Surgery for urinary incontinence in women: Report from the 6th international consultation on incontinence

Long-term results of artificial urinary sphincter in women: A retrospective monocentric study

BACKGROUND

Stress urinary incontinence (SUI) is a public health issue, with major impact on quality of life. An efficient treatment for intrinsic sphincter deficiency (ISD) is the artificial urinary sphincter (AUS).

OBJECTIVES

Analyzing patient survival in terms of revision-free survival, removal-free survival and global survival without reintervention long-term results concerning continence status and complications.

DESIGN

Women with severe ISD and negative Bonney test who were treated with AUS first implantation between 1987 and 2022 were included.

RESULTS

In our study, 478 patients were treated by AUS first implantation with a mean age of 59.7. The median follow-up time was 13.2years. The median revision-free survival was 19.5years with survival rates at 10, 20 and 30years were 86%, 47% and 32% respectively. Removal-free survival rates at 10, 20 and 30years were 84%, 80% and 60% respectively. Median reintervention-free survival was 17.5years. Survival was negatively affected by neurological etiology of the ISD, history of previous incontinence treatment and intraoperative complications with more early removals in the latter group. The absence of previous incontinence surgery was a protecting factor. Continence status was assessed at 10, 20 and 30years follow-up with a fully continence rate of respectively 83%, 68% and 61%. Intraoperative complication rate was 17.7%, explantation rate was 14% and the revision rate was 23%.

CONCLUSION

Women treated with AUS have an excellent revision-free, removal-free and global survival rate. AUS is a very efficient treatment for women with ISD in terms of continence results with an acceptable intraoperative and long-term complication rate of which patients should be well informed before choosing this treatment for their SUI.

LEVEL OF EVIDENCE: 4

An update on surgical management for stress urinary incontinence

PURPOSE OF REVIEW

Stress urinary incontinence (SUI) is a common condition for which women often opt for surgical management. Synthetic midurethral slings (MUS) have been the dominant treatment for decades. Single-incision slings (SIS) have been introduced to lower the morbidity associated with trocar passage during MUS placement. Urethral bulking has been used less frequently owing to its lower cure rates. New data have recently emerged in support of single-incision slings (SIS) and urethral bulking with Bulkamid polyacrylamide hydrogel (PAHG).

RECENT FINDINGS

Several studies with a follow-up ≥10 years have shown stable efficacy and complication rates of retropubic (RMUS) and transobturator (TMUS) midurethral slings over time. SIS products show equivalent efficacy to traditional TMUS and RMUS at up to 3 years of follow-up and can be placed under local anesthesia. While urethral bulking with PAHG results in lower cure rates compared to slings, satisfaction rates are high and responders have sustained improvement at 7 years follow-up.

SUMMARY

All three types of available slings, TMUS, RMUS, and SIS, are now considered appropriate surgical options for the treatment of SUI. Although the absence of comparative data precludes a formal recommendation for one injectable over another, urethral bulking with PAHG has favorable long-term results and an excellent safety profile.

Rates of subjective and objective cure, satisfaction, and pain 10-20 years after tension-free vaginal tape (TVT) surgery: A retrospective cohort study

OBJECTIVE

To evaluate rates of subjective and objective cure, treatment satisfaction, pain, and the correlation between cure and body mass index (BMI), at 10 and 20 years after tension-free vaginal tape (TVT) surgery.

DESIGN

Retrospective cohort study.

SETTING

Multicentre study including 19 units in Norway.

POPULATION

Women undergoing TVT surgery for stress urinary incontinence (SUI) during 2001-2006 (20-year cohort) and 2011-2012 (10-year cohort).

METHODS

The Norwegian Female Incontinence Registry was used to identify women eligible for the study, who answered validated questionnaires about urinary incontinence, pain and satisfaction.

MAIN OUTCOME MEASURES

Subjective cure of SUI (with stress index of <3, range 0-12), objective cure (<3 g on stress test) and persisting pain and satisfaction after TVT (scored on a five-point Likert scale).

RESULTS

In total, 1210 of 1903 (64%) patients responded. The subjective cure rate was 68% after 10 years, versus 59% after 20 years, and did not significantly differ after adjusting for age, BMI, parity and preoperative stress index (adjusted OR 1.27, 95% CI 0.82-1.94). The objective cure rate was 100% versus 93% (P < 0.001), with 89% versus 76% reporting subjective satisfaction (P < 0.001), and with 4.7% versus 2.7% reporting persisting pain (P < 0.001), after 10 versus 20 years, respectively. Women in obesity classes I and II, compared with women of normal weight, had an increased risk of not being subjectively cured (crude OR 2.02, 95% CI 1.42-2.90; OR 2.95, 95% CI 1.60-5.46, respectively).

