TVT and Sparc suburethral slings: a case?control series

Long-Term Results after Suprapubic ARC Procedure for the Treatment of Stress Urinary Incontinence in Women: A Retrospective Data Analysis

INTRODUCTION

The aim of this study was to evaluate long-term safety and efficacy of the suprapubic arc (SPARC) procedure for the surgical treatment of stress urinary incontinence (SUI).

MATERIALS AND METHODS

139 female patients treated by SPARC were included in this retrospective analysis, whereby 126 patients were available for follow-up after 1 year, 70 after 6 years, and 41 after 9 years. The cough test, pad test, uroflowmetry, and post-void residual volume measurements were performed. Severity of bother (visual analogous scale [VAS] 0-10), continence, and the satisfaction rate were assessed. Objective cure was defined as a negative cough test and pad weight ≤1 g, subjective cure as no urine loss during daily activities and no usage of pads. The VAS, pad weight, number of pads per day, and maximal flow rate were compared preoperatively and postoperatively.

RESULTS

Objective cure rates at 1, 6, and 9 years were 78.6, 71.4, and 70.7% and subjective cure rates were 72.2, 55.7, and 65.8%, respectively. The VAS, pad weight, number of pads, and maximal flow rate decreased significantly. Study limitations include a relatively small sample size and the retrospective fashion of the analysis.

CONCLUSIONS

In the long-term context, SPARC showed to represent an efficient and safe procedure for treatment of female SUI.

Transvaginal retropubic sling systems: efficacy and patient acceptability

Stress urinary incontinence is a common, disabling, and costly medical problem that affects approximately 50% of women with urinary incontinence. Suburethral retropubic slings have been developed as a minimally invasive and effective surgical option, and they have been used as a first-line treatment for stress urinary incontinence since 1995. However, complications including vaginal extrusion, erosion, pain, bleeding, infections, lower urinary tract symptoms, urinary retention, and incontinence have been reported with use of the slings. Several companies manufacture sling kits, and the sling kits vary with regard to the composition of the mesh and introducer needle. The aim of this review was to determine which sling kit was most effective for patients, had minimal reported side effects, and was best accepted by patients and surgeons. In a review of the literature, it was found that a total of 38 studies were published between 1995 and 2014 that reported on eight tension-free retropubic sling kits: SPARC, RetroArc, Align, Advantage, Lynx, Desara, Supris, and Gynecare TVT. The Gynecare TVT was the most cited sling kit; the second most cited was the SPARC. This review provides a summary of the studies that have examined positive and negative outcomes of the retropubic tension-free suburethral sling procedure using various sling kits. Overall, the results of the literature review indicated that data from comparisons of the available sling kits are insufficient to make an evidenced-based recommendation. Therefore, the decision regarding which sling kit is appropriate to use in surgery is determined by the medical provider’s preference, training, and past experience, and not by the patient.

Minimally invasive treatment for female stress urinary incontinence (SUI): a review including TVT, TOT, and mini-sling

Treatment for female stress urinary incontinence (SUI) has progressed rapidly over the past ten years in the search for less invasive methods to treat this disease. There have been over 100 procedures described in the literature to date to treat female SUI; however, only two procedures have stood the test of time and have adequate cure rates: the retropubic colposuspension (Burch, MMK) and the sling. The laparoscopic approach to minimize the Burch procedure was described in the 1990s, but the evolution of the retropubic tension-free vaginal tape sling (TVT) in the late 1990s revolutionized the treatment of female SUI. More recently, the transobturator technique (TOT) and the single-incision mini-sling have been reported in attempts to further reduce the risks of sling placement. The current chapter reviews the history of treatment of female SUI and the development of these newer, less-invasive techniques. The procedures themselves are described, the risks of mesh complications reviewed, and the literature reviewed for current data on the different approaches and procedures.

Pelvic floor ultrasound in incontinence: what's in it for the surgeon?

