffered UTI within a year following SMUS surgery. The study population comprised of all patients who underwent a SMUS surgery between the years 2014 and 2015. Demographic and clinical data were retrieved from the patients' medical records, and a comparison between patients with and without a positive urine culture was performed.

RESULTS

During the study period, there were 178 SMUS surgeries. Urine culture positive UTI was noted in 21% (38 patients) within the first year following surgery. The mean age and BMI of patients complicated with UTI was 64.8 and 29.1, respectively. The most common pathogen found in urine culture was E. coli that accounted for 55% of all UTIs. When comparing patients with and without UTI, no significant difference was noted in the pre- and intra-operative characteristics. However, duration of hospitalization and readmissions in the first year following surgery, were significantly associated with the risk of UTI (p < 0.026 and p < 0.003, respectively).

CONCLUSIONS

Approximately one in every five women undergoing a SMUS operation in our population will suffer from UTI within a year from surgery. A significant association was found between the duration of hospitalization and readmissions in the first postoperative year and suffering from UTI.

Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion

Voiding dysfunction following midurethral sling procedures is not a rare event. There is no current consensus regarding management of this complication. Although it is often transient and self-limiting, chronic post-midurethral sling voiding dysfunction may lead to irreversible changes affecting detrusor function. Initial management includes intermittent catheterization, and addressing circumstantial factors interfering with normal voiding, such as pain. Early sling mobilization often resolves the dysfunction, and is associated with minimal morbidity. Sling incision or excision at a later stage, although fairly effective, could be associated with recurrence of stress urinary incontinence. There is insufficient evidence to justify urethral dilatation in this context.

Update on complications of synthetic suburethral slings

Synthetic suburethral slings have become the most widely used technique for the surgical treatment of stress urinary incontinence. Despite its high success rates, significant complications have been reported including bleeding, urethral or bladder injury, urethral or bladder mesh erosion, intestinal perforation, vaginal extrusion of mesh, urinary tract infection, pain, urinary urgency and bladder outlet obstruction. Recent warnings from important regulatory agencies worldwide concerning safety issues of the use of mesh for urogynecological reconstruction have had a strong impact on patients as well as surgeons and manufacturers. In this paper, we reviewed the literature regarding surgical morbidity associated with synthetic suburethral slings.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are one of the surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, we calculated a summary statistic: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

We included 26 trials involving 2284 women. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6 to 24 months.One medium-sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of women with mixed urinary incontinence. Surgery appeared to be more effective than drugs in treating participant-reported incontinence (n = 75, risk ratio (RR) 0.18, 95% confidence interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21, 95% CI 0.09 to 0.21)Seven trials compared slings with open abdominal retropubic colposuspension. Participant-reported incontinence was lower with the slings after one year (RR 0.75, 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long-term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations. These seemed to be equally effective in the short term (RR for incontinence within first year 0.97, 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Participant-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45, 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Gore-Tex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting participant characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long-term adverse event profile is still unclear. A brief economic commentary (BEC) identified two studies suggesting that traditional slings may be more cost-effective compared with collagen injection but not cost-effective when compared with minimally invasive sling operations. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

Midurethral slings in the mesh litigation era

Stress urinary incontinence (SUI) has always been a major health issue for women. With the progression of technology and surgical techniques, mid urethral slings (MUS) used in both transvaginal and transobturator routes have become the gold standard in the treatment of SUI. There is ample short to mid-term data confirming the efficacy and safety in using MUS in treating SUI in women. However, long-term data supporting the use of MUS in women to treat SUI is scarce. There has been much controversy surrounding the US Food and Drug Administrations' (FDA) public notification of potential complications surrounding the use of transvaginal mesh, which has been magnified and generalised by the media; but despite this there has still been substantial growth and uptake of MUS for treating SUI. In this review, we aim to explore some of the issues with MUS, the factors around litigation with mesh use, the impact of FDA's notification on the uptake of MUS and ultimately, the results and efficacy of MUS for the treatment of SUI.

Canadian Urological Association position statement on the use of transvaginal mesh

Stress incontinence (SUI) and pelvic organ prolapse (POP) are common conditions. There is high-level evidence that midurethral mesh slings for stress incontinence are effective and safe; however, the rare but serious potential risks of this surgery must be discussed with the patient. The use of transvaginal mesh for prolapse repair does not appear to be supported by the current evidence, and its use should be restricted to specialized pelvic floor surgeons and specific clinical situations.