CONCLUSIONS

Tension-free vaginal tape (TVT) provided high rates of subjective and objective cure at 10 and 20 years after surgery, with no significant difference between the two cohorts. Although 3%-5% of women experienced persisting pain, most women were satisfied with TVT surgery. Obesity was associated with a lower cure rate.

The Potential of Non-ablative Erbium (YAG) Laser Treatment for Complications After Midurethral Sling Surgery: A Narrative Review

Midurethral sling (MUS) surgery, using tension-free vaginal tape and transobturator tape, has been widely adopted for the treatment of stress urinary incontinence (SUI). However, postoperative complications, including persistent urinary incontinence, mesh exposure, and pain, have become problematic, and surgical treatments for these complications face challenges, such as invasiveness, treatment-resistant cases, and recurrence. This review provides an overview of the current evidence regarding these complications and the potential of vaginal non-ablative erbium (YAG) laser (VEL) treatment as a minimally invasive option with low risk of complications. Studies have suggested the effectiveness of VEL treatment, performed using devices such as IncontiLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), for persistent urinary incontinence after MUS surgery, pain following mesh removal, and asymptomatic mesh exposure. VEL treatment is expected to be a new treatment option for complications following MUS surgery; however, further large-scale comparative trials are required to verify its efficacy and safety and to establish criteria for its indications. Appropriate assessment of the indications and provision of sufficient information to patients is important when presenting VEL as a treatment option.

Methodologies Used in Studies of Self-Management Interventions for Urinary Incontinence in Adult Women: An Integrative Review

BACKGROUND

Urinary incontinence (UI) affects approximately 60% of women in the United States and negatively impacts self-esteem, sexual function, participation in social activities, and quality of life (QOL). Self-management interventions show promise for improving UI symptoms and QOL. Previous reviews of UI self-management studies have focused on outcomes for older women. However, the literature lacks a synthesis of methodologies of these studies.

PURPOSE

The purpose of this integrative review was to synthesize and evaluate methodologies used in studies of self-management interventions for UI in adult women.

METHODS

Using an integrative review approach, a search of PubMed, CINAHL, and Embase was conducted yielding 1404 results, 23 of which met inclusion criteria. Data abstracted from each article included author(s), year of publication, study design and purpose, sample, country and setting, measures of UI symptoms, and intervention description.

RESULTS

Findings showed methodological differences, particularly in design, assessment of UI subtypes, measures of UI symptoms, and intervention components. Multicomponent self-management interventions were used in 18 studies and 1 component used in 5 studies. Education, pelvic floor muscle exercises, and bladder training were the intervention components most frequently used, either alone or in combination; however, intervention components were not consistently aligned with the UI subtypes. Analysis of ethical matters revealed areas for improvement, specifically in reporting privacy and confidentiality and in methods to obtain informed consent.

CONCLUSIONS

Results highlight opportunities to improve the rigor of methodologies used in studies of self-management interventions for UI in adult women.

Comparison of Er:YAG and CO2 laser therapy for women with stress urinary incontinence

OBJECTIVE

To compare the effectiveness of Er:YAG and CO2 laser therapies for treating female stress urinary incontinence (SUI).

METHODS

This retrospective study included 139 women who were divided into four groups: group 1 received two therapy sessions with the Er:YAG laser, group 2 received two therapy sessions with the CO2 laser, group 3 received one therapy session with the Er:YAG laser, and group 4 received one therapy session with the CO2 laser. Patients completed three questionnaires to assess SUI symptom severity at baseline, 1 month, and 3 months after laser therapy.

RESULTS

Urinary incontinence symptoms significantly improved in groups 1 and 2 at both the 1- and 3-month follow-up evaluations compared to the baseline (p < 0.001). Symptoms improved after one therapy session in groups 3 and 4 at the 3-month follow-up (p < 0.001). The Er:YAG laser was more effective than the CO2 laser in improving SUI symptoms (Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7) 3 months after treatment, regardless of the number of sessions. Both Er:YAG and CO2 laser therapies were found to be effective in reducing symptoms associated with an overactive bladder, as demonstrated by improvements in overactive bladder symptom scores. Two sessions of laser therapy were more effective than one.