There is increasing interest in imaging techniques such as magnetic resonance and ultrasound amongst pelvic floor surgeons, as evidenced by the number of workshops and conference presentations in this field. Ultrasound is employed more commonly, due to much lower costs, greater accessibility and practicability. Consequently, this review focuses on sonography. At this time, imaging is probably under-utilised in urogynaecology and female urology, although it has the potential to greatly benefit our patients. In this review, I will outline the main uses of imaging in the work-up of women with urinary incontinence, before and after treatment, and focus on areas in which this benefit to patients and clinicians is most evident.

Safety and efficacy of sling for persistent stress urinary incontinence after bulking injection

OBJECTIVES

To evaluate the impact of injectable agents on subsequent incontinence surgery outcomes to assess safety and efficacy of this treatment combination. Periurethral bulking agents are a minimally invasive treatment option for stress urinary incontinence (SUI), but often lack durability necessitating further surgical intervention.

METHODS

Retrospective review of 43 patients with SUI following bulking agent who underwent subsequent sling placement from November 2000 to September 2009 were evaluated for demographics, symptoms, urodynamics (UDS), bulking agent characteristics, concomitant procedures, pad requirements per day (PPD), subjective outcomes, and complications.

RESULTS

Mean patient age was 67 years, with mean follow-up of 37.3 months. All demonstrated SUI, and mixed urinary incontinence (MUI) was noted in 81.4%. Almost half (48.8%) had undergone a prior antiincontinence procedure. Mean number of injections was 3. After a bulking injection, 25 autologous fascia pubovaginal slings, 13 midurethral slings, and 5 biological pubovaginal slings were placed. Concomitant pelvic surgery was performed in 37.2%. Postoperatively, mean PPD decreased from 5.3 to 0.65, with a 60.5% subjective cure rate (no pads or leakage under any circumstances). No association was seen between number or type of injection, or type of sling with regards to patient outcomes. Results were significantly related to concomitant surgery (P = .007). SUI recurred in 8 patients (18.6%), which was not statistically associated with other parameters. Complications included urinary retention (8 patients) de novo urgency (1 patient), UTI (4 patients), abdominal wound infection (3 patients), and cystotomy (1 patient).

CONCLUSIONS

Prior treatment with bulking agents does not appear to negatively affect outcomes for future antiincontinence surgery in our patient population.

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery.

METHODS

The charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial.

RESULTS

Forty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3-9.8).

CONCLUSIONS

A higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.

Treatment of stress urinary incontinence--midurethral slings: top-down, bottom-up, "outside-in," or "inside-out"

Two randomized trials have reported no differences in efficacy between suprapubic arc and tension-free vaginal tape at 2 years. There are no long-term studies comparing the inside-out and outside-in transobturator (TOT) approach, although short-term data show no difference in cure rates or complications. The short-term efficacy of TOT midurethral slings is comparable with the retropubic slings; however, preliminary evidence suggests that TOT slings may have a lower success rate compared with retropubic slings for the treatment of intrinsic sphincter deficiency. The risk of bladder injury may be the least with the "inside-out" approach, whereas retropubic techniques have a higher risk of cystotomy as compared with the TOT approach. Four randomized controlled trials comparing the retropubic and TOT approaches show no differences in rate of de novo urgency, retention, frequency, nocturia, or incomplete voiding.

Effect of tension-free vaginal tape position on the resolution of irritative bladder symptoms in women with mixed incontinence

The aim of this study was to determine whether the position of the tension-free vaginal tape (TVT) has an effect on the resolution of irritative symptoms in women undergoing the TVT operation. Initial audit suggested that more distally placed tapes were more likely to result in the resolution of irritative symptoms. An appropriately powered study was designed to test this theory. Seventy-seven women with urodynamic evidence of detrusor overactivity and urodynamic stress incontinence underwent a transperineal ultrasound scan to ascertain the position of the tape after a TVT. The tape was categorised as proximal, middle or distal urethra. The resolution of irritative symptoms was assessed compared to the TVT position. Forty-five women had distal tapes, 30 had mid-urethral tapes and two had proximal tapes. Women with the TVT placed on the distal urethra were no more likely to experience resolution of their irritative symptoms than women with tapes on the mid-urethra (p > 0.05). Placement of the TVT on any one part of the urethra is not more likely to result in resolution of irritative bladder symptoms.

