Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis

Management of mixed urinary incontinence: IUGA committee opinion

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is defined by the International Urogynecology Association (IUGA) and International Continence Society as the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing. It therefore implies the coexistence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). MUI is a heterogeneous diagnosis that requires an assessment of its individual components of SUI and UUI. Management requires an individualised approach to the symptom components. The aim of this review is to identify the assessment/investigations and management options for MUI.

METHODS

A working subcommittee from the IUGA Research & Development (R&D) Committee was created and volunteers invited from the IUGA membership. A literature review was performed to provide guidance focused on the recommended assessment and management of MUI. The document was then evaluated by the entire IUGA R&D Committee and IUGA Board of Directors and revisions made. The final document represents the IUGA R&D Committee Opinion.

RESULTS

The R&D Committee MUI opinion paper provides guidance on the assessment and management of women with MUI and summarises the evidence-based recommendations.

CONCLUSIONS

Mixed urinary incontinence is a complex problem and successful management requires alleviation of both the stress and urge components. Care should be individualised based on patient preferences. Further research is needed to guide patients in setting goals and to determine which component of MUI to treat first. The evidence for many of the surgical/procedural treatment options for MUI are limited and needs to be explored in more detail.

Factors predicting treatment success in mixed urinary incontinence treated with midurethral sling

OBJECTIVES

We aimed to investigate success rates and predictive factors for midurethral slings (MUS) in women with mixed urinary incontinence (MUI).

METHODS

Women with MUI (urodynamically diagnosed detrusor overactivity and stress urinary incontinence) treated with MUS between 2013 and 2020 were retrospectively investigated. Prior to MUS, all participants completed bladder diary and questionnaires and underwent a urodynamic study. Six months after surgery, patients were evaluated for lower urinary tract symptoms with pelvic examination, pad test, and the 8-item Overactive Bladder Questionnaire (OAB-V8) and the International Consultation on Incontinence Questionnaire-Short-Form (ICIQ-SF). Success rates after MUS were determined separately according to the predominant component of MUI. In addition, multivariable logistic regression analysis was used to determine the most important independent variables affecting the surgical outcome.

RESULTS

There were 117 participants. The overall MUI cure rate was 73.5%, but surgical success in the presence of postoperative urgency was 60.7%. Moreover, MUS success rate was 84.8% in those with preoperative stress-dominant MUI. However, the success rates for equally and urgency-dominant MUI were both 29.4%. Preoperative OAB-V8 score, symptom duration >9.5 years, and preoperative anticholinergic medication were risk factors for persistent urgency and urgency urinary incontinence (UUI) postoperatively (p < .05). In addition, diabetes mellitus (DM) for persistent urgency and voiding frequency (daily) for persistent UUI were predictive factors (p < .05).

CONCLUSIONS

MUS may be offered to women with stress-dominant MUI. However, postoperative urgency might change a patient's perception of treatment despite successful incontinence treatment. MUS does not appear to be a good option when MUI patients have a high OAB-V8 score, symptom duration >9.5 years, DM, or use of anticholinergic medication preoperatively.

Treatment outcome of women with urodynamic mixed urinary incontinence: an observational study

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is a common yet understudied condition. It remains a therapeutic challenge, with the presence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). There is limited information on the optimal management for women with urodynamic MUI (urodynamic stress incontinence and detrusor overactivity). We assessed the treatment outcome of pelvic floor muscle training (PFMT), medical treatment and surgery for women who were diagnosed with urodynamic MUI.

METHODS

A prospective observational study was carried out on women with urodynamic MUI from 2010 to 2018. All women underwent clinical assessment and standardised urodynamic evaluation. All women received PFMT from a specialised continence advisor as initial management. Antimuscarinics and/or continence surgery were considered according to the woman's response and symptoms after PFMT. Subjective outcome after each treatment modality was analysed.

RESULTS

A total of 198 women were included for analysis. All women received PFMT, 104 (52.5%) showing improvement in urinary incontinence. Eighty-seven (43.9%) women were offered antimuscarinics, of whom 58 (29.3%) showed subjective improvement in both SUI and UUI, and 10 (5%) reported a reduction in UUI but persistent SUI. A total of 55 (27.7%) women received surgical treatment, with 20 receiving continence procedures. Sixteen out of twenty (80%) of them reported improvement in both SUI and UUI. None reported worsening of urgency or UUI. Overall, across all treatment modalities, 73.8% of women showed improvement in both SUI and UUI.

CONCLUSION

Future analyses can help to inform which patients will have a higher success rate after each treatment modality and help focus treatment effort on those with a high risk of persistent symptoms. This will provide relevant data in counselling women, giving reasonable expectations and directing the management of women with urodynamic MUI.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Preoperative abdominal straining in uncomplicated stress urinary incontinence: is there a correlation with voiding dysfunction and de novo overactive bladder after mid-urethral sling procedures?

Objectives:

To evaluate the role of preoperative abdominal straining in predicting de novo overactive bladder (OAB) and voiding dysfunction in female patients undergoing suburethral taping by trans-obturator approach (TVT-O) for uncomplicated stress urinary incontinence (SUI).

Methods:

Data from patients who underwent TVT-O surgery for SUI were retrospectively analyzed. Inclusion criteria included: history of pure SUI. Exclusion criteria included previous surgery for urinary incontinence, pelvic radiation, pelvic surgery within the last 3 months, and anterior or apical pelvic organ prolapse (POP) ⩾ +1 cm. Voiding dysfunction has been defined through symptoms and or urodynamics (UDS) signs. Accordingly, patients were divided into group A and group B according to the presence of abdominal straining during UDS. Patients were observed clinically and with UDS at a 3-year follow-up.

Results:

A total of 192 patients underwent TVT-O surgery for uncomplicated SUI. Preoperative abdominal straining was identified in 60/192 patients (Group A: 31.2% vs Group B: 68.8%). Qmax was not different in the two groups (Group A: 19.5 vs Group B: 20.5 mL/s, p = 0.76). Demographics was similar for the two groups regarding age, parity. At 3-year follow-up, voiding dysfunction was reported in Group A: 9 and Group B: 8 patients (p = 0.056), de novo OAB was significantly reported in Group A: 23 and Group B: 26 patients (p = 0.007).

Conclusion:

Preoperative abdominal straining was found to be related to a significant incidence of de novo OAB. A significant correlation was not assessed for postoperative voiding dysfunction. Further studies may better define the impact of preoperative abdominal straining.