CONCLUSION

Vaginal laser therapy could be an effective alternative treatment for mild to moderate SUI. The Er:YAG laser was more effective than CO2 laser therapy, with results lasting for at least 3 months. However, further large-scale, randomized, controlled trials are needed to confirm our findings.

Pelvic floor dysfunction and obesity

Obesity is a growing condition within the society and more patients, who have underlying obesity, are presenting with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction (PFD). The effect of obesity on general health has been well documented, and its impact on the cardiovascular, endocrine, and musculoskeletal systems has been extensively studied. There is now a growing body of evidence on the effects of obesity on the female urogenital system. It seems to influence the prevalence, presentation, assessment, management, and outcome of various types of LUTS and PFD. A holistic approach is needed to assess and manage these patients. A clear understanding of the functions of the pelvic floor and the way it can be affected by obesity is essential in providing holistic care to this group. A frank discussion about patient weight is required in the clinics handling PFD. A multimodal approach to weight loss would help improve PFD symptoms and progression. Patients with obesity should still be offered standard treatment options for all PFDs and should not be forced to lose weight as a prerequisite before starting treatment. However, they should also be made aware of the impediments that being overweight adds to their care and their expectations should be managed accordingly.

Long-term Safety of Synthetic Midurethral Sling Implantation for the Treatment of Stress Urinary Incontinence in Adult Women: A Systematic Review

Context

Midurethral slings (MUSs) are the most used therapy for the treatment of stress urinary incontinence (SUI). While warning signals about potential complications have been raised worldwide, there is a lack of safety data especially in the long term.

Objective

Our objective was to evaluate synthetic MUS safety outcomes at long term in adult women.

Evidence acquisition

We included all studies evaluating MUSs in adult women with SUI. All synthetic MUSs have been considered: tension-free vaginal tape (TVT), transobturator tape (TOT), and mini-slings. The primary outcome was the reoperation rate at 5 yr.

Evidence synthesis

Of 5586 references screened after duplicate removal, 44 studies (8218 patients) were included. Among these, nine were randomized controlled trials and 35 were cohort studies. The overall reoperation rates at 5 yr varied between 0% and 19% for TOT (11 studies), 0% and 13% for TVT (17 studies), and 0% and 19% for mini-slings (two studies). The overall reoperation rates at 10 yr varied between 5% and 15% for TOT (four studies) and between 2% and 17% for TVT (four studies). There were few safety data beyond 5 yr: 22.7% of the articles reported a follow-up at ≥10 yr and 2.3% at ≥15 yr.

Conclusions

The incidence rates of reoperations and complications are heterogeneous, and data beyond 5 yr are rare.

Patient summary

There is an urgent need to improve safety monitoring of mesh as our review highlights that available safety data are heterogeneous and of insufficient quality to guide the decision.

Update on Urethral Bulking for Stress Urinary Incontinence in Women

PURPOSE OF REVIEW

Urethral bulking agents are an effective treatment for stress urinary incontinence in select females. The material and techniques used for urethral bulking are constantly evolving. With the introduction of several new agents, there is an ongoing debate over which agent is the most effective, durable, and safe.

RECENT FINDINGS

Current available bulking agents include Bulkamid®, Macroplastiue®, Durasphere®, Coaptite®, or Urolastic®. Each of these agents has its own biophysical properties that affect its efficacy and safety. Evidence evaluating bulking agents has increased over time but there is no definitive data that suggest superiority of one agent over another. The ideal urethral bulking agent for female stress incontinence has yet been identified. Currently available agents have acceptable short-term and medium-term efficacy with few adverse events.

Morphological and histological changes in the urethra after intraurethral nonablative erbium YAG laser therapy: an experimental study in beagle dogs

The purpose of this study was to investigate the morphological and histological changes in the urethra in beagle dogs after intraurethral Er:YAG laser irradiation in nonablative mode to confirm the safety of this therapy. Six 2-year-old healthy female virgin beagle dogs (13 ± 1.51 kg) were used in this study. The animals were divided into 2 groups: the sham group, which received sham treatment (n = 3) involving insertion of an intraurethral cannula and laser delivery handpiece into the urethra without laser irradiation, and the experimental group (n = 3), which received intraurethral Er:YAG laser irradiation. The laser irradiation parameters were set according to clinical criteria (4 mm spot size, 1.5 J/cm², 1.4 Hz, and 4 pulses) in nonablative mode. All animals received three sequential sessions at 4-week intervals. Urethrography and urethroscopy were performed in the 12th week and 13th week, respectively, after the first treatment. After urethroscopy, the animals were sacrificed, and urethral tissue was harvested for histological investigations. All procedures were performed under general anesthesia (40 mg/kg 3% sodium pentobarbital, i.v.). Transforming growth factor β1 (TGF-β1) and α-smooth muscle actin (α-SMA) expression levels were measured to evaluate the biochemical characteristics of the scar. Urethral stricture was not found by urethrography or urethroscopy in either group. Urethral epithelium thickness and collagen expression under the urethral mucosa were significantly increased in the experimental group compared with the sham group. However, there were no significant differences in TGF-β1 and α-SMA expression between the experimental group and sham group (p > 0.05). Urethral stricture is not found in beagle dogs after clinically relevant intraurethral nonablative mode Er:YAG laser irradiation. Proliferation of urethral collagen and the urethral mucosa may be one of the mechanisms by which urine leakage symptoms can be improved.