Polypropylene Midurethral Tapes Do Not Have Similar Biologic and Biomechanical Performance in the Rat

OBJECTIVES

To evaluate the biomechanical properties and histologic changes of different commercially available polypropylene midurethral tapes (MUTs) after implantation in the rat.

METHODS

Pieces of Advantage, intravaginal slingplasty (IVS), suprapubic arch sling (SPARC), and tension-free vaginal tape (TVT) were implanted over the rectus fascia of rats, with six rats serving as controls. On retrieval 24 wk later, the degree of adherence and sample measurements were recorded. Biomechanical testing of the retrieved samples was performed using the uniaxial loading method. Histologic evaluation of the samples under light microscopy included the following parameters: inflammatory infiltrate, fibrosis, mast cell presence, muscular infiltration, and collagen filling of the mesh.

RESULTS

No mesh extrusion or infection was encountered. The biomechanical and histologic results were consistent within each group. TVT displayed peculiar adherence characteristics not found among the other brands. No statistically significant difference were found in mean peak load and extension at peak load among the four tested brands. Stiffness of TVT was significantly lower than that of each of the other three brands. Stiffness of Advantage was significantly higher than that of SPARC. The histologic findings differed from one MUT brand to another. By grading certain histologic parameters, an untested model to assign a score for biocompatibility potential in the rat, to different MUTs, was developed.

CONCLUSIONS

Commercially available polypropylene MUTs display different biologic and biomechanical properties in the rat.

One year follow-up on the SPARC sling system for the treatment of female urodynamic stress incontinence

AIM

To evaluate the safety and efficacy of the SPARC sling in women with urinary incontinence.

METHODS

Women who presented with urinary incontinence symptoms were included in this prospective study. In total, 103 women underwent evaluation of subjective and objective cure rates, quality of life and urodynamic parameters following the SPARC procedure.

RESULTS

The objective cure rate, defined as a pad weight test less than 1 g and negative cough stress test, was 84.4% at 12 months. Subjective cure rates, defined as no usage of pads/no urine loss during daily activities, were also encouraging: 75.0% at 12 months. Quality of life evaluation included asking patients to rate the amount of bother caused by their incontinence symptoms on a scale from 0 to 100. Preoperatively, the average was 76.7, dropping to 15.9 at 12 months. At 6 months, 93.7% (75/79) were 'very satisfied' and 5.1% (4/79) were 'satisfied;' one patient was 'dissatisfied' (1.2%, 1/79). Seventy-eight of 79 patients (98.7%) would recommend the procedure to a friend and undergo the procedure again. Patients returned to inside work an average of 1.4 days and to outside work 5.4 days after the procedure. The maximum flow rate decreased from a mean of 43.4 mL/s preoperatively to 37.08 mL/s at 12 months postoperatively (P = 0.049). Detrusor pressure at maximum flow and maximal urethral closure at rest increased from 16.94 and 50.85 cmH(2)O preoperatively to 21.69 and 60.61 cmH(2)O at 12 months, respectively (P = 0.015; P < 0.001). There were few postoperative complications, with no reported infections, erosions or hematomas.

CONCLUSIONS

This prospective study demonstrates that the SPARC suprapubic sling is a safe and effective treatment for female stress urinary incontinence. Both objective and subjective measures of success were achieved, with low complication rates. Quality of life and urodynamic parameters were improved. The SPARC method provides safe and highly effective treatment for female stress urinary incontinence at one year.

SPARC Sling System for Treatment of Female Stress Urinary Incontinence in the Elderly

OBJECTIVE

To investigate the safety and efficacy of the suprapubic arch (SPARC) sling procedure for the management of stress urinary incontinence (SUI) in elderly women.