Two-year outcomes of surgeon-tailored trans obturator tape for female stress urinary incontinence: a randomized, comparative, trial with traditional trans obturator tape

Background

Previously, we presented the short-term outcomes of surgeon-tailored mesh in patients with SUI undergoing TOT. In this report, we aim to highlight the two-year outcomes of surgeon tailored mesh in terms of subjective and objective cure rates, as well as late complications.

Methods

We performed a randomized, open-label comparative trial that recruited women with SUI who were scheduled to undergo TOT. Eligible patients were randomly allocated in a 1:1 ratio to receive traditional TOT mesh or surgeon-tailored polyethylene mesh. All patients were followed up for two years.

Results

At the end of the follow-up, there were 13 women in the traditional TOT mesh group and 14 patients in the surgeon-tailored polyethylene mesh group. Concerning the primary outcome of the present study, the cure rate was 100% in the surgeon-tailored polyethylene mesh (n = 14) and 92.9% in the traditional TOT mesh group (p = 0.39). One woman reported improved symptoms in the traditional TOT mesh group. There were no reported failures in both groups. Concerning safety, the incidence of de novo urgency was 0% in the surgeon-tailored polyethylene mesh group, compared to 7.1% in the traditional TOT mesh group (p = 0.34). None of the women in both groups reported mesh erosions, dyspareunia, or need for reoperation.

Conclusion

Surgeon-tailored mesh for patients undergoing TOT is a cost-effective technique, which has comparable long-term outcomes, in terms of cure rate and complications, to the traditional costly meshes. Larger multicentre studies should confirm our results.

Efficacy of combination therapy of mid-urethral sling and low-dose Abobotulinumtoxin-A injection in mixed urinary incontinence

OBJECTIVES

To determine the outcome of combined transobturator tape sling (TOT) and low dose intradetrusor injection of Abobotulinumtoxin-A (Abobot-A, Dysport®) in women with mixed urinary incontinence (MUI).

METHODS

This randomized, active comparator-controlled, parallel-group, two-part clinical trial was conducted on women who had positive Valsalva leak point pressure (VLPP) + detrusor overactivity (DO), cough-associated DO. In Part 1, 20 women with MUI who had a failure of medical and behavioral therapies to cure MUI, randomized in two groups receiving TOT surgery alone, or in combination with Dysport® injection (n = 10 in each group), and then Part 2 was initiated as a prospective open-label on 40 more patients. We performed cystoscopy and injected 300 U of Dysport®in 20-30 intradetrusor injection sites in each patient.

RESULTS

The patient's symptoms in both groups decreased significantly after treatment. The symptoms were improved significantly in the combination therapy group according to the International Consultation on Incontinence Questionnaire-overactive bladder (ICIQ-OAB) questionnaire (p < .001), and International Consultation on Incontinence Questionnaire-urinary Incontinence-short form (ICIQ-UI-SF) (p = .041) in comparing with the TOT group. In Part 2, the mean score was 17.10 (4.75) for ICIQ-UI-SF and 9.22 (2.89) for ICIQ-OAB before the treatment. Twelve weeks after the intervention, the median (interquartile range: IQR) of ICIQ-OAB symptoms (2.0 [3.0]; p < .001) and ICIQ-UI-SF decreased, too (1. 0 [2.0]; p < .001). Considering improvement using Patient Global Impression of Improvement scale, 46 (92.0%) stated that they had significant subjective improvement of their symptoms.

CONCLUSIONS

Combination therapy was accompanied with a promising effect in the patients with MUI according to the results of standardized questionnaires. However, further studies with controlled arms are recommended.

[Non-neurological overactive bladder and pelvic-perineal pathology in women]

INTRODUCTION

The aim was to synthesize current knowledge on overactive bladder (OAB) and female pelvic-perineal diseases.

METHOD

A systematic literature review based on PubMed, Embase and Google Scholar was conducted in April 2020.

RESULTS

Women with pelvic organ prolapse very often have OAB. Prolapse surgery should be considered if the prolapse is symptomatic and never be indicated in case of overactive bladder symptoms solely. In case of symptomatic prolapse and OAB, pessary and surgical treatments are effective on both pathologies up to 71 % of the cases. OAB may occur in parallel or as part of a menopausal genitourinary syndrome. In the latter case, only local estrogen therapy is effective. OAB may occur alongside stress urinary incontinence (SUI) or be integrated into mixed urinary incontinence. The initial treatment should be based on the most troublesome symptoms. In case of SUI, the outcome of surgical treatment on OAB remains uncertain. De novo, OAB follows prolapse or SUI surgery. It requires investigations to exclude urinary tract infection, bladder outlet obstruction or erosion. The treatment is the same as OAB.

CONCLUSION

The clinician's challenge is to draw a balance between the OAB and a pelvic-perineal pathology in order to adapt the treatment.

Overactive bladder syndrome - focus onto detrusor overactivity

INTRODUCTION AND HYPOTHESIS

To determine in patients with overactive bladder (OAB), urodynamic differences as well to compare the characteristics of patient's, with presence of detrusor overactivity on urodynamics with those with absence of detrusor overactivity.

METHODS

Taking into account the urodynamic findings, the patients with OAB symptoms were categorized into one of two groups: group 1 (with detrusor overactivity) or group 2 (without detrusor overactivity), and comparative analyses for both groups were performed (epidemiological data, patient history, urodynamic criteria, bladder diaries, IC-OAB, IC-OABqol - questionnaires).

RESULTS

There was a significant difference in age as well in the disease duration between group 1 and group 2. Although the mean number of micturitions and nocturia episodes was comparable, the numbers of urgency episodes differed significantly. The number of 'wet' patients was significantly higher in the group 1 with the significantly higher number of incontinence episodes. Group 1 demonstrated higher OAB symptom scores and higher impact on the patients' quality of life.

CONCLUSIONS

More than half of the patients complaining of urgency-frequency do not have detrusor overactivity upon urodynamic testing, and only half have detrusor overactivity that correlates with urge perception. The patients with no detrusor overactivity appear to be significantly younger and have fewer symptoms, with a less pronounced impact on quality of life. They also have significantly higher maximal bladder capacity. This data supports the hypothesis that both conditions are different phases (early and late) of the same pathological state, or may be two different subtypes of OAB.