The Efficacy and Mid-term Durability of Urethral Sphincter Injections of Platelet-Rich Plasma in Treatment of Female Stress Urinary Incontinence

Aims: This study investigated the therapeutic effect of repeated urethral sphincter injections of autologous platelet-rich plasma (PRP) in treatment of stress urinary incontinence (SUI) in women due to intrinsic sphincter deficiency (ISD) refractory to medical treatment or after the first anti-incontinence surgery. Methods: Twenty-six women with SUI due to urodynamically proven ISD were prospectively enrolled. Five milliliters of PRP (2.5-5 times of the platelet concentrations in peripheral blood) were injected into the external sphincter at 5 sites, with 4 treatments at monthly interval. The primary end-point was post-treatment Global Response Assessment (GRA, scored 0-3) score after four PRP treatments. A GRA ≥ 2 was considered as a successful result. The secondary endpoints included changes in visual analog scale (VAS) of SUI and urodynamic parameters. The follow-up date was 12 months after the fourth PRP treatment. Results: The mean age was 61.7 ± 15.3 years. The overall success rate was 50% with the post-treatment mean GRA of 1.5 ± 1.1. Complete dryness was achieved in 12 patients (46.2%) after the PRP treatment, and 7 (26.9%) kept total continence at 12 months. The mean VAS of SUI score decreased significantly from 6.4 ± 2.3 to 3.9 ± 2.3 after treatment (p < 0.001). The abdominal leak point pressure increased significantly from 117.5 ± 63.8 to 133.6 ± 61.7 cmH2O (p = 0.045). No perioperative adverse events or severe complications occurred, except 1 (3.8%) patient reported straining to void which was self-limited. Conclusion: Repeated urethral sphincter injections of autologous PRP are a safe procedure that provides significant reduction in the severity of female SUI and a mid-term durability, suggesting PRP treatment is effective to increase urethral sphincter resistance for female SUI.

Is it the Surgeon? A Re-examination of Mid-urethral Sling Complications

OBJECTIVE

To identify potential technical factors during initial mid-urethral sling (MUS) placement that contribute to subsequent sling revision procedures.

METHODS

A retrospective chart review was performed examining synthetic MUS reoperations at a single institution from 2008-2020. The implanting surgeon's operative note, when available, was critically reviewed with respect to trocar placement, sling location, and tensioning technique. The reoperative report was reviewed for aberrant intraoperative findings relating to the index surgery.

RESULTS

A total of 306 women underwent revision of their MUS. Operative reports from the implanting surgeon were available for 276 (90.2%) women. Review of index operative reports revealed 47 unambiguous descriptions of improper technique, including 19 cases of described excessive tensioning and 2 cases of MUS placement despite noted urethral injury during the index case. Indications for reoperation were clinical obstruction (63%), pain (40%), and mesh erosion/exposure (33%). In 186 (67.4%) women, there was an intraoperative finding during the revision that likely contributed to the need for reoperation. Among these 186 women, 110 (59.1%) slings were noted to have been placed too proximally, 78 (41.9%) were over-suspended, and 57 (30.6%) were placed too deep in the periurethral fascia.

CONCLUSION

Review of the index operative note and findings at operative re-exploration of MUS surgeries, often reveals evidence that the initial MUS implantation was technically suboptimal. Such findings suggest that intraoperative surgical technique is a critically important factor contributing to postoperative complications in MUS surgery. This underscores the importance of surgical training and adherence to surgical principles during the placement of a synthetic MUS.