METHOD

Forty-three women, aged 65-91 yr, underwent the SPARC procedure for urodynamic SUI. Before surgery, a complete medical history was obtained and a urogynecology examination and urodynamic test were performed. The objective cure rate was evaluated by clinical and urodynamic examination at 3, 6, and 12 mo and the subjective cure rate was assessed using a visual analogue score and a global patient impression questionnaire.

RESULTS

No severe intraoperative or postoperative complications occurred. No patient referred de novo urge incontinence. Significant differences were found between the preoperative and postoperative number of daytime voidings (p < 0.001), the pad weights and numbers of pads used (p < 0.001), and the visual analogue score (p = 0.021). No significant differences in preoperative and postoperative urodynamic parameters were reported. At the mean follow-up of 36+/-14 mo (range, 12-54 mo), objective and subjective cure rates were 91% and 95%, respectively.

CONCLUSIONS

The SPARC procedure is effective and offers a satisfactory cure rate without significant morbidity in elderly women with SUI.

Laparoscopic Burch colposuspension and the tension-free vaginal tape procedure

PURPOSE OF REVIEW

Minimally invasive procedures for urinary incontinence and pelvic organ prolapse have gained increasing popularity in the past decade. The advantages of minimal access through laparoscopic and vaginal routes include smaller incisions, shortened hospital stay, decreased analgesia, rapid recovery and rapid return to work. The laparoscopic Burch colposuspension and the tension-free vaginal tape procedure were at the forefront of minimal access antiincontinence procedures. The most recent and significant publications regarding laparoscopic Burch colposuspension and tension-free vaginal tape procedure are highlighted in this article.

RECENT FINDINGS

The laparoscopic Burch is time-consuming and requires a steep learning curve in laparoscopic suturing, thwarting its adoption and staying power. The advantages and success of the retropubic midurethral sling procedures such as tension-free vaginal tape have largely replaced all other antiincontinence procedures and have ignited the development and adoption of transobturator midurethral sling procedures and vaginal 'kit' procedures for pelvic organ prolapse.

SUMMARY

Clinical trials show that laparoscopic Burch cure rates are equal or inferior to tension-free vaginal tape cure rates. Publications regarding laparoscopic Burch colposuspension have tapered significantly in the past year, which may represent the ebb of its utilization. Tension-free vaginal tape and other midurethral sling procedures may become the new 'gold standard' antiincontinence therapy.

A randomized controlled equivalence trial of short-term complications and efficacy of tension-free vaginal tape and suprapubic urethral support sling for treating stress incontinence

OBJECTIVE

To establish the equivalence between the tension-free vaginal tape (TVT) and the suprapubic urethral support sling (SPARC). Approximately 35% of women have stress urinary incontinence (SUI), and although TVT is now perceived as the standard treatment, the SPARC is a very similar procedure and is thought to have fewer peri-operative complications.

PATIENTS AND METHODS

Patients with clinical SUI were recruited from public and private urology/urogynaecology clinics, and participated in the trial of TVT vs SPARC. The primary outcome was bladder perforation; secondary outcomes were blood loss, voiding difficulty, urgency, and cure of SUI symptoms. Sample size calculations, based on an estimated 2% perforation rate, showed that 290 patients would be needed to detect a clinically significant difference of 5%. Stratification was by previous incontinence surgery and the experience of the surgeon.

RESULTS

There were 301 operations; the difference in bladder perforations was not statistically significant, at one/147 TVT (0.7%), and three/154 SPARC (1.9%), with the difference in rate of 0.013 (95% confidence interval (CI) - 0.01 to 0.04; odds ratio 2.89, 95% CI 0.30-28.21; P = 0.62), and nor were differences in estimated blood loss of >100 mL (TVT, 32/147, 21.8%; SPARC 28/154, 18.2%); de novo urgency (TVT 15/37, 40.5%; SPARC 14/33, 42.4%), objective cure (TVT 143/147, 97.3%; SPARC 148/152, 97.4%) or vaginal mesh erosion (TVT 7/147, 4.8%; SPARC 16/152, 10.5%). Acute urinary retention (TVT none of 147; SPARC 10/154, 6.5%; odds ratio infinity, 95% CI 2.2-infinity; P = 0.002) and subjective cure (TVT 128/147, 87.1%; SPARC 117/153, 76.5%; odds ratio 2.07, 95% CI 1.13-3.81; P = 0.03) were statistically significantly different.