Effects of the transobturator tape procedure on overactive bladder symptoms and quality of life: a prospective study

Introduction:

This study aimed to evaluate the effects of transobturator tape (TOT) on overactive bladder (OAB) symptoms and quality of life.

Materials and Methods:

Patients with stress-predominant mixed urinary incontinence (MUI) who had undergone TOT procedures were considered candidates for this research. Preoperative assessment included anamnesis, pelvic examination, cough stress test (CST), and validated symptom severity and quality of life (QoL) questionnaires. The primary outcome, improvement and cure rates of OAB symptoms were determined based on the patient's baseline scores in symptom-related questions in OAB-V8. Secondary outcomes included the success rates of SUI, changes in the QoL score and patient satisfaction rates.

Results:

A total of 104 patients were included in the study. Sixty-two patients underwent TOT placement alone, and 42 patients underwent TOT placement along with prolapse surgery. The mean follow-up period of the patients was 30.47 months range: 13-52 months. At the first-year follow-up, 52 patients (50.0%) and 59 patients (56.7%) reported cure in preoperative urgency and urgency incontinence, respectively. The objective and subjective cure rates were 96.2% and 56.7%, respectively. A total of 80.7% of the cases had a 15-point improvement in QoL scores.

Conclusions:

MUS is not only a gold standard treatment in SUI but also presents as a promising treatment modality in stress-dominant MUI. Although the improvement rates of OAB symptoms significantly decrease over time, QoL and patient satisfaction rates remain higher than any other treatment in this patient group at the third-year follow-up.

Credé maneuver to adjust tape tension during trans-obturator tape mid-urethral sling in mixed urinary incontinence

INTRODUCTION AND HYPOTHESIS

To evaluate the efficacy of intraoperative extrinsic manual bladder compression (Credé maneuver) for trans-obturator tape adjustment during mid-urethral sling surgery in women with stress urinary incontinence and those with mixed urinary incontinence.

METHODS

The study included 148 randomly selected women who underwent mid-urethral sling surgery with trans-obturator tape for stress urinary incontinence between January 2016 and May 2017. Subgroup analysis of 66 women with mixed urinary incontinence included 43 patients from the Credé maneuver group and 23 from the non-Credé maneuver group. In the Credé maneuver group, the pattern of urine leakage was determined during the Credé maneuver, and tape tension was adjusted according to the pattern.

RESULTS

The cure rate was 86.6% and improved rate was 11.9% in the Credé maneuver patients. The cure rate was 50.6% and improved rate was 38.3% in the non-Credé maneuver patients. The success rate was significantly higher in the Credé than in the non-Credé maneuver group (p = 0.023). In subgroup analysis of patients with mixed urinary incontinence, the cure rate was 81.4% and improved rate was 16.3% in the Credé maneuver group. The cure rate was 43.5% and improved rate was 47.8% in the non-Credé maneuver group. The cure rate was significantly higher in the Credé maneuver group (p = 0.007).

CONCLUSIONS

Intraoperative trans-obturator tape adjustment using the Credé maneuver to identify the leaking pattern significantly improved the success rate in women with mixed urinary incontinence, and Credé maneuver-directed adjustment significantly improved the cure rate.

Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial

IMPORTANCE

Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman's quality of life. Studies evaluating treatments to simultaneously improve both components are lacking.

OBJECTIVE

To determine whether combining behavioral and pelvic floor muscle therapy with midurethral sling is more effective than sling alone for improving mixed urinary incontinence symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial involving women 21 years or older with moderate or severe stress and urgency urinary incontinence symptoms for at least 3 months, and at least 1 stress and 1 urgency incontinence episode on a 3-day bladder diary. The trial was conducted across 9 sites in the United States, enrollment between October 2013 and April 2016; final follow-up October 2017.

INTERVENTIONS

Behavioral and pelvic floor muscle therapy (included 1 preoperative and 5 postoperative sessions through 6 months) combined with midurethral sling (n = 209) vs sling alone (n = 207).

MAIN OUTCOMES AND MEASURES

The primary outcome was change between baseline and 12 months in mixed incontinence symptoms measured by the Urogenital Distress Inventory (UDI) long form; range, 0 to 300 points; minimal clinically important difference, 35 points, with higher scores indicating worse symptoms.

RESULTS

Among 480 women randomized (mean [SD] age, 54.0 years [10.7]), 464 were eligible and 416 (86.7%) had postbaseline outcome data and were included in primary analyses. The UDI score in the combined group significantly decreased from 178.0 points at baseline to 30.7 points at 12 months, adjusted mean change -128.1 points (95% CI, -146.5 to -109.8). The UDI score in the sling-only group significantly decreased from 176.8 to 34.5 points, adjusted mean change -114.7 points (95% CI, -133.3 to -96.2). The model-estimated between-group difference (-13.4 points; 95% CI, -25.9 to -1.0; P = .04) did not meet the minimal clinically important difference threshold. Related and unrelated serious adverse events occurred in 10.2% of the participants (8.7% combined and 11.8% sling only).

CONCLUSIONS AND RELEVANCE

Among women with mixed urinary incontinence, behavioral and pelvic floor muscle therapy combined with midurethral sling surgery compared with surgery alone resulted in a small statistically significant difference in urinary incontinence symptoms at 12 months that did not meet the prespecified threshold for clinical importance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01959347.

De novo or resolved urgency and urgency urinary incontinence after midurethral sling operations: How can we properly counsel our patients?

Purpose

To evaluate de novo and resolved urgency and urgency urinary incontinence (UUI) after midurethral sling operations in patients with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI).

Materials and Methods

Patients who underwent midurethral sling operations because of SUI and MUI between January 2012 and December 2016 were reviewed. Patients were divided into three groups (pure SUI, SUI with urgency, and MUI). Patients with MUI were subcategorized as SUI predominant, equivalent, and UUI predominant. Postoperative de novo, persistent or disappearance of urgency or UUI were compared.

Results

A total of 334 patients were included: 76 with pure SUI, 78 with SUI with urgency, and 180 with MUI. In the MUI group, 138 patients were SUI predominant, 12 patients were equivalent, and 30 patients were UUI predominant. De novo urgency developed in 5 patients (6.6%) in the pure SUI group. In the SUI with urgency group, 51 patients (65.4%) became urgency-free, and 3 (3.8%) developed de novo UUI. UUI resolved in 135 patients (75.0%): 110 (79.7%) in the SUI-predominant group, 9 (75.0%) in the equivalent group, and 16 (53.3%) in the UUI-predominant group. The patients' preoperative perception of predominant UUI was the predictive factor for persistent UUI in the multivariate analysis (hazard ratio, 5.722; p=0.001).

