Transobturator mid-urethral sling in females with stress urinary incontinence and detrusor underactivity: effect on voiding phase

European Urogynaecological Association Position Statement: The role of urodynamics in stress urinary incontinence evaluation and treatment decision

Stress urinary incontinence (SUI) is defined as a condition characterized by the involuntary leakage of urine during activities that increase intra-abdominal pressure which may decrease quality of life with a significant economic impact on health systems, necessitating the implementation of cost-effective management plans. Urodynamics (UDS) has been considered during the last decades as the gold standard for assessment of lower urinary tract symptoms (LUTS) due to their high reproducibility. At the same time, concerns about the systematic use of UDS before SUI surgery were raised due to a limited evidenced base to recommend their routine use. In uncomplicated female patients with SUI, UDS can offer further insights into LUTS, potentially assisting the physician in determining the appropriate therapeutic approach. However, it has not been shown that preoperative UDS can directly impact the surgical outcome for continence. Indeed, evidence supports the conclusion that pre-operative UDS in women with uncomplicated, clinically demonstrable, SUI does not improve the outcome of surgery for SUI. Nevertheless, asymptomatic detrusor overactivity (DO) identified by urodynamic testing or pre-existing voiding dysfunction are associated with an increased occurrence of postoperative overactive bladder (OAB) and voiding dysfunction, respectively. The EUGA Working Group concluded that the evidence does not support the systematic preoperative use of UDS for uncomplicated cases. However, in cases where mixed symptoms, voiding dysfunction, previous surgery, or concomitant prolapse are present, preoperative UDS are advised as they can be beneficial in anticipating postoperative outcomes. This aids in conducting comprehensive and thorough preoperative counseling. The Group recommend performing preoperative UDS considering the patient's specific clinical situation and the surgeon's judgment, with consideration given to the potential benefits, risks, and impact on treatment decisions and patient outcomes.

Biomimetic urine flow control can preserve bladder function in patients with indwelling catheterization

For patients with long-term indwelling catheterization, bladder function will be affected. It is necessary to explore whether biomimetic urine flow control (BUFC) can improve bladder function in patients undergoing indwelling catheterization. A retrospective, data-only, cohort study was carried out. The patients admitted to the intensive care unit, who had retained catheter and been continuously using a urodynamic monitoring system for over 30 days were selected. They were divided into 2 groups based on whether they were using BUFC function. The urodynamic monitoring data of the 2 groups were compared and analyzed. A total of 30 patients were included in the final analysis, including 15 in the BUFC group and 15 in the unobstructed group. The Urinary Volume and maximal urinary flow rate of the unobstructed group showed a continuous downward trend, while the BUFC group remained stable, and there was a statistical difference (P < .05) between the 2 groups since day 20. The bladder ultrasound imaging showed that the bladder volume of the BUFC group did not decrease significantly on the 30th day. BUFC technology, which provided by a urodynamic monitoring system, has potential protective effects of the bladder function after indwelling catheterization.

Low detrusor contractility has a less favorable outcome of anti-incontinence surgery for women with stress urinary incontinence

PURPOSE

Few studies exist comparing the effect of different lower urinary tract dysfunctions (LUTDs) on anti-incontinence surgery. This study investigates the long-term therapeutic outcome of a suburethral sling procedure among women with stress urinary incontinence (SUI) and different LUTDs.

METHODS

This study retrospectively reviewed 401 women treated with a suburethral sling for SUI. Following baseline videourodynamic findings, the patients were divided into pure SUI or SUI with concomitant LUTD (mixed detrusor overactivity and SUI, low detrusor contractility and SUI, and presence of bladder outlet obstruction and SUI) groups. The primary endpoint was the SUI-free-specific survival rate. A successful outcome was defined as the absence of any SUI event. The secondary endpoints included postoperative complications, surgical revision rate, and changes in videourodynamic parameters.

RESULTS

At a mean follow-up of 5.1 (standard deviation: 5.4, range 0.1-24.1) years, the median cumulative duration of SUI-free survival was 15.4 years and 15.9 years in the pure SUI and SUI and concomitant LUTD subgroup, respectively, without significant difference between the groups. No between-group difference in postoperative complications was also noted. The cumulative incidences of the overall reoperation rate were 15.3%, 11.6%, 30.9%, and 7.3% in the pure SUI, detrusor overactivity, low detrusor contractility, and bladder outlet obstruction subgroups, respectively, with a significant difference between the groups (p = 0.006).

CONCLUSIONS

Women who underwent suburethral sling surgery for SUI treatment had comparable long-term success rates regardless of baseline LUTD. However, those with low detrusor contractility may experience less favorable results in terms of higher reoperation rates.

Is detrusor underactivity associated with voiding dysfunction after single incision sling surgery?

BACKGROUND

Some women experience voiding dysfunction after stress urinary incontinence (SUI) surgery. We explore if detrusor underactivity (DU) found in urodynamic study (UDS) prior to SUI surgery using an adjustable single incision sling (SIS) may be related to voiding dysfunction after surgery.