Current pharmacotherapy of overactive bladder

Overactive bladder is a symptom complex consisting of bothersome storage urinary symptoms that is highly prevalent among both sexes and has a significant impact on quality of life. Various antimuscarinic agents and the beta-3 agonists mirabegron and vibegron are currently available for the treatment of OAB. Each drug has specific pharmacologic properties, dosing schedule and tolerability profile, making it essential to individualize the medical treatment for the patient's characteristics and expectations. In this manuscript, we review the most important factors involved in the contemporary pharmacological treatment of OAB.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Medical malpractice in stress urinary incontinence management: A 30-year legal database review

BACKGROUND

The purpose of this study is to investigate the most common reasons for and judicial outcomes of malpractice claims related to stress urinary incontinence (SUI) management.

MATERIALS AND METHODS

Using the Westlaw database, a search was performed using the terms "medical malpractice" or "negligence" in combination with "stress incontinence" or "stress urinary incontinence" between January 1, 1990 and January 1, 2020. Extracted information included trial date, demographic information, defendant profession, procedure performed, procedure complications, alleged malpractice, trial outcome, and monetary award. Data were analyzed using descriptive statistics.

RESULTS

The Westlaw search yielded 79 case results. Of the cases, 70.4% (n = 38/54) had a defense verdict, 22.2% (n = 12/54) had a plaintiff verdict, and 7.4% (n = 4/54) were settled. The most commonly implicated procedure was mid-urethral sling (63.2%, n = 36/57). Among the plaintiffs, 48.4% (n = 61/126) claimed negligence in preoperative care, 33.3% (n = 42/126) claimed negligence in surgical performance, and 18.3% (n = 23/126) claimed negligence in postoperative care. Lack of informed consent was the most common complaint related to negligence in preoperative care (42.6%, n = 26/61). The average indemnity payment was $1,253,644 for preoperative care negligence, $1,254,491 for surgical performance negligence, and $2,239,198 for postoperative care negligence. Of the defendants, 63.4% (n = 52) were gynecologists and 36.6% (n = 30) were urologists.

CONCLUSIONS

Negligent preoperative care, with a particular emphasis on failure to obtain informed consent, and negligent surgical performance are the leading causes of malpractice claims during SUI management. Mid-urethral sling was the most commonly litigated procedure. This study highlights key factors to consider in minimizing malpractice risk during SUI management.

Robot-assisted artificial urinary sphincter implantation

PURPOSE OF REVIEW

The aim of the present manuscript was to provide an overview on the current state of robotic artificial urinary sphincter (AUS) implantation in male and female patients.

RECENT FINDINGS

Over the past few years, several series have been reported, with promising outcomes for the most part. This has contributed to expand the use of bladder neck AUS, especially in female patients, which was, until then, hampered by its perioperative morbidity.

SUMMARY

Robotic AUS has been developed to overcome the technical challenge of bladder neck implantation in female patients and in specific male subgroups, especially self-catheterizing neurological patients. All the series of robotic AUS implantation published in the past few years reported much lower rates of cuff erosion and AUS explantation than the historical open cohorts suggesting that the robotic approach might become the standard for female AUS implantation. This less morbid approach along with technological improvement of the AUS device may contribute to make it a more popular option in the treatment of female stress urinary incontinence due to intrinsic sphincter deficiency. There are much less data available on robotic bladder neck AUS implantation in male patients.

Current Use of the Artificial Urinary Sphincter in Adult Females

PURPOSE OF REVIEW

The aim of the present report was to review the recent evidences regarding the use of artificial urinary sphincter (AUS) in adult females.

RECENT FINDINGS

While the excellent functional outcomes of AUS in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) have been reported for decades, its use has remained confidential in most countries likely due to its challenging implantation and inherent morbidity. Over the past few years, laparoscopic and, more recently, robotic techniques of AUS implantation in female patients have been described with promising perioperative outcomes. As a result, the use of AUS has increased in several countries. The indications are mostly recurrent or persistent SUI after previous anti-incontinence procedures and neurogenic SUI. Owing to its unique potential to restore continence while maintaining low outlet resistance during the voiding phase, AUS may be of special interest in female patients with detrusor underactivity. High level of evidence data from trials which are underway, along with developments in robotic surgery and technological refinements of the device, may well, almost 50 years after its introduction, give to the AUS its momentum as a major contributor in the female SUI armamentarium. While the use of AUS in female patients has been restricted to some countries and a few high-volume centers, it has started spreading again over the past few years, thanks to the rise of minimally invasive approaches which facilitate its implantation, and this is yielding promising outcomes.