Conclusions

De novo urgency and UUI developed in a relatively small number of patients after a midurethral sling operation. The resolution rate of UUI was significantly low in patients who had previous pelvic surgery or who preoperatively perceived UUI as a more bothersome symptom.

A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment

CONTEXT

Current literature suggests that several pathophysiological factors and mechanisms might be responsible for the nonspecific symptom complex of overactive bladder (OAB).

OBJECTIVE

To provide a comprehensive analysis of the potential pathophysiology underlying detrusor overactivity (DO) and OAB.

EVIDENCE ACQUISITION

A PubMed-based literature search was conducted in April 2018, to identify randomised controlled trials, prospective and retrospective series, animal model studies, and reviews.

EVIDENCE SYNTHESIS

OAB is a nonspecific storage symptom complex with poorly defined pathophysiology. OAB was historically thought to be caused by DO, which was either "myogenic" (urgency initiated from autonomous contraction of the detrusor muscle) or "neurogenic" (urgency signalled from the central nervous system, which initiates a detrusor contraction). Patients with OAB are often found to not have objective evidence of DO on urodynamic studies; therefore, alternative mechanisms for the development of OAB have been postulated. Increasing evidence on the role of urothelium/suburothelium and bladder afferent signalling arose in the early 2000s, emphasising an afferent "urotheliogenic" hypothesis, namely, that urgency is initiated from the urothelium/suburothelium. The urethra has also recently been regarded as a possible afferent origin of OAB-the "urethrogenic" hypothesis. Several other pathophysiological factors have been implicated, including metabolic syndrome, affective disorders, sex hormone deficiency, urinary microbiota, gastrointestinal functional disorders, and subclinical autonomic nervous system dysfunctions. These various possible mechanisms should be considered as contributing to diagnostic and treatment algorithms.

CONCLUSIONS

There is a temptation to label OAB as "idiopathic" without obvious causation, given the poorly understood nature of its pathophysiology. OAB should be seen as a complex, multifactorial symptom syndrome, resulting from multiple potential pathophysiological mechanisms. Identification of the underlying causes on an individual basis may lead to the definition of OAB phenotypes, paving the way for personalised medical care.

PATIENT SUMMARY

Overactive bladder (OAB) is a storage symptom syndrome with multiple possible causes. Identification of the mechanisms causing a patient to experience OAB symptoms may help tailor treatment to individual patients and improve outcomes.

Usefulness of Ospemifene in the treatment of urgency in menopausal patients affected by mixed urinary incontinence underwent mid-urethral slings surgery

The aim of this study was to assess the effectiveness and safety of Ospemifene in the improvement of urgency component in women affected by mixed urinary incontinence (MUI) who underwent surgery with mid-urethral sling (MUS). Eighty-one patients with MUI underwent surgical intervention with MUS were enrolled. After surgical intervention 38 patients received Ospemifene 60 mg one tablet daily per os for 12 weeks. Physical examination, 3-day voiding diary, urodynamic testing were performed at the start and the follow-up after 12 weeks in the Trans-Obturator-Tape (TOT)-Alone group and TOT-Ospemifene. Patients completed the Overactive Bladder Symptom and Health-Related Quality of Life Short-Form (OAB-Q SF), International Consultation on Incontinence Questionnaire (ICIQ-UI-SF), and King' s Health Questionnaire (KHQ). A significant difference between the two groups was observed in peak flow (ml/s), in first voiding desire (ml), in maximum cystometric capacity (ml), and in detrusor pressure at peak flow (cmH₂O) at urodynamic evaluation. A significative difference between the two groups at voiding diary was observed in the mean number of voids, urgent micturition episodes/24 h, urge urinary incontinence, and in nocturia events. The OAB-Q symptoms and OAB-Q (HRQL) scores after 12 weeks showed a significative difference between the two groups. Ospemifene is an effective potential therapy after MUSs in women with MUI improving urgency symptoms and quality of life.

Comparison between erbium-doped yttrium aluminum garnet laser therapy and sling procedures in the treatment of stress and mixed urinary incontinence

Purpose

Stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) lead to poor quality of life. In Japan, urinary incontinence is treated with tension-free vaginal tape (TVT) or transobturator tape (TOT) sling procedures, which involves inserting a synthetic material; however, problems arise with artificial mesh in some instances, requiring new treatment methods. Hence, laser therapy, whereby an erbium-doped yttrium aluminum garnet laser is directed into the vagina and urethra, may be useful. The study aimed to compare the effects of these three treatments.

Methods

Subjects included patients who received TVT, TOT, or laser therapy (n = 50 each). The 1-h pad test, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and overactive bladder symptom score were used to assess the patients before and 12 months after treatment. For laser therapy, a probe was inserted into the vagina after applying a local anesthetic to the vaginal wall, and irradiation was performed for 20 min at a wavelength of 2940 nm. This treatment was performed three times every alternate month.

Results

As per the 1-h pad test and ICIQ-SF, the TVT, TOT, and laser therapy groups showed comparable improvements in SUI. For patients with MUI, some in the TVT and TOT groups showed exacerbation; however, all patients in the laser therapy group tended to improve.

Conclusions

The efficacy of laser therapy for urinary incontinence was confirmed. This is the first study to report on the effect of laser therapy on urinary incontinence in Japanese women.

Structured behavioral treatment research protocol for women with mixed urinary incontinence and overactive bladder symptoms

AIMS

The primary aim is to provide detailed rationale and methodology for the development and implementation of a perioperative behavioral/pelvic floor exercise research protocol for women who self-chose surgical intervention and who may or may not have been offered behavioral treatments initially. This protocol is part of the ESTEEM trial (Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence Trial) which was designed to determine the effect of a combined surgical and perioperative behavioral/pelvic floor exercise intervention versus surgery alone on improving mixed urinary incontinence (MUI) and overactive bladder (OAB) symptoms.

METHODS

As part of a multi-site, prospective, randomized trial of women with MUI electing midurethral sling (MUS) surgical treatment, participants were randomized to a standardized perioperative behavioral/pelvic floor exercise intervention + MUS versus MUS alone. The specific behavioral intervention included: education on voiding habits, pelvic floor muscle training (PFMT), bladder training (BT), strategies to control urgency and reduce/prevent urinary symptoms, and monitoring/promoting adherence to behavioral recommendations. To ensure consistency across all eight research sites in the pelvic floor disorders network (PFDN), selective behavioral treatments sessions were audiotaped and audited for protocol adherence.