Case distribution and complications of mid-urethral sling surgery in a Canadian city before and after the Health Canada advisory on pelvic floor mesh

INTRODUCTION AND HYPOTHESIS

Increased incidences of complications related to the use of mid-urethral slings (MUS) for the treatment of stress urinary incontinence resulted in both the Food and Drug Administration (FDA) and Health Canada issuing advisories in 2008 and 2010 respectively. The purpose of this study was to assess the effect these advisories had on the number of surgeons performing MUS surgery and post-surgical complications in Calgary, Canada.

METHODS

In this study, we conducted a retrospective analysis of administrative data between 2006 and 2011. Post-surgical complications were identified using diagnostic codes. All rates were adjusted for the increase in the female population in Calgary during the study period. An interrupted time series model was used to evaluate any changes in the number of surgeons performing MUS surgery and any post-surgical changes from the period before and that after the advisories.

RESULTS

The number of surgeons performing MUS surgery and the number of surgeries performed decreased over the study period, although neither of these was significantly related to the advisories. In terms of complications, we did not observe a significant change in the rate of repeat MUS surgeries, inpatient admissions, emergency department visits, or ambulatory care visits within 2 years of initial surgery.

CONCLUSION

The FDA and Health Canada advisories had no effect on the use of MUS in Calgary. This suggests either that they bear little influence on local surgeons' practices, or that safety was already at such a high level that improvements were not possible.

To evaluate the safety and efficacy of the TVT-Secur procedure in the treatment of stress urinary incontinence in women

BACKGROUND

The prevalence of stress urinary incontinence (SUI) in the middle-aged Indian women is around 16%. The use of transvaginal tapes (TVTs) has revolutionised the surgical management of SUI. Patients who undergo placement of the tape via the transobturator route often complain of persistent thigh pain at the site of trocar insertion. The use of minimally invasive tapes with a single suburethral incision reduces surgical trauma by eliminating thigh incisions, while maintaining the cure achieved by conventional TVTs. The study was conducted to test the efficacy and safety of minimally invasive TVT-Secur tape placement for treatment of SUI in women.

METHODS

20 women with stress incontinence were implanted with TVT-Secur tapes and followed up for a year.

RESULTS

The objective cure rate of SUI was 85% at the end of a year. The improvement in the patient satisfaction and Incontinence-specific QOL scores, of both Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7), was statistically significant at 95% and 99% confidence levels. There were no complaints of thigh pain; however, there were intraoperative complications in the form of bladder perforation in 5% (n = 1), urethral injury in 5% (n = 1) and urethral tape exposure in 10% (n = 2), at 3 months requiring tape sectioning.

CONCLUSIONS

These cure rates and complications are comparable to the standard TVT implantations at the end of a year, without thigh pain; however, a greater number of patients and a longer follow-up is required to see whether the long-term cure is maintained or not, before recommending the same as a standard of treatment.

[Urinary bladder injuries. Diagnosis and treatment]

BACKGROUND

Injuries of the urinary bladder can be associated with blunt and penetrating abdominal or pelvic trauma. In addition, they can be an iatrogenic complication in open, laparoscopic, and endoscopic urogenital or abdominal surgery.

OBJECTIVES

The present article reviews relevant causes of bladder injuries and the subsequent diagnostic and treatment modalities.

Long-term functional results after unilateral mid-urethral sling transection for voiding dysfunction

OBJECTIVE

To investigate the long-term outcomes of unilateral mid-urethral sling transection to treat voiding dysfunction after synthetic mid-urethral sling placement for stress urinary incontinence.

STUDY DESIGN

Twenty-three patients who underwent an unilateral sling transection were analyzed retrospectively. Patient records were analyzed for subjective outcome, and pre- and postoperative flow patterns were used as objective outcome parameters.

RESULTS

At the first postoperative follow-up, 77.3% of the patients remained dry. After a mean follow-up of 42 months, 73.9% of patients were continent. The flow pattern after lateral sling transection was significantly better than pre-operatively, with higher maximum flow rate (24.2ml/s, p=0.001), higher mean flow rate (10.4ml/s, p=0.001), higher voided volume (308.5ml, p=0.002) and lower residual volume (28.7ml, p=0.003). At final postoperative follow-up, eight patients (34.8%) reported urgency and six patients (26.1%) were incontinent; four of these patients (17.4%) mainly had urge incontinence.