CONCLUSION

These results are consistent with clinical equivalence between TVT and SPARC for bladder perforation. There was no statistically significant difference between TVT and SPARC in blood loss, urgency or objective cure of SUI symptoms at 6 weeks. However, SPARC was more difficult to adjust correctly, and a statistically significant number of patients required loosening of the tape in theatre (P = 0.002). TVT had a lower rate of vaginal erosion and a statistically significantly higher cure rate of subjective SUI symptoms than SPARC. Overall, voiding difficulty (loosening of the tape), urgency and vaginal mesh erosion were the most important clinical problems. This trial showed the importance of testing new devices which appear to be similar, but which might have relevant differences. There was no financial assistance for this study, and a long-term follow up is planned.

TVT vs Monarc: a comparative study

Following the success of the tension-free vaginal tape (TVT), there has been considerable interest in technique modifications such as the transobturator approach for implant placement. We attempted to elucidate possible anatomical and clinical differences between the two methods in a retrospective cohort study. One hundred and fourteen women who had undergone TVT or Monarc implantation were assessed by or under the supervision of the senior author, with identical tensioning technique. They were followed up by an interview, uroflowmetry, and translabial 3D ultrasound. There were significant differences for patient satisfaction (P=0.013), subjective overall cure/improvement (P=0.0018), and the symptom of poor stream (P=0.03), all favoring the Monarc group. On imaging Monarc tapes appeared more proximal at rest (P=0.006) and Valsalva (P=0.002) and remained further from the symphysis pubis on Valsalva (P=0.01). At 9 months follow-up, there was no significant difference as regards to cure rates for stress incontinence between the two suburethral slings. Monarc tapes are located more proximally and may be less obstructive, judging from a lower incidence of symptoms of voiding dysfunction. Patient satisfaction and overall subjective cure/improvement were higher after Monarc. In summary, the Monarc is an effective TVT alternative, achieving cure of stress incontinence by similar means. It may be less obstructive, resulting in improved patient satisfaction.

Transobturator tape (TOT): Two years follow-up

AIMS

The aim of this study is to report the functional results, patient satisfaction, and morbidity of the Transobturator tape procedure (TOT) in the treatment of stress incontinence (SUI).

METHODS

One hundred and thirty patients were prospectively evaluated with history, physical examination, quality of life questionnaire including Incontinence Impact Questionnaire (IIQ), urogenital distress inventory (UDI), and analog global satisfaction scale (GSS), and urodynamic studies.

RESULTS

One hundred and seventeen patients (90%) had history of SUI, and 78 (60%) had urge incontinence. Pads/day (PPD) used was 2.48 +/- 2.42, and the score of IIQ 16.13 +/- 7.86, UDI 10.95 +/- 3.4, and GSS 1.41 +/- 1.67. All patients underwent TOT using the ObTape. Hospital stay was 0.84 +/- 0.76 days and catheter duration was 1.42 +/- 2.08 days. At a follow-up of 16.85 +/- 4.68 months, 13 patients (10%) have recurrent SUI, 21 (16.15%) persistent urge incontinence, and 1 (1.92%) de novo urge incontinence. The mean PPD is 0.15 +/- 0.56, IIQ 1.47 +/- 5.14, UDI 3.28 +/- 3.09, and GSS 8.29 +/- 1.64. Two patients (1.52%) developed urethral obstruction, five (3.84%) had vaginal extrusion of the tape, and two (1.52%) had intra-operative bladder perforation.

