Stress urinary incontinence after transobturator mesh for cystocele repair

[Treatment of Urinary incontinence associated with genital prolapse: Clinical practrice guidelines]

INTRODUCTION

Prolapse and urinary incontinence are frequently associated. Patente (or proven) stress urinary incontinence (SUI) is defined by a leakage of urine that occurs with coughing or Valsalva, in the absence of any prolapse reduction manipulation. Masked urinary incontinence results in leakage of urine occurring during reduction of prolapse during the clinical examination in a patient who does not describe incontinence symptoms at baseline. The purpose of this chapter is to consider on the issue of systematic support or not of urinary incontinence, patent or hidden, during the cure of pelvic organs prolapse by abdominal or vaginal approach.

MATERIAL AND METHODS

This work is based on an systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systematic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement).

RESULTS

In case of patent IUE, concomitant treatment of prolapse and SUI reduces the risk of postoperative SUI. However, the isolated treatment of prolapse can treat up to 30% of preoperative SUI. Concomitant treatment of SUI exposed to a specific overactive bladder and dysuria morbidity. The presence of a hidden IUE represents a risk of postoperative SUI, but there is no clinical or urodynamic test to predict individually the risk of postoperative SUI. Moreover, the isolated treatment of prolapse can treat up to 60% of the masked SUI. Concomitant treatment of the hidden IUE therefore exposes again to overtreatment and a specific overactive bladder and dysuria morbidity.

CONCLUSION

In case of overt or hidden urinary incontinence, concomitant treatment of SUI and prolapse reduces the risk of postoperative SUI but exposes to a specific overactive bladder and dysuria morbidity (NP3). The isolated treatment of prolapse often allows itself to treat preoperative SUI. We can suggest not to treat SUI (whether patent or hidden) at the same time, providing that women are informed of the possibility of 2 stages surgery (Grade C). © 2016 Published by Elsevier Masson SAS.

A Proximal Straining Mesh Location Is Associated With De Novo Stress Urinary Incontinence After Transobturator Mesh Procedures

OBJECTIVES

The purpose of this study was to explore the association between mesh location and de novo stress urinary incontinence (SUI) after transvaginal mesh procedures.

METHODS

We retrospectively analyzed a database of women who had received transvaginal mesh procedures for stage III or greater cystocele according to the Pelvic Organ Prolapse Quantification system. Only data for women who neither reported SUI preoperatively nor had received concomitant anti-incontinence surgery were included for analyses. The mesh location was investigated by sonography via the percentage of the urethra covered by mesh, defined as the number calculated by dividing the portion of the urethral length covered by mesh (the distance from the bladder neck to the point of the urethra, which was indicated by an imaginary line at the level of the lower [caudal] mesh end and perpendicular to the urethra) by the total urethral length (the distance from the bladder neck to the external urethral meatus) in the sagittal plane. The resting, straining, coughing, and squeezing mesh locations of women who did (n = 29) and did not (n = 54) report SUI at the 12-month follow-up were compared.

RESULTS

At the 12-month follow-up, women who reported SUI had a significantly smaller straining percentage of the urethra covered by mesh (mean ± SD, 28.5% ± 9.6%) compared with continent women (35.2% ± 15.8%), indicating a more proximal straining mesh location.

CONCLUSIONS

Sonography is useful in investigating the location of the transvaginal mesh. De novo SUI after transvaginal mesh procedures is associated with a more proximal straining mesh location.

Imaging of slings and meshes

The popularity of imaging in pelvic floor medicine continues to increase. Among the various modalities, ultrasound is superior as it is cheap, safe, easily accesible and simple, resulting in high patient compliance. It is the only technique that allows imaging of modern wide-weave polypropylene sling or mesh implants, and imaging of such implants is commonly required due to the popularity of surgical techniques that involve the placement of slings and meshes. This review article will discuss the role of translabial ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse.

The use of 3-dimensional ultrasound of the pelvic floor to predict recurrence risk after pelvic reconstructive surgery

AIMS

Female pelvic organ prolapse is a common condition. Prolapse recurrence following surgical treatment is a significant clinical issue. The aim of this study was to determine risk factors for recurrence, attempting to improve clinical practice by allowing better patient selection prior to surgery.

METHODS

This was a retrospective study utilising patient records and ultrasound volume imaging data sets obtained in four clinical audits following anterior colporrhaphy ± mesh. Prolapse recurrence was diagnosed clinically and by ultrasound; findings were analysed against potential predictors.

RESULTS

Symptomatic prolapse recurrence was demonstrated in 86 (26%), on clinical examination in 141 (42%) and on ultrasound in 113/334 women (34%). None of the tested predictors were predictive of recurrent symptoms, likely due to a lack of power. However, both levator avulsion and hiatal area on Valsalva were shown to be highly significant predictors of objective prolapse recurrence on clinical examination and ultrasound.