CONCLUSIONS

Unilateral mid-urethral sling transection is a safe, effective technique to treat voiding symptoms with good preservation of continence. The technique repairs the obstructive flow effectively. Urgency and urge incontinence after mid-urethral sling placement are difficult to treat with transection alone.

A digital anatomical study of the corona mortis in females

It was a different study from traditional anatomy to construct three-dimensional (3D) model of the corona mortis (CMOR) through contrasted enhanced computed tomography (CT) scanning. This will provide an aid for the understanding of the fine anatomy of CMOR, as well as surgical produces. A medical image processing system was used to process computed tomography scanning data collected from 330 cases of woman patients. Accurate digital 3D models of the CMOR were used to study the incidence, location, and the morphological patterns. These models have a rotation of 360° and allow displaying from different views. The incidence was 51.1% for the venous CMOR, 14.1% for the arterial CMOR in the 660 sides pelvic wall and vessel models. The mean distance from the symphysis pubis for the venous CMOR was 66.87 mm, and 59.60 mm for the arterial CMOR. The morphological patterns we identified were classified in three types (I-III). The model of CMOR serves as a useful tool for the learning and investigation of the CMOR. In the future, the digital anatomical data can be beneficial to illustrating the operation approach and decreasing the surgical complications.

Retropubic Midurethral Sling Colonization With Staphylococcus lugdunensis

BACKGROUND

We present a case of Staphylococcus lugdunensis colonization of a midurethral sling. Staphylococcus lugdunensis is a common skin colonizer and has been isolated in cases of implanted prosthetic devices.

CASE

A 52-year-old female presented with suprapubic pain and recurrent urinary tract infections with S. lugdunensis starting 3 months after a retropubic sling procedure. After several months of continued pain and a suspicion of a mesh-related infection, the sling was removed. Culture of the sling material grew oxacillin-susceptible S. lugdunensis. Her symptoms resolved after sling removal and a postoperative course of antibiotics.

CONCLUSIONS

To our knowledge, this is the first reported case of S. lugdunensis colonization of vaginal mesh. Surgeons should be aware and knowledgeable about the possible complications arising from insertion of midurethral slings.

Cost utility analysis of urethral bulking agents versus midurethral sling in stress urinary incontinence

OBJECTIVE

The aim of this study was to determine the cost utility of urethral bulking agents (BA) compared with midurethral slings (MUS) in the treatment of stress urinary incontinence (SUI) in patients without urethral hypermobility.

METHODS

A decision tree was constructed to compare the cost utility of urethral BA versus MUS in the setting of SUI without urethral hypermobility. Probability estimates for success, failure, and complications were obtained from the published literature. Immediate-term, short-term, and longer-term complications were accounted for over a 1-year time horizon in the model. One-way and 2-way sensitivity analyses and Monte Carlo simulations were performed to assess the robustness of our results.

RESULTS

Our model demonstrated that MUS cost $436,465 more than BA for every 100 women treated in 1 year. Using MUS compared with BA leads to an incremental cost-effectiveness ratio of $70,400 per utility gained. Assuming a willingness to pay of $50,000, this makes MUS not cost-effective as a first-line treatment in many situations. When MUS costs less than $5132, it becomes a cost-effective first-line treatment, and when it costs less than $2035, it is cost saving.

CONCLUSIONS

Bulking agents are more cost-effective than MUS over a 1-year time horizon in the treatment of SUI in patients without urethral hypermobility. In women who lack urethral hypermobility, BA remain a cost-effective option in this patient population.

Adipose-derived stem cells seeded on polyglycolic acid for the treatment of stress urinary incontinence

PURPOSE

To evaluate the effect and possible mechanism of suburethral tissue-engineered sling in an animal model of stress urinary incontinence (SUI).