RESULTS

The behavioral intervention protocol includes individualization of interventions using an algorithm based on pelvic floor muscle (PFM) assessment, participant symptoms, and findings from the study visits. We present, here, the specific perioperative behavioral/pelvic floor exercise interventions administered by study interventionists.

CONCLUSIONS

This paper details a perioperative behavioral/pelvic floor exercise intervention research study protocol developed for women undergoing surgery for MUI.

The Efficiency and Safety of Tension-Free Vaginal Tape (TVT) Abbrevo Procedure Versus TVT Exact in the Normal Weight and Overweight Patients Affected by Stress Urinary Incontinence

OBJECTIVE

To compare the efficacy between 2 different slings in normal weight and overweight women.

METHODS

Of 426 women, 220 (119 normal weight and 101 overweight) accepted the tension-free vaginal tape Abbrevo (TVT-A) and 206 (114 normal weight and 92 overweight) accepted the TVT Exact (TVT-E) procedure. Data collected contained the subjective efficiency, objective efficiency International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Incontinence Quality of Life Questionnaire (I-QOL), Pelvic Floor Impact Questionnaire-Short Form (PFIQ-7), Urogenital Distress Inventory-Short Form (UDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-Short Form (PISQ)-12 at 36 months after surgery.

RESULTS

In the normal weight patients, the subjectively and objectively cured rates were all high in both TVT-A and TVE-E (94.12% and 95.61% in objective result; 92.44% and 94.74% in subjective result). In addition, the score of I-QOL, PFIQ-7, and UDI-6 have significantly changed (P <.00001 in each one). In the overweight patients, the subjective and objective efficiency were better in TVT-E than TVT-A. Moreover, the score of I-QOL, PFIQ-7, and UDI-6 of overweight women have significantly changed only in the TVT-E (P <.00001 in each one), whereas both procedures have no effect on the score of PISQ-12 (P = .063 and P = .180 for TVT-A and TVT-E, respectively).

CONCLUSION

The TVT-E might be a better choice for the overweight patient than TVT-A.

The management of mixed urinary incontinence in women

Mixed urinary incontinence is a common diagnosis among women with urinary leakage and is often present in women who are unable to characterize their incontinence. Research and optimized clinical treatment of these patients is limited by the challenges in objectively defining and stratifying this population. The evaluation of these patients should follow the same general principles as any assessment of any women with incontinence; however, it is essential to define whether urge or stress incontinence is the predominant symptom. Urodynamics (UDS) may be helpful in this regard and may help predict surgical outcomes. Behavioural therapy, weight loss, and pelvic floor muscle therapy are usually appropriate initial management strategies. In postmenopausal women, vaginal estrogen can be considered, and in women with equal parts stress and urge incontinence or urge-predominant mixed incontinence, a trial of anticholinergics or beta-3 agonists is appropriate. In women with stress-predominant or equal parts stress and urge incontinence, stress incontinence surgery can be considered, with the caveat that outcomes are generally worse among women with more severe levels of urgency, success rates may not be as durable, and a significant proportion of women may need additional medical therapy.

Mixed urinary incontinence- what should we treat first?

Mixed urinary incontinence (MUI) is defined as ‘the involuntary loss of urine associated with urgency and also with effort or physical exertion, or on sneezing or coughing’. It is highly prevalent, increases with age and affects women more than men. It has a significant negative impact on health-related quality of life (HRQL). Additionally, treatment of mixed urinary incontinence places a large financial burden on both individuals and the NHS. Optimal management of this common condition is contested – should we treat the urge urinary incontinence (UUI), stress urinary incontinence (SUI) or predominant symptom first? At the 2015 BAUS Section of Female, Neurological and Urodynamic Urology this subject was debated. Based on a common scenario, the authors of the debate present the arguments for treating the urge urinary incontinence component, stress urinary incontinence component or the predominant symptom of mixed urinary incontinence first, before making recommendations for current practice.

Long-term outcomes for transobturator tension-free vaginal tapes in women with urodynamic mixed urinary incontinence

AIMS

To assess the long-term patient reported outcomes following transobturator tension-free vaginal tapes (TO-TVT) in women with urodynamic mixed urinary incontinence (MUI).

METHODS

A secondary analysis of the 9-year follow-up of the E-TOT study: 341 women with predominant stress urinary incontinence symptoms were randomized to undergo either inside-out or outside-in TO-TVT between April 2005 and April 2007. Forty-eight women had preoperative urodynamic MUI and were available for 9-year follow-up. Primary outcome was the patient-reported success rate defined as very/much improved on Patient's Global Impression of Improvement PGI-I. Secondary outcomes included impact on women's quality of life, sexual function, overactive bladder symptoms,and late adverse events. Statistical analysis was performed using SPSS v.23.

RESULTS

Forty-eight women completed the 9-year follow-up, with adjusted response rate of 63%. The success based on the PGI-I was 64.6% (n = 31), with a further 14.6% (n = 7) who reported "improved." There was no significant difference between groups (OR 1.11; 95%CI 0.33, 3.70; P > 0.999). Clinically significant improvement in quality of life was found in 85.3%. Cure of urgency and UUI was reported by 35% and 41%, whereas worsening was reported in 6.5% and 2.3%, respectively. One patient reported chronic groin/leg pain. The small sample size and the sizeable loss to follow-up are limitations in this study.

CONCLUSIONS

This is the first study to report the long-term outcomes of TO-TVT in women with urodynamic MUI; TO-TVT is associated with a good and sustained patient-reported success rate in women with MUI up to 9-years follow-up.

Medium-term results of Mini-arc for urinary stress incontinence in ambulatory patients under local anesthesia

OBJECTIVE

To evaluate the medium-term outcome and patient's satisfaction after Single-incision mini-sling (SIMS) procedure done under local anesthesia in ambulatory set up for patients with stress urinary incontinence (SUI).

MATERIALS AND METHODS

This is a retrospective cohort study, including all patients submitted to SIMS procedure for SUI with MiniArc (AMS, U.S.A) without concomitant surgery between January 2011 and March 2013. Patients were followed up during 12 months after surgery and once a year subsequently. Telephone interviews were conducted to evaluate patient satisfaction. Outcome masseurs included: SUI cure rate, urinary urge incontinence (UUI) cure rate in patients with mixed urinary incontinence (MUI), intra and post-operative complications and patient satisfaction.