CONCLUSIONS

These results demonstrate the safety and efficacy of the TOT. The short hospitalization and catheterization, low incidence of de novo urge incontinence and obstructive voiding offers a distinct advantage over existing techniques. No significant difference in outcome between patients with VLPP < or =60 cm H2O, and patients with VLPP >60 cm H2O was observed.

Voiding dysfunction after the tension-free vaginal tape procedure

Throughout the past decade, pubovaginal slings have become the most widely used surgical procedure for the treatment of stress urinary incontinence. However, despite its widespread use and success rates, it is associated with a significant complication rate. In response to the high complication rate, the tension-free vaginal tape (TVT) was introduced. Based on the integral theory that stress urinary incontinence results from defective urethral support, the TVT consists of a loosely placed piece of prolene mesh under the urethra to recreate the pubourethral ligament. However, despite its tension-free nature, studies have shown that the TVT causes postoperative voiding dysfunction in 2.8% to 14% of patients. Radiologic and urodynamic studies suggest that postoperative voiding dysfunction is related to a change in outflow resistance during voiding, not to a change in the bladder neck positioning at rest. Although voiding dysfunction appears to be less after TVT than colposuspensions and the early pubovaginal slings, it does exist and patients should be warned of the potential complication.

Synthetic biomaterials for pelvic floor reconstruction

Pelvic organ prolapse and stress urinary incontinence increase with age. The increasing proportion of the aging female population is likely to result in a demand for care of pelvic floor prolapse and incontinence. Experimental evidence of altered connective tissue metabolism may predispose to pelvic floor dysfunction, supporting the use of biomaterials, such as synthetic mesh, to correct pelvic fascial defects. Re-establishing pelvic support and continence calls for a biomaterial to be inert, flexible, and durable and to simultaneously minimize infection and erosion risk. Mesh as a biomaterial has evolved considerably throughout the past half century to the current line that combines ease of use, achieves good outcomes, and minimizes risk. This article explores the biochemical basis for pelvic floor attenuation and reviews various pelvic reconstructive mesh materials, their successes, failures, complications, and management.

Prospective randomized comparison of transobturator suburethral sling (Monarc) vs suprapubic arc (Sparc) sling procedures for female urodynamic stress incontinence

The aims of this trial were to compare the attendant complications and postoperative voiding function of the Monarc and suprapubic arc (Sparc) suburethral sling procedures. This is the first article in English literature to compare different suburethral sling procedures using prosthesis of the same material and the same weave. Sixty women with urodynamic stress incontinence alone or combined with pelvic prolapse less than International Continence Society stage II were randomly allocated to either the Monarc or Sparc group. A comparison of the peri- and postoperative results comprising complications and symptoms of voiding function revealed no significant differences between the two groups in a follow-up ranged from 6 to 14 months (median, 9 months). However, the nonsignificant increase in tendency of inadvertent vaginal perforation and disability/pain of thigh (Monarc 12.9 vs Sparc 0.0%, p=0.112 and Monarc 12.9 vs Sparc 0.0%, p=0.112, respectively) has clinical significance. Based on the analyses of the comparison of Blaivas obstruction nomograms, postoperative voiding function was not significantly different between the two surgical groups. We concluded that Monarc and Sparc suburethral taping proved to be equally safe and posed no remarkable impact on voiding function in a short term postoperative follow up. However, intraoperative urethrocystoscopy is recommended for safety in both the Monarc and Sparc procedures.

Ultrasound and urodynamic comparison between caudocranial and craniocaudal tension-free vaginal tape for stress urinary incontinence

OBJECTIVES

To compare the efficacy and safety of the conventional caudocranial tension-free vaginal tape (TVT) procedure and craniocaudal TVT procedure for the treatment of primary stress urinary incontinence.

METHODS

Ninety patients with urodynamic stress incontinence and without prolapse underwent a caudocranial TVT (45 women) or craniocaudal TVT (45 women) procedure. The two patient groups were comparable in terms of age, parity, body weight, previous pelvic surgery, and menopausal status. Both methods were performed under local anesthesia with adequate sedation. Introital ultrasound evaluation on the mid-urethra TVT tapes and urodynamic evaluation was performed before and after surgery.