METHODS

Adipose-derived stem cells (ADSCs) were obtained from the adipose tissues of rats. The differentiation potential, proliferation, and viability of rat ADSCs were evaluated after infecting these cells with a lentiviral vector-encoding green fluorescent protein (GFP). Next, GFP transfected ADSCs were seeded on polyglycolic acid (PGA) fibers to construct the tissue-engineered sling with the induction of 5-azacytidine (5-Aza). Afterward, the tissue-engineered slings were transplanted into a rat model of SUI that was established by vaginal balloon dilatation method and bilateral ovariectomy. Histology and the leak point pressure measurements were performed at 2 months after tissue-engineered sling implantation.

RESULTS

The ADSCs were found to be efficiently transfected with GFP, without any effects on proliferation, cell cycle and multi-differentiation potential. After been seeded on PGA fibers, ADSCs formed tissue-engineered slings in 4 weeks of induction culture. Two months after implantation, the mean leak point pressure (LPP) was significantly increased in sling-treated rats compared with the balloon-injured ovariectomized rats. Immunofluorescence assay showed that some of the GFP expressing cells stained positive for muscle-specific markers.

CONCLUSIONS

The newly suburethral tissue-engineered sling restores LPP in the rat model of SUI, which could be an effective treatment in future SUI therapy.

Efficacy and Safety of Tension-Free Vaginal Tape-Secur Mini-Sling Versus Standard Midurethral Slings for Female Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

Purpose:

To assess the efficacy and safety of tension-free vaginal tape (TVT)-Secur for stress urinary incontinence (SUI).

Methods:

A literature review was performed to identify all published trials of TVT-Secur. The search included the following databases: MEDLINE, Embase, and the Cochrane Controlled Trial Register.

Results:

Seventeen publications involving a total of 1,879 patients were used to compare TVT-Secur with tension-free obturator tape (TVT-O) and TVT. We found that TVT-Secur had significant reductions in operative time, visual analog score for pain, and postoperative complications compared with TVT-O. Even though TVT-Secur had a significantly lower subjective cure rate (P<0.00001), lower objective cure rate (P<0.00001), and higher intraoperative complication rate, compared with TVT-O at 1 to 3 years, there was no significant difference between TVT-Secur and TVT-O in the subjective cure rate (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.22–1.08; P=0.08), objective cure rate (OR, 0.49; 95% CI, 0.22–1.09; P=0.08), or complications at 3 to 5 years. Moreover, TVT-Secur had significantly lower subjective and objective cure rates compared with TVT.

Conclusions:

This meta-analysis indicates that TVT-Secur did not show an inferior efficacy and safety compared with TVT-O for SUI in 3 to 5 years, even though displaying a clear tread toward a lower efficacy in 1 to 3 years. Considering that the safety is similar, there are no advantages in using TVT-Secur.

Fatal Injury of the Small Intestine during Retropubic Sling Placement

We describe a case of injury of the small intestine in a patient who underwent placement of Align R retropubic urethral support system (BARD). Absence of characteristic symptoms of the bowel injury and peritonitis led to a rapid development of sepsis, multiple organ failure, and death. Although the placement of midurethral sling is a minimally invasive surgery, good diagnostic skills, proper evaluation of indications, safe performance of the procedure, and thorough postsurgical monitoring are paramount for safe and effective outcome of the surgery.

Relationship between BMI and three different devices used in urinary incontinence procedures and anatomical structures in fresh cadavers. A pilot study

OBJECTIVE

To demonstrate the needle positioning during three types of slings in relation to anatomical structures in fresh cadavers and to evaluate if this positioning is influenced by body mass index (BMI).

METHODS

TVTr sling (retropubic), TVT-O sling (transobturator) and mini-sling (TVT-Secur™) were performed in ten fresh cadavers, followed by dissection of the pudendal (genital) area (external evaluation) and abdominal cavity (internal evaluation). The distance between the devices used in each technique and specific anatomical structures (vessels and bowel) was measured.

RESULTS

The mean distance between TVTr needles and the closest segment of the bowel was 5.0±1.1cm. The mean distance between the TVTr needles and iliac vessels was 8.55±1.59cm, and this distance was inversely proportional to BMI. However, the both correlations were not significantly (p<0.05). The mean distance from TVT-O needle to obturator vessels and nerve was 2.25±0.34cm. This distance was inversely proportional to BMI, but it was not statistically significant.

CONCLUSION

Our data suggested that BMI may be not an important factor for influencing the relationship between the devices and anatomical structures in three different slings in fresh cadavers.