RESULTS

Ninety-three patients were included with mean follow-up of 23 months. Fifty percent had MUI with predominant SUI. The cure rates of SUI (objective and subjective) were 89%. UUI was cured in 40% of patients. No major complications occur, neither voiding obstruction or groin pain. Telephone interviews conducted after 26 months on average revealed high satisfaction rate from the procedure (8.8 out of 10) and from the local anesthesia. Visual analog scale (VAS) rating was low during and after the procedure (2.38 and 2.69 respectively).

CONCLUSIONS

The SIMS procedure is safe and highly effective for SUI and it can be performed successfully under local anesthesia in an ambulatory setup.

Predicting urinary incontinence after surgery for pelvic organ prolapse

PURPOSE OF REVIEW

Many women choosing to have surgery for pelvic organ prolapse also choose to undergo continence surgery. This review focuses on available evidence that clinicians may use to counsel patients when choosing whether to perform continence surgery and how predictive analytic tools improve this decision-making process.

RECENT FINDINGS

Midurethral sling, Burch cystourethropexy and bladder neck sling are highly effective for the surgical treatment of stress urinary incontinence. Trials demonstrate that continence surgery may be routinely performed to reduce the risk of postoperative incontinence in women undergoing surgery for pelvic organ prolapse with or without preoperative stress urinary incontinence. Although these procedures are effective and well tolerated on average, media concerns, regulatory warnings and litigation reinforce the need for a balanced discussion regarding efficacy and potential adverse events directed at the individual patient during the preoperative visit. Advances in predictive analytics allow surgeons to quantitate individual risk using algorithms that tailor estimates for the individual patient and facilitate shared understanding of risks and benefits. These models are less prone to cognitive biases and frequently outperform experienced clinicians.

SUMMARY

This review discusses how predictive analytic tools can be used to improve decisions about continence surgery in the woman planning to undergo prolapse surgery.

Bladder ultrasonography for diagnosing detrusor overactivity: test accuracy study and economic evaluation

BACKGROUND

Urodynamics (UDS) has been considered the gold standard test for detrusor overactivity (DO) in women with an overactive bladder (OAB). Bladder ultrasonography to measure bladder wall thickness (BWT) is less invasive and has been proposed as an alternative test.

OBJECTIVES

To estimate the reliability, reproducibility, accuracy and acceptability of BWT in women with OAB, measured by ultrasonography, in the diagnosis of DO; to explore the role of UDS and its impact on treatment outcomes; and to conduct an economic evaluation of alternative care pathways.

DESIGN

A cross-sectional test accuracy study.

SETTING

22 UK hospitals.

PARTICIPANTS

687 women with OAB.

METHODS

BWT was measured using transvaginal ultrasonography, and DO was assessed using UDS, which was performed blind to ultrasonographic findings. Intraobserver and interobserver reproducibility were assessed by repeated measurements from scans in 37 and 57 women, respectively, and by repeated scans in 27 women. Sensitivity and specificity were computed at pre-specified thresholds. The smallest real differences detectable of BWT were estimated using one-way analysis of variance. The pain and acceptability of both tests were evaluated by a questionnaire. Patient symptoms were measured before testing and after 6 and 12 months using the International Consultation on Incontinence modular Questionnaire Overactive Bladder (short form) (ICIQ-OAB) questionnaire and a global impression of improvement elicited at 12 months. Interventions and patient outcomes were analysed according to urodynamic diagnoses and BWT measurements. A decision-analytic model compared the cost-effectiveness of care strategies using UDS, ultrasonography or clinical history, estimating the cost per woman successfully treated and the cost per quality-adjusted life-year (QALY).

RESULTS

BWT showed very low sensitivity and specificity at all pre-specified cut-off points, and there was no evidence of discrimination at any threshold (p = 0.25). Extensive sensitivity and subgroup analyses did not alter the interpretation of these findings. The smallest detectable difference in BWT was estimated to be 2 mm. Pain levels following both tests appeared relatively low. The proportion of women who found the test 'totally acceptable' was significantly higher with ultrasonography than UDS (81% vs. 56%; p < 0.001). Overall, subsequent treatment was highly associated with urodynamic diagnosis (p < 0.0001). There was no evidence that BWT had any relationship with the global impression of improvement responses at 20 months (p = 0.4). Bladder ultrasonography was more costly and less effective than the other strategies. The incremental cost-effectiveness ratio (ICER) of basing treatment on the primary clinical presentation compared with UDS was £491,500 per woman successfully treated and £60,200 per QALY. Performing a UDS in those women with a clinical history of mixed urinary incontinence had an ICER of £19,500 per woman successfully treated and £12,700 per QALY compared with the provision of urodynamic to all women. For DO cases detected, UDS was the most cost-effective strategy.

CONCLUSION

There was no evidence that BWT had any relationship with DO, regardless of the cut-off point, nor any relationship to symptoms as measured by the ICIQ-OAB. Bladder ultrasonography has no diagnostic or prognostic value as a test in this condition. Furthermore, despite its greater acceptability, BWT measurement was not sufficiently reliable or reproducible.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46820623.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 7. See the NIHR Journals Library website for further project information.

Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study

Objective

To compare the cost-effectiveness of bladder ultrasonography, clinical history, and urodynamic testing in guiding treatment decisions in a secondary care setting for women failing first line conservative treatment for overactive bladder or urgency-predominant mixed urinary incontinence.

Design

Model-based economic evaluation from a UK National Health Service (NHS) perspective using data from the Bladder Ultrasound Study (BUS) and secondary sources.

Methods

Cost-effectiveness analysis using a decision tree and a 5-year time horizon based on the outcomes of cost per woman successfully treated and cost per Quality-Adjusted Life-Year (QALY). Deterministic and probabilistic sensitivity analyses, and a value of information analysis are also undertaken.

Results

Bladder ultrasonography is more costly and less effective test-treat strategy than clinical history and urodynamics. Treatment on the basis of clinical history alone has an incremental cost-effectiveness ratio (ICER) of £491,100 per woman successfully treated and an ICER of £60,200 per QALY compared with the treatment of all women on the basis of urodynamics. Restricting the use of urodynamics to women with a clinical history of mixed urinary incontinence only is the optimal test-treat strategy on cost-effectiveness grounds with ICERs of £19,500 per woman successfully treated and £12,700 per QALY compared with the treatment of all women based upon urodynamics. Conclusions remained robust to sensitivity analyses, but subject to large uncertainties.