CONCLUSIONS

Prolapse recurrence following surgery is a common complaint. The state of the patient's pelvic floor muscle seems to be the strongest determinant.

Utilizing preoperative 20-minute pad testing with vaginal gauze packing for indicating concomitant midurethral sling during cystocele repair

OBJECTIVE

To investigate the feasibility of using preoperative 20-minute pad testing with vaginal gauze packing for cystocele reduction to indicate a concomitant midurethral sling during cystocele repair.

STUDY DESIGN

Retrospective review of the records of consecutive women with pelvic organ prolapse quantification≥stage II symptomatic cystocele who visited the urogynecologic outpatient clinics and underwent cystocele repair between July 2005 and December 2010. Only patients who underwent preoperative urodynamic studies and 20-minute pad testing with vaginal gauze packing for cystocele reduction were enrolled.

RESULTS

Twenty-one patients did not demonstrate any stress urinary incontinence. For evident stress urinary incontinence (>1g pad weight before reduction), the criterion of ≥8g pad weight before reduction was chosen for concomitant midurethral sling. For patients with occult stress urinary incontinence (≤1g pad weight before reduction), the criterion of ≥8g pad weight after reduction was chosen as an indication for concomitant midurethral sling. Among 22 patients with evident stress urinary incontinence (<8g) without concomitant midurethral sling, only one patient (4.5%) received a midurethral sling during the follow-up period (median follow-up interval: 30.5 months). Among 21 patients with occult stress incontinence but <8g after reduction without concomitant midurethral sling, only one patient (4.8%) received midurethral sling during the follow-up period (median follow-up interval: 38 months).

CONCLUSIONS

A preoperative 20-minute pad test with vaginal gauze packing for cystocele reduction is a feasible and practical method to decide for a concomitant midurethral sling.

Two-/three-dimensional transperineal sonography of complicated tape and mesh implants

Transperineal sonography (TPS) affords dynamic evaluation of suburethral slings using tensionless vaginal tape and mesh implants used to treat complications associated with surgical procedures of the pelvic floor. This review describes and illustrates the TPS findings in postoperative complications such as recurrent prolapse, cystocele, enterocele, and rectocele. The potential use of live 3-dimensional TPS to delineate the dynamics aspects of pelvic floor disorder is also mentioned.

State of the art: an integrated approach to pelvic floor ultrasonography

Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost-effective and widely available. In this review, pelvic floor ultrasonography, including two-dimensional (2D), three-dimensional (3D) and 4D imaging as well as transvaginal, endoanal and transperineal techniques, is discussed from a global and multicompartmental perspective, rather than using a compartmentalized approach. The role of the different sonographic modalities in the major disorders of the pelvic floor-urinary and fecal incontinence, pelvic organ prolapse and obstructed defecation syndrome-is evaluated critically.

Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up

OBJECTIVE

The objective of the study was to compare anterior colporrhaphy with and without a mesh.

STUDY DESIGN

Two hundred two women with anterior prolapse were assigned to undergo colporrhaphy alone or reinforced with a tailored polypropylene mesh. Before and 2, 12, 24, and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of anterior vaginal prolapse. Secondary outcomes were symptom resolution, reoperation, and mesh exposure.

RESULTS

Recurrences of anterior vaginal prolapse were noted in 40 of the 97 (41%) in the colporrhaphy group and 14 of 105 (13%) in the mesh group (P < .0001). The number needed to treat was thus 4. The proportion of symptomatic patients, including those with dyspareunia, did not differ between the groups. The mesh erosion rate was 19%.

CONCLUSION

At 3 year follow-up, anterior colporrhaphy with mesh reinforcement significantly reduced anatomic recurrences of anterior vaginal prolapse, but no difference in symptomatic recurrence were noted and the mesh erosion rate was high. The use of mesh was not associated with an increase in dyspareunia.

[How to manage multicompartment pelvic organe prolapse?]

Repair of pelvic organ prolapse by vaginal route may use native tissues or meshes, which have been in extensive use over the last decades. Traditional surgery, and particularly sacrospinous fixation, has been proven to be effective with long term follow-up with well-known specific risks that could be avoided by skilled surgeons on condition that he observes basic vaginal surgery rules. This surgery is still recommended as first choice in patients over 70 years old with high-grade prolapse. Nevertheless recurrence rate after high-grade cystocele repair using native tissues as been reported between 30 and 50% depending on the technique used. Mesh repair and particularly the use of mesh kits is a valid option in case of prolapse with cystocele behind the hymen, specifically in case of paravaginal defect. Meshes use is licit in patients with prolapse recurrence as well. In contrast, spread use of transvaginal meshes in young patients with grade 3 or 4 prolapse whom tissues have a poor quality, has to be considered very carefully because of the lack of knowledge about long term results and sexual outcome.