Topographical relationships between the obturator nerve, artery, and vein in the lateral pelvic wall

INTRODUCTION AND HYPOTHESIS

The aims of this study were to determine the topographical relationships between the obturator nerve (ON), artery (OA), and vein (OV) in the lateral pelvic wall.

METHODS

One hundred and fifty hemipelvises of 84 Korean cadavers were dissected.

RESULTS

The ON, OA, and OV ran in that order (from upper to lower) within the lateral pelvic wall in 46.7 % of specimens. In 32 % of cases, the three structures were separated at the posterior portion of the wall and then converged toward the obturator canal (OC). In 10 %, the OA and OV were in contact with each other and separate from the ON; in 2 %, the ON was contiguous with the OA and separate from the OV; in 2.7 %, all three structures were in contact with each another. Alternately, the order of ON, OA, and OV was altered in the lateral pelvic wall in 41.3 % of specimens. Finally, in 12 % specimens, either the OA or OV or both were absent from the lateral pelvic wall.

CONCLUSIONS

The possibility of the presence of either the OA or OV being between the ON and the external iliac vein, and the potential contact between the ON and either the OA or OV in the lateral pelvic wall, should be borne in mind during pelvic procedures.

Computer aided biomanufacturing of mechanically robust pure collagen meshes with controlled macroporosity

Reconciliation of high strength and high porosity in pure collagen based structures is a major barrier in collagen's use in load-bearing applications. The current study developed a CAD/CAM based electrocompaction method to manufacture highly porous patterned scaffolds using pure collagen. Utilization of computerized scaffold design and fabrication allows the integration of mesh-scaffolds with controlled pore size, shape and spacing. Mechanical properties of fabricated collagen meshes were investigated as a function of number of patterned layers, and with different pore geometries. The tensile stiffness, tensile strength and modulus ranges from 10-50 N cm(-1), 1-6 MPa and 5-40 MPa respectively for all the scaffold groups. These results are within the range of practical usability of different tissue engineering application such as tendon, hernia, stress urinary incontinence or thoracic wall reconstruction. Moreover, 3-fold increase in the layer number resulted in more than 5-fold increases in failure load, toughness and stiffness which suggests that by changing the number of layers and shape of the structure, mechanical properties can be modulated for the aforementioned tissue engineering application. These patterned scaffolds offer a porosity ranging from 0.8 to 1.5 mm in size, a range that is commensurate with pore sizes of repair meshes in the market. The connected macroporosity of the scaffolds facilitated cell-seeding such that cells populated the entire scaffold at the time of seeding. After 3 d of culture, cell nuclei became elongated. These results indicate that the patterned electrochemical deposition method in this study was able to develop mechanically robust, highly porous collagen scaffolds with controlled porosity which not only tries to solve one of the major tissue engineering problems at a fundamental level but also has a significant potential to be used in different tissue engineering applications.

Urethral complications after tension-free vaginal tape procedures: A surgical management case series

AIM: To analyze the clinical features, diagnostic modalities, and the surgical management of urethral complications after tension-free vaginal tape procedures.

METHODS: This study encompasses a retrospective review of nine patients presented with urethral complications after midurethral sling procedures. The patients underwent the procedures during a period from 1999 to 2012 in three different regional hospitals in the southwest part of Sweden. The time from sling placement to diagnosis, the risk factors, clinical features, diagnosis, surgical management, and functional outcome are presented. The presenting symptoms were described as either early onset (< 12 mo) or late onset (> 12 mo) according to when they were first reported.

RESULTS: Eight cases of urethral erosion and one case of bladder-neck erosion were detected. The mean interval for diagnoses of the erosions ranged from 3 mo to 11 years. The most common presenting symptoms included de novo urgency with or without incontinence (7/9 patients), urinary retention/voiding dysfunction (4/9 patients), urethritis (4/9 patients), relapse of stress-incontinence (3/9 patients), recurrent urinary tract infections (5/9 patients), and hematuria (1/9 patient). In most cases, voiding dysfunction and urethritis occurred early after the operation. The surgical management applied in most cases was transurethral resection of the intraurethral part of the mesh. The removal of the intraurethral mesh resulted in improvement or complete cure of urgency symptoms in 5/7 patients with urgency. Four patients were reoperated with a new stress-incontinence surgery, one with laparoscopic Burch, and three with retropubic tension-free vaginal tape procedures.