Conclusions

Treatment based upon urodynamics can be seen as a cost-effective strategy, and particularly when targeted at women with clinical history of mixed urinary incontinence only. Further research is needed to resolve current decision uncertainty.

Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) can be a challenging condition to manage. We describe the protocol design and rationale for the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial, designed to compare a combined conservative and surgical treatment approach versus surgery alone for improving patient-centered MUI outcomes at 12 months.

METHODS

ESTEEM is a multisite, prospective, randomized trial of female participants with MUI randomized to a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone. We describe our methods and four challenges encountered during the design phase: defining the study population, selecting relevant patient-centered outcomes, determining sample size estimates using a patient-reported outcome measure, and designing an analysis plan that accommodates MUI failure rates. A central theme in the design was patient centeredness, which guided many key decisions. Our primary outcome is patient-reported MUI symptoms measured using the Urogenital Distress Inventory (UDI) score at 12 months. Secondary outcomes include quality of life, sexual function, cost-effectiveness, time to failure, and need for additional treatment.

RESULTS

The final study design was implemented in November 2013 across eight clinical sites in the Pelvic Floor Disorders Network. As of 27 February 2016, 433 total/472 targeted participants had been randomized.

CONCLUSIONS

We describe the ESTEEM protocol and our methods for reaching consensus for methodological challenges in designing a trial for MUI by maintaining the patient perspective at the core of key decisions. This trial will provide information that can directly impact patient care and clinical decision making.

Efficacy of Transurethral Vesical Deafferentation with Mid-Urethral Sling Operation for Female Mixed Urinary Incontinence: Preliminary Results

OBJECTIVES

In female patients with mixed urinary incontinence (MUI), a mid-urethral sling operation (MUS) is an effective treatment for stress urinary incontinence (SUI), but urgency urinary incontinence (UUI) frequently persists. We developed a novel transurethral vesical deafferentation procedure and assessed its efficacy in these patients.

METHODS

From December 2009 to December 2012, 41 female patients with MUI were enrolled prospectively. After baseline evaluation including urodynamic study and symptom questionnaires (Overactive Bladder Symptom Score (OABSS) and International Consultation on Incontinence Questionnaire - Overactive Bladder [ICIQ-OAB]), patients in the study group underwent both the deafferentation procedure and MUS, and those in the control group underwent MUS alone. The outcome was assessed 3 months after the operation by subjective assessment of SUI and OABSS.

RESULTS

At 3 months, the treatment response rate of UUI was significantly higher in the study group than in the control group; UUI was improved in 80 and 57.1% of patients, respectively. SUI was cured in most patients. There were no serious complications, such as voiding symptom and urinary retention.

CONCLUSIONS

The transurethral vesical deafferentation procedure combined with MUS is effective for the treatment of MUI. The procedure is simple, safe and efficacious in treating urgency and UUI without affecting voiding function.

A Large Retrospective Series of Pregnancy and Delivery After Midurethral Sling for Stress Urinary Incontinence

OBJECTIVES

The aim of this study was to review the complete medical course, including safety, efficacy, and medical decision making, of patients who delivered a pregnancy after the placement of midurethral sling (MUS) within a large health maintenance organization.

METHODS

We conducted a retrospective case series of patients within the Northern and Southern California Permanente Medical Group who were identified based on procedural codes for placement of MUS for stress urinary incontinence. Electronic medical records with MUS code were referenced against records of live births within the health care system. Demographic and clinical data were abstracted through extensive, standardized physician review of the electronic medical records of all identified patients.

RESULTS

Twenty-six patients were identified and included in analysis. Sixteen patients had a retropubic MUS, and 10 had a transobturator MUS. Twenty-one of 26 patients reported subjective resolution of urinary incontinence after MUS. Fourteen of the 25 first deliveries after MUS were cesarean section (CS). Of these, 5 CS were elective primary for the indication of previous MUS, 5 were elective repeat CS, and the remaining 4 were for fetal indications. Eleven patients had spontaneous vaginal deliveries. There were no MUS-related pregnancy complications. One patient developed recurrent stress urinary incontinence postpartum, for which she underwent repeat MUS within a year resulting in cure of incontinence.

CONCLUSIONS

This case series corroborates previous series demonstrating the safety and durability of MUS after subsequent pregnancy.

Factors affecting medication discontinuation in patients with overactive bladder symptoms

OBJECTIVE

To find out the factors affecting medication discontinuation in patients with overactive bladder (OAB) symptoms.

METHODS

The clinical data of 125 patients with OAB symptoms who had taken antimuscarinics and behavioral therapy were retrospectively reviewed. Antimuscarinics related outcomes were evaluated by an independent observer with telephone interview. All patients were asked about duration of medication and reason of continuation or discontinuation of antimuscarinics. To determine pre-treatment factors predicting self-report discontinuation of antimuscarinics, variables of only those with P-values <0.25 on the univariate analysis were included in the Cox proportional hazard modeling.

RESULTS

Mean follow-up was 39.6 months and the proportion of discontinuation of antimuscarinics was 60.0% (75/125). The mean duration of medication was 21.2 months in the continuation group and 3.3 months in the discontinuation group. The reasons of discontinuation of antimuscarinics were improved OAB symptoms (46.7%), tolerable OAB symptoms (33.3%), no change of OAB symptoms (1.3%), side-effects (8.0%) and no desire to take long-term medication (10.7%). The variables affecting remaining cumulative probability of antimuscarinics were age, history of anti-incontinence surgery or vaginal surgery, and having stress predominant urinary incontinence on urodynamic study.

CONCLUSION

The lower rate of cumulative continuation of antimuscarinics encourages us to give a more detailed counseling and education to the patients with OAB symptoms before prescription. And explorations about newer agent and non-pharmacologic treatment with good efficacy and lower side-effects are needed.