RESULTS

The average follow-up period for caudocranial TVT and craniocaudal TVT was 1.9 years and 1.4 years, respectively. Objective evaluations were performed at similar times at 1 year postoperatively. No significant differences were found in the cure rate at 88.9% (40 of 45 women) after caudocranial TVT and 91.1% (41 of 45 women) after craniocaudal TVT (P = 1.000). The intraoperative complications were minor. No patient had long-term voiding difficulty or required long-term catheterization. Both groups had the vaginal tape implanted at the mid-urethra, with a urethral knee angle observed during maximal straining. A more proximal tape position, less elasticity of the tape, and more obstruction by the sling were found using the craniocaudal approach. Postoperative dysfunctional voiding was minor.

CONCLUSIONS

The caudocranial and craniocaudal TVT procedures are highly effective, minimally invasive, and safe procedures in the treatment of urinary stress incontinence. The variations in implanted tape position and postoperative sling obstruction were most likely caused by the mode of insertion.

Suburethral slingplasty evaluation study in North Queensland, Australia: the SUSPEND trial

OBJECTIVE

To compare the safety and efficacy of three types of suburethral slings for the treatment of urodynamic stress incontinence.

METHODS

Following ethics approval, 195 (3 x 65) patients with urodynamic stress incontinence were randomly assigned to undergo suburethral slingplasty with the Tension-free Vaginal Tape (TVT; Gynecare, Ethicon, Somerville, NJ, USA), Intravaginal Sling (IVS; Tyco Healthcare, Mansfield, MA, USA), or Suprapubic Arc Sling (SPARC; American Medical Systems, Minnetonka, MN, USA). The patients were blinded to the type of sling implanted. MAIN OUTCOME MEASURES WERE: (1) operative and short-term complications; (2) pre- and postoperative symptomatology; and (3) pre- and postoperative urodynamic findings.

RESULTS

There was a statistically significant increased rate of sling protrusion (13.1% vs. 3.3% and 1.7%; P = 0.04) in the SPARC group when compared to TVT and IVS. Otherwise, there were no significant differences between the groups with respect to the incidences of other operative complications, patients' main subjective outcomes, satisfaction rates, or postoperative urodynamic findings. The overall objective stress incontinence cure rates were 87.9%, 81.5% and 72.4% for the TVT, IVS, SPARC groups respectively (P = 0.11).

CONCLUSIONS

All three slings appear quite successful for the treatment of stress incontinence. The SPARC tapes showed more sling protrusion complications and a trend towards lower objective cure rates; probably as a result of the insertion method used in this study which favoured a loose SPARC sling placement. The authors recommend that the SPARC slings be left tighter than TVT, or for the cough test to be carried out.

Two-dimensional and three-dimensional ultrasound imaging of suburethral slings

OBJECTIVE

Suburethral slings have become the most commonly performed anti-incontinence procedures in many developed countries. Three types of implant account for the majority of such surgery in Australia: tensionless vaginal tape (TVT), suprapubic arc procedure (SPARC) and intravaginal slingplasty (IVS). The aim of this study was to determine differences in position and mobility of these implants, and to determine whether such differences explain variations in clinical outcome.

METHODS

In a prospective randomized controlled trial, 195 women were randomized to TVT (n = 67), IVS (n = 64) or SPARC (n = 64). Thirteen women were excluded from the study due to incomplete preoperative data. Of the remaining 182 women, 146 (50 TVT, 48 IVS, 48 SPARC) were seen between 2 and 23 months after their procedure (80%). After an interview, two-dimensional (2D) and three-dimensional (3D) pelvic floor ultrasound was performed. 3D-volume analysis was carried out on a computer with the help of proprietary software (GE Kretz 4D View). Assessors of ultrasound data were blinded against group allocation.