CONCLUSION: Urethral complications should be suspected in the case of de novo urgency and relapse of stress-incontinence. Transurethral excision of the intraurethral mesh is the recommended treatment.

TVT-Exact and midurethral sling (SLING-IUFT) operative procedures: a randomized study

OBJECTIVES

The aim of the study is to compare results, effectiveness and complications of TVT exact and midurethral sling (SLING-IUFT) operations in the treatment of female stress urinary incontinence (SUI).

METHODS

A single center nonblind, randomized study of women with SUI who were randomized to TVT-Exact and SLING-IUFT was performed by one surgeon from April 2009 to April 2011. SUI was diagnosed on coughing and Valsalva test and urodynamics (cystometry and uroflowmetry) were assessed before operation and 1 year after surgery. This was a prospective randomized study. The follow up period was 12 months. 76 patients were operated using the TVT-Exact operation and 78 patients - using the SLING-IUFT operation. There was no statistically significant differences between groups for BMI, parity, menopausal status and prolapsed stage (no patients had cystocele greater than stage II).

RESULTS

Mean operative time was significantly shorter in the SLING-IUFT group (19 ± 5.6 min.) compared with the TVT-Exact group (27 ± 7.1 min.). There were statistically significant differences in the effectiveness of both procedures: TVT-Exact - at 94.5% and SLING-IUFT - at 61.2% after one year. Hospital stay was statistically significantly shorter in the SLING-IUFT group (1. 2 ± 0.5 days) compared with the TVT-Exact group (3.5 ± 1.5 days). Statistically significantly fewer complications occurred in the SLING-IUFT group.

CONCLUSION

the TVT-Exact and SLING-IUFT operations are both effective for surgical treatment of female stress urinary incontinence. The SLING-IUFT involved a shorter operation time and lower complications rate., the TVT-Exact procedure had statistically significantly more complications than the SLING-IUFT operation, but a higher effectiveness.

Dual growth factor-loaded in situ gel-forming bulking agent: passive and bioactive effects for the treatment of urinary incontinence

Stress urinary incontinence (SUI) is one of the major medical problems for adult females and has a devastating effect on their quality of life. The major cause of the development of the SUI is dysfunction of the urethral supporting tissues as a result of aging and childbirth. In this study, in situ gel-forming bulking agent loaded with dual growth factors, nerve growth factor (NGF) and basic fibroblast growth factor (bFGF), was fabricated. The bulking agent consisted of three components; (i) polycaprolactone (PCL) beads, (ii) bFGF-loaded nanogels, and (iii) NGF-loaded in situ gel forming solution. The bulking agent can provide an initial passive bulking effect (from the PCL beads) and regenerate malfunctioning tissues around the urethra (from the sequential and continuous release of growth factors from the hydrogel) for the effective treatment of SUI. The PCL beads were located stably at the applied urethra site (urinary incontinent SD rat) without migration to provide a passive bulking effect. The sequential release of the growth factors (NGF within a week and bFGF for more than 4 weeks) from the bulking agent provided regeneration of damaged nerve and smooth muscle, and thus enhanced biological function around the urethra. From the findings, we suggest that dual growth factor (NGF and bFGF)-loaded in situ gel-forming bulking agent may be a promising injectable bioactive system for the treatment for SUI.

Female urinary incontinence: effective treatment strategies

Urinary incontinence is a dysfunction that tremendously affects women's quality of life, involving social, emotional and economic aspects. Although various treatments for urinary incontinence have been described, it is important to know which of them are truly effective. This review seeks to determine the current available therapies for women with stress urinary incontinence and overactive bladder syndrome, based on the best scientific evidence.

Success of autologous pubovaginal sling after failed synthetic mid urethral sling

PURPOSE

There is no consensus on the management of persistent or recurrent stress incontinence after a failed synthetic mid urethral sling. After a mesh complication or sling failure many women and surgeons prefer to avoid a repeat mesh procedure and choose an autologous pubovaginal sling. However, little empirical work has been performed to assess the efficacy.

MATERIALS AND METHODS

We performed a retrospective review of 66 women who underwent autologous pubovaginal sling with rectus fascia after 1 or more failed synthetic mid urethral sling from 2007 to 2012.