Clinical Guideline for Female Lower Urinary Tract Symptoms

The "Japanese Clinical Guideline for Female Lower Urinary Tract Symptoms," published in Japan in November 2013, contains two algorithms (a primary and a specialized treatment algorithm) that are novel worldwide as they cover female lower urinary tract symptoms other than urinary incontinence. For primary treatment, necessary types of evaluation include querying the patient regarding symptoms and medical history, examining physical findings, and performing urinalysis. The types of evaluations that should be performed for select cases include evaluation with symptom/quality of life (QOL) questionnaires, urination records, residual urine measurement, urine cytology, urine culture, serum creatinine measurement, and ultrasonography. If the main symptoms are voiding/post-voiding, specialized treatment should be considered because multiple conditions may be involved. When storage difficulties are the main symptoms, the patient should be assessed using the primary algorithm. When conditions such as overactive bladder or stress incontinence are diagnosed and treatment is administered, but sufficient improvement is not achieved, the specialized algorithm should be considered. In case of specialized treatment, physiological re-evaluation, urinary tract/pelvic imaging evaluation, and urodynamic testing are conducted for conditions such as refractory overactive bladder and stress incontinence. There are two causes of voiding/post-voiding symptoms: lower urinary tract obstruction and detrusor underactivity. Lower urinary tract obstruction caused by pelvic organ prolapse may be improved by surgery.

Change in Overactive Bladder Symptoms After Surgery for Stress Urinary Incontinence in Women

OBJECTIVE

To assess change in overactive bladder (OAB) symptoms up to 5 years after surgery and to identify associated predictors of change from baseline.

METHODS

This is a secondary analysis of data from three multicenter urinary incontinence (UI) surgical trials of women with stress-predominant mixed UI assigned to Burch colposuspension, autologous fascial sling, or retropubic or transobturator midurethral slings. The primary outcome was improvement of 70% or greater from baseline in symptoms measured by the Urinary Distress Inventory-Irritative subscale. Surgical groups were compared within respective trials. Generalized linear models were fit using 1-year and up to 5-year data.

RESULTS

Significant improvements in Urinary Distress Inventory-Irritative scores were reported by each surgical group 1 year after surgery (P<.001). Most women (50-71%) reported improvement in OAB symptoms. Improvements were similar between midurethral sling groups at 1 year (65.5% compared with 70.7%, P=.32; odds ratio [OR] 0.83, 95% confidence interval [CI] 0.57-1.20 for retropubic compared with transobturator sling) and throughout the 5-year follow-up period. More women reported OAB symptom improvement after Burch compared with pubovaginal sling (67.9% compared with 56.6%, P=.01; OR 1.59, 95% CI 1.10-2.31 for Burch compared with sling); this group difference at 1 year persisted throughout the 5-year follow-up. At 1-year, 50.0-64.3% of patients reported 70% greater improvement in UI. This proportion declined to 36.5-54.1% at 5 years (P<.001). Preoperative use of anticholinergics and urodynamic parameters was not predictive of OAB symptom change after surgery.

CONCLUSION

Most women with stress-predominant mixed UI experienced significant improvement in OAB symptoms after incontinence surgery although this initial improvement diminished over time. Obesity blunted symptom improvement.

LEVEL OF EVIDENCE

II.

Effectiveness of Transobturator Tape Procedure in Obese and Severely Obese Women: 3-Year Follow-up

OBJECTIVE

To assess the efficacy and safety of transobturator tape (TOT) for the treatment of stress urinary incontinence in severely obese and obese women.

METHODS

We retrospectively reviewed the women who underwent a TOT procedure at 2 institutions between March 2005 and March 2013. The patients were divided into 3 groups according to the World Health Organization body mass index (BMI) values: normal weight group (BMI <25 kg/m(2); group 1), obese group (BMI = 30-34 kg/m(2); group 2), and severely obese group (BMI ≥35 kg/m(2); group 3). Overweight women (BMI = 25-29 kg/m(2)) were omitted. Patients filled in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) preoperatively and at the postoperative follow-up visits. The severity of urinary incontinence was classified by ICIQ-SF: slight (1-5), moderate (6-12), severe (13-18), and very severe (19-21). Patient satisfaction was assessed using a visual analog scale. Subjective improvement was defined as an ICIQ-SF score ≤12 and satisfaction with surgery (visual analog scale score ≥80).

RESULTS

A total 470 women met the requirements for inclusion. There were 153 women in group 1, 72 women in group 2, and 32 women in group 3. Mean follow-up period was at least 12 months in all the groups. The difference between the groups according to mean operative time was significant (P <.001). The objective cure, subjective success (cured and improved), patient satisfaction rates, and complications were similar between the groups.

CONCLUSION

Obesity and severe obesity do not seem to be risk factors for the failure of TOT procedure. However, postoperative urgency urinary incontinence rate was higher in severely obese women, and more women showed improvement instead of cure among severely obese women.

Effect of Transobturator Midurethral Sling Placement on Urgency and Urge Incontinence: 1-Year Outcomes

TVT-O placement has been associated with short-term cure/improvement of urgency (U) and urge urinary incontinence (UUI) in a significant proportion of patients. Further, the observed improvement in U/UUI is associated with improved quality of life (QOL). This study is a prospective continuation aimed to determine if the short-term benefit of TVT-O on U/UUI persists at 12 months postoperatively.

METHODS

Patients with stress-predominant mixed incontinence undergoing TVT-O placement were prospectively assessed using 3-day bladder diary and multiple validated incontinence questionnaires focusing on U (Urgency Perception Score), UUI (International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms), and QOL (Incontinence Impact Questionnaire, Short Form).

RESULTS

Eighty-seven patients achieved 12-month assessment, at which point improvements (versus baseline) in mean daily pad use (2.5-0.9) and mean incontinence episodes (3.6-0.7) were seen (P < 0.05, both comparisons). Seventy-eight percent of patients reported cure of stress incontinence. Questionnaire scores for UUI improved from 2.0(±1.1) to 1.0(±1.1) (P < 0.001), with 32% and 31% of patients reporting cure and improvement, respectively. Similarly, mean Urgency Perception Score improved from 10.1(±4.4) to 6.7(±4.5) (P < 0.001). Eighty-two percent of the patients did not require anticholinergics over the 12-month follow-up period. Furthermore, U outcomes are associated with improvements in QOL.

CONCLUSIONS

TVT-O placement is associated with cure/improvement of U and UUI in a significant proportion of patients with mixed urinary incontinence. Further, the observed improvements in U/UUI persist at 12 months and appear to have a durable positive association with QOL.

[Intrinsic sphincter deficiency and female urinary incontinence]

OBJECTIVE

Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article.

MATERIAL AND METHODS

This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association.

RESULTS

Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary.

CONCLUSION

Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.