Current and Future Directions of Stem Cell Therapy for Bladder Dysfunction

Stem cells are capable of self-renewal and differentiation into a range of cell types and promote the release of chemokines and progenitor cells necessary for tissue regeneration. Mesenchymal stem cells are multipotent progenitor cells with enhanced proliferation and differentiation capabilities and less tumorigenicity than conventional adult stem cells; these cells are also easier to acquire. Bladder dysfunction is often chronic in nature with limited treatment modalities due to its undetermined pathophysiology. Most treatments focus on symptom alleviation rather than pathognomonic changes repair. The potential of stem cell therapy for bladder dysfunction has been reported in preclinical models for stress urinary incontinence, overactive bladder, detrusor underactivity, and interstitial cystitis/bladder pain syndrome. Despite these findings, however, stem cell therapy is not yet available for clinical use. Only one pilot study on detrusor underactivity and a handful of clinical trials on stress urinary incontinence have reported the effects of stem cell treatment. This limitation may be due to stem cell function loss following ex vivo expansion, poor in vivo engraftment or survival after transplantation, or a lack of understanding of the precise mechanisms of action underlying therapeutic outcomes and in vivo behavior of stem cells administered to target organs. Efficacy comparisons with existing treatment modalities are also needed for the successful clinical application of stem cell therapies. This review describes the current status of stem cell research on treating bladder dysfunction and suggests future directions to facilitate clinical applications of this promising treatment modality, particularly for bladder dysfunction.

Durability of Retropubic Suburethral Sling Procedure and Predictors for Successful Treatment Outcome in Women With Stress Urinary Incontinence

OBJECTIVE

To investigate the long-term durability of retropubic suburethral sling procedure for female stress urinary incontinence (SUI) and to identify urodynamic factors that might predict long-term successful outcomes.

MATERIALS AND METHODS

In total, 286 women who underwent a retropubic suburethral sling for SUI were enrolled in this retrospective survey. Most patients received uroflowmetry, postvoid residual volume study and standardized video urodynamic testing preoperatively and 6 months postoperatively in half of them. Surgical results, demographic characteristics, preoperative and postoperative urodynamic parameters, and postoperative clinical manifestation were retrospectively analyzed. Urodynamic parameters that predict a failure outcome were investigated.

RESULTS

The median follow-up period was 10 years (4-29 years). The overall subjective cure rate was 80.8%. The success rates of the sling procedures at 3, 5, 10, 15, and 20 years were 89.2%, 87.7%, 78.8%, 68.6%, and 60.0%, respectively. Vaginal delivery and greater parity had negative influence on cure rate (P = .004 and .013, respectively). A significant interaction was detected from the baseline to 6 months between successes and failures for maximum flow rate (Qmax) (P = .007), voided volume (P = .020), and bladder outlet obstruction index (P = .001). Univariate analysis revealed significant decrease of Qmax, volume, and voiding efficiency; and increase of postvoid residual volume, detrusor pressure, and bladder outlet obstruction index in patients with successful outcome. However, multivariate logistic regression failed to find predictive factors for a failure suburethral sling procedure.

CONCLUSION

Retropubic suburethral sling has a durable long-term effect for SUI. Slightly increased bladder outlet resistance after retropubic suburethral sling might be helpful for achieving long-term dryness.

Management of Occult Urinary Incontinence with Prolapse Surgery

PURPOSE OF REVIEW

The purpose of this paper is to review (1) the epidemiology and pathophysiology of pelvic organ prolapse (POP) and occult stress urinary incontinence (SUI), (2) examine the data on combined operative management of POP and occult SUI, (3) discuss the approaches to clinical decision making, and (4) present future therapies.

RECENT FINDINGS

Prospective data on many approaches to concomitant treatment of prolapse and occult stress urinary incontinence, such as minimally invasive sacrocolpopexy and midurethral sling, or older approaches that have regained favor among patients and clinicians wishing to avoid synthetic mesh, such as native tissue prolapse repair and pubovaginal sling, are limited. Safe durable treatments with absorbable graft materials that promote a beneficial host response are intriguing but may be far from clinical implementation. Stem cell therapy for the treatment of stress urinary incontinence has demonstrated benefit in phase I/II trials but has not been studied in the setting of concomitant treatment of occult SUI with POP surgery and remains in the preclinical phase for the treatment of POP. A personalized approach to concomitant SUI surgery that incorporates individual risk assessment as well as informed patient preferences likely optimizes the risk/benefit ratio and patient satisfaction. Novel therapies, including graft materials and cellular therapies that stimulate a regenerative response, may improve or maintain continence outcomes while mitigating risk and alter the approach to both POP and SUI surgery.