RESULTS

Mesh removal was performed before autologous pubovaginal sling in 21 patients (31.8%) while 6 (9.1%) had mesh removed simultaneously with autologous pubovaginal sling. Indications for the autologous pubovaginal sling were pure stress urinary incontinence in 16 patients (24.2%) and mixed incontinence in 50 (75.8%), 8 of whom were deemed complex with a prior urethral diverticulum or urethrovaginal fistula/urethral mesh erosion. At a mean of 14.5 months after autologous pubovaginal sling 46 (69.7%) patients reported cure of stress urinary incontinence. Of these patients 25 (37.9%) had complete cure with no stress or urgency incontinence, 17 had cure of stress urinary incontinence but had persistent urgency incontinence, and 4 had cure of stress urinary incontinence but experienced do novo urgency incontinence. Requiring a mesh excision did not predict worse outcomes compared to cases in which mesh was not removed (p=0.13). Patients with pure stress urinary incontinence were significantly more likely to be cured of all incontinence (62.5%) than those women with preoperative mixed incontinence (30.0%) (p=0.006).

CONCLUSIONS

Even after a failed synthetic mid urethral sling, autologous pubovaginal sling is effective and cured stress urinary incontinence in 69.7% of cases.

The value of surgical release after obstructive anti-incontinence surgery: An aid for clinical decision making

AIMS

To present satisfaction rates after surgical release of obstructive anti-incontinence surgery, to look for predictive factors for outcome and to define the optimal moment to perform the surgical release.

METHODS

We reviewed the charts of 87 women at first, second, and last follow-up at a median of 2 (0.5-7), 4 (2-12), and 108 (29-156) months after surgical release. Obstruction was defined as urinary retention, straining to void after overcorrected anti-incontinence treatment or urodynamic bladder outlet obstruction. Patients' satisfaction was assessed using a 4 point Likert scale.

RESULTS

Satisfaction rates at first, second, and last follow-up were 66% (n = 54/82), 54% (n = 37/69), and 74% (n = 43/58) respectively. Postoperatively, patients complained about overactive bladder (OAB) symptoms in 37% (n = 30/81) and SUI in 28% (n = 23/81) at first follow-up and in 41% (n = 28/68) and 27% (n = 18/68) at second follow-up for OAB symptoms and stress urinary incontinence (SUI) respectively. When surgical release was performed more than 180 days after original surgery, less SUI (P = 0.008) was reported. When performed within 70 days in patients without pre-operative OAB symptoms, less post-operative OAB symptoms (P = 0.05) were reported.

CONCLUSIONS

Surgical release can be very successful in relieving obstruction due to bladder outlet obstruction (BOO) after anti-incontinence surgery. Persistent OAB symptoms and recurrent SUI are the main reasons for being dissatisfied. To lower the odds for recurrent SUI, surgical release should be performed more than 180 days after original surgery. Patients without pre-operative OAB symptoms are at higher risk of developing post-operative OAB symptoms when treatment is delayed more than 70 days.

Outcomes of two different incision techniques for surgical treatment of stress urinary incontinence with concomitant anterior vaginal wall prolapse

PURPOSE

To assess the outcomes of two different incision techniques used in the surgical treatment of stress urinary incontinence (SUI) with concomitant anterior vaginal wall prolapse and to identify possible associated risk factors with a medium-term follow-up in patients who underwent TOT procedure.

METHODS

We conducted a retrospective cohort study of 233 women who underwent transobturator tape procedure with cystocele repair. The women were divided into two groups according to two different incision techniques. The outcomes were analyzed considering five postoperative parameters: objective cure, subjective cure, patient satisfaction, resolution of urgency urinary incontinence and complications. The mean follow-up period was 43.6 months (range 12-85).

RESULTS

A total of 226 women were documented in this study: 79 women in single-incision technique (group 1) and 147 women in double-incision technique (group 2). The objective and subjective cure and patient satisfaction (visual analog scale score ≥80) rates were 89.8, 73.4, 84.8 % and 90.4, 74.1, 86.4 % in group 1 and group 2, respectively. Complications reported according to the Clavien-Dindo classification were grade I 5.2 %, grade II 42.1 %, grade IIIa 47.3 %, and grade IIIb 5.2 %, and grade I 22.2 %, grade II 77.7 %, grade IIIa 0 % and grade IIIb 0 % in group 1 and group 2, respectively. The mean operative time was significantly shorter in group 1 compared to group 2 (p = 0.001).