RESULTS

There were no significant differences in subjective cure/improvement of stress or urge incontinence or overall subjective cure/improvement. Symptoms, including those of voiding dysfunction, did not vary between groups. All tapes could be imaged by ultrasound. TVT and SPARC were highly echogenic, with the SPARC generally flatter and of wider weave. The IVS seemed narrower and less echogenic. Tape position and mobility were similar, with a trend towards greater distances between tape and symphysis pubis and greater horizontal tape mobility in the SPARC group.

CONCLUSIONS

The three types of suburethral sling, namely TVT, SPARC and IVS, investigated using 2D and 3D ultrasound, have comparable short-term clinical and anatomical outcomes.

An evidence-based approach to the evaluation and management of stress incontinence in women

PURPOSE OF REVIEW

The aim of this article is to use evidence-based criteria to review recent publications on the evaluation and management of stress urinary incontinence in women.

RECENT FINDINGS

Longitudinal studies suggest that a familial predisposition towards stress urinary incontinence may exist. There is mounting evidence that cesarean section may play a protective role against pelvic floor damage due to labor, but this continues to be investigated. Objective parameters in the evaluation of stress urinary incontinence, such as questionnaires, pad test, and urodynamic studies, continue to undergo refinements to become more clinically relevant outcome tools. Non-invasive and minimally-invasive therapies for stress urinary incontinence are expanding. The search continues for the optimal non-autologous material in the pubovaginal sling procedure. Despite concerns over the use of synthetic material and better defined early complications, midurethral slings continue to enjoy popularity with short-term and intermediate success.

SUMMARY

Further research into the cause of stress urinary incontinence is necessary. There is still no unified protocol in the evaluation of the condition and its severity. Mid-urethral slings appear to be as efficacious as more established procedures (bladder neck suspensions, pubovaginal slings), but long-term results on safety and efficacy remain scarce.

An update on slings

PURPOSE OF REVIEW

The aim of this article is to review the year's literature on the treatment of female incontinence with suburethral slings.

RECENT FINDINGS

The use of slings to treat female stress urinary incontinence has had resurgence with new surgical techniques. The tension-free vaginal tape created in 1996 was the basis of most of the studies performed over the past year. The device was compared with more traditional surgical techniques as well as new techniques such as the trans-obturator tape. In addition the tension-free vaginal tape was examined in women with pelvic organ prolapse and older in age. The complications of the device are well known and several studies recounted these with an attempt to predict patients who will have success. Modifications to surgical technique are described to improve patient results as well as further analysis of outcomes with post-surgical urodynamic-based studies.

SUMMARY

The majority of papers center on the tension-free vaginal tape and comparing other methods of incontinence surgery with the tape's success. With 7-year data, the device has secured its place in the treatment of female stress incontinence. Newer methods are being explored and are now compared with the tension-free vaginal tape's outcomes.

The completely dry rate: A critical re-evaluation of the outcomes of slings

OBJECTIVE

To critically evaluate sling outcomes and revisit the realistic goals of anti-incontinence surgery.

MATERIALS AND METHODS

A review of an Institutional Review Board-approved prospective database revealed the outcomes of four different sling techniques that are utilized at our institution.

RESULTS

Four hundred ninety-eight patients had a mean follow-up varying from 9 to 24 months (range 6-50) after undergoing one of four different sling techniques utilized at our institution. The techniques had similar results with regard to completely dry rate, overall success rate, and rate of urgency regardless of the variation in follow-up time. Success was defined as completely dry or leakage = 1/week or = 70% improved by questionnaire in those patients who leaked 1/week. Success, by this definition, varied from 74.9% to 85.7%, but the completely dry rate varied from 36.1% to 45.2%. An additional 31.0% to 33.3% leaked = 1/week, and of the remaining patients, 24.5% to 44.4% considered themselves = 70% improved despite leakage > 1/week. Urge incontinence was reported by 24.4% to 33.3% of patients.

CONCLUSION

As surgeons, we must constantly reevaluate the outcomes and purposes of the procedures we perform on our patients.