CONCLUSIONS

Both incision techniques have satisfactory outcomes in the surgical treatment of SUI with cystocele; nevertheless, the postoperative complications favor the double-incision technique.

Long-term durability, functional outcomes, and factors associated with surgical failure of tension-free vaginal tape procedure

PURPOSE

The cure rate of tension-free vaginal tape (TVT) appeared to decrease overtime, with an associated increased in the stress urinary incontinence (SUI) recurrence rate. We evaluated the long-term durability and functional outcomes of TVT and identified the risk factors that may affect recurrence.

METHODS

Eighty-eight patients, who were cured of SUI 6 months after undergoing TVT, were followed-up for at least 12 years. At post-operative, the patients were evaluated with a Severity Index for Urinary Incontinence questions regarding cure, patient's satisfaction, goal achievement, 3-day voiding diary with urinary urgency scale, uroflowmetry, and complications.

RESULTS

Cure rates decreased from 96.6 % at 1-year post-surgery to 83.0 % at 5 years and that the cure rates between 5 and 12 year were similar (83.0 vs. 79.6 %). Valsalva leak point pressure (VLPP) < 60 H(2)O was the only independent factor that predicted recurrence (p = 0.011; hazard radio 5.31). At last follow-up, 39.2 and 70.0 % of patients were free of urgency and urgency incontinence, respectively; and de novo urgency and urgency incontinence developed in 40.5 and 17.2 % of these patients, respectively. Age was the only factor that predicted freedom from overactive bladder (OAB) symptom. There was a significant reduction in the maximal flow rate from 23.3 ± 9.0 ml/s pre-operation to 18.8 ± 6.7 ml/s at 12 years post-operation.

CONCLUSIONS

TVT is an effective long-term treatment for SUI, although the cure rate may decrease with time. A low VLPP was predictive of SUI recurrence, and patients showing no OAB symptoms tended to be younger.

Perineal abscess three years after a transobturator sling

OBJECTIVE

This study aimed to report a unique perineal abscess after placement of a transobturator sling, involving the thighs and obturator regions bilaterally without involving mesh exposure.

CASE REPORT

A 66-year-old woman treated for stress urinary incontinence with a transobturator sling developed a late bilateral obturator infection 30 months after surgery. This complication appeared 6 months after chemotherapy for breast cancer. Sling removal through vaginal and bilateral inguinal incisions was performed. The patient evolved well, without recurrence of the infection or incontinence.

DISCUSSION

This case presents a unique scenario of muscle and skin infection after sling placement without any mesh exposure or vaginal involvement. The occurrence of the infection only after chemotherapy may indicate that immunosuppression had participation on its development. Care should be taken when exposing this mesh in contaminated perineal areas.

Outcome of transvaginal mesh and tape removed for pain only

PURPOSE

Because there is reluctance to operate for pain, we evaluated midterm outcomes of vaginal mesh and synthetic suburethral tape removed for pain as the only indication.

MATERIALS AND METHODS

After receiving institutional review board approval we reviewed a prospective database of women without a neurogenic condition who underwent surgery for vaginal mesh or suburethral tape removal with a focus on pain as the single reason for removal and a minimum 6-month followup. The primary outcome was pain level assessed by a visual analog scale (range 0 to 10) at baseline and at each subsequent visit with the score at the last visit used for analysis. Parameters evaluated included demographics, mean time to presentation and type of mesh or tape inserted.

RESULTS

From 2005 to 2013, 123 patients underwent surgical removal of mesh (69) and suburethral tape (54) with pain as the only indication. Mean followup was 35 months (range 6 to 59) in the tape group and 22 months (range 6 to 47) in the mesh group. The visual analog scale score decreased from a mean preoperative level of 7.9 to 0.9 postoperatively (p = 0.0014) in the mesh group and from 5.3 to 1.5 (p = 0.00074) in the tape group. Pain-free status, considered a score of 0, was achieved in 81% of tape and 67% of mesh cases, respectively. No statistically significant difference was found between the groups.

CONCLUSIONS

When pain is the only indication for suburethral tape or vaginal mesh removal, a significant decrease in the pain score can be durably expected after removal in most patients at midterm followup.