METHODS

This is a prospective, diagnostic, transversal, single center study comparing voiding dysfunction after SUI surgery with a SIS (Altis®; Coloplast, Humlebæk, Denmark) between women with DU (cases) or normal detrusor (controls). Inclusion criterium was women ≥18 years with SUI/mixed UI (stress predominant) operated between June 2013 and December 2020. Exclusion criteria were: women without UDS prior to surgery or without voiding phase in the P/Q, previous incontinence surgery, POP stage ≥2, neurogenic conditions, other pelvic floor surgery. Urinary symptoms were assessed using structured questions evaluating storage/voiding symptoms. Patients were divided into two groups according to projected Isovolumetric Pressure Index (PIP1) with 30-75 cmH2O indicating normal contractility.

RESULTS

A total of 139 women were included, 29 (20.9%) in DU group and 110 (79.1%) in control group. Control and DU groups have shown similar objective (75.5% vs. 71.4% P=0.66) and subjective (85.4% vs. 96.1% P=0.22) success rates, respectively, without statistical differences. Voiding symptoms increased after surgery in both groups (+20.7% DU group vs. +8.1% normal group, P=0.29). More voiding symptoms (persistent/de novo) were found in DU group vs. normal group, but without statistically significant differences.

CONCLUSIONS

According to our results, the presence of DU previous to SUI surgery with a SIS (Altis®, Coloplast) has no impact on objective and subjective success rates. On the other hand, patients with preoperative DU showed higher proportion of voiding dysfunction but no statistical difference.

Modification of bladder thermodynamics in stress urinary incontinence patients submitted to trans-obturator tape: A retrospective study based on urodynamic assessment

Importance: It needs to be clarified whether trans-obturator tape (TOT)-enhanced urethral resistance could impact the voiding function.

Objective: Although TOT has been well-recognized for enhancing urethral resistance to restore continence in stress urinary incontinence (SUI) patients, whether the bladder’s voiding functions adapt to the TOT-enhanced resistance has not been adequately investigated. This study thereby aimed to investigate whether TOT impacts the bladder’s thermodynamic efficacy during the voiding phase.

Design: A retrospective analysis of urodynamics performed before and after TOT was assessed.

Setting: A tertiary referral hospital in Taiwan.

Participants: A total of 26 female SUI patients who underwent urodynamic investigations before and after TOT.

Main outcomes and measures: The area enclosed by the pressure-volume loop (Apv), which represents the work performed by the bladder during voiding, in a pressure-volume analysis established by plotting the detrusor pressure versus intra-vesical volume was retrospectively analyzed. Paired Student’s t-tests were employed to assess the difference in values before and after the operation. Significance in difference was set at p &lt; 0.05.

Results: TOT increased Apv in 20 of 26 (77%) patients and significantly increased the mean Apv compared to the preoperative control (2.17 ± 0.18 and 1.51 ± 0.13 × 103 cmH2O-ml, respectively p &lt; 0.01). TOT also increased the mean urethral resistance (1.03 ± 0.30 vs. 0.29 ± 0.05 cmH2O-sec/ml, p &lt; 0.01) and mean voiding pressure (25.87 ± 1.72 and 19.30 ± 1.98 cmH2O p &lt; 0.01) but did not affect the voided volume and voiding time. Moreover, the TOT-induced Apv increment showed a moderate correlation with the changes in urethral resistance and voiding pressure (both r &gt; 0.5) but no correlation with changes in voided volume or voiding time. It is remarkable that the TOT-induced urethral resistance increment showed a strong correlation with changes in voiding pressure (r &gt; 0.7).

Conclusion and Relevance: The bladder enhances thermodynamic efficacy by adapting the voiding mechanism to increased urethral resistance caused by TOT. Further studies with higher case series and longer follow-ups should assess whether this effect could be maintained over time or expire in a functional detrusor decompensation, to define diagnostic criteria that allow therapeutic interventions aimed at its prevention during the follow-up.

Clinical Trial Registration: (clinicaltrials.gov), identifier (NCT05255289)

Urodynamics criteria of detrusor underactivity in women underwent middle urethral sling for stress urinary incontinence: What is the clinical role?

AIMS

To assess the role of detrusor underactivity (DUA), diagnosed by different urodynamic criteria, on outcomes of women underwent middle urethral sling (MUS) for stress urinary incontinence (SUI).

METHODS

In this prospective study, DUA criteria of women with SUI, naïve for SUI surgery, candidates to MUS were: I Pdet@Qmax ≤10 cm H2O and Qmax ≤12 mL/s (Jeong et al.) ii Pdet@Qmax<30 cm H2O and Qmax<10 mL/s (Abarbanel and Marcus) iii Pdet@Qmax<20 cm H2O and Qmax<15 mL/s and BVE < 90% (BVE criteria) iv Pdet@Qmax<20 cm H2O + Qmax (PIP1 Griffiths) Control group (CG) comprised non-DUA patients. Preoperative and at 2-years follow-up evaluation included physical examination, uroflowmetry, post void residual urine (PVR), ICIQ-FLUTS.

RESULTS

102 patients fulfilled 2-years controls. DUA rate range was 16.7% (BVE) - 53.9% (PIP1-Griffith). The POUR rate varied: 20% (PIP1-Griffith) - 35.3% (BVE), 10% in CG. Tape incision rate for POUR was 3.4% in DUA, 4.5% in CG. No patients had urinary retention at 2-years follow-up. In DUA groups, Qmax did not change significantly after surgery and PVR was low. SUI recurrence rate was 2.8% in DUA, 4.5% in CG. Preoperatively, urgency and post-micturition dribble were the most (82.4%) and the less (26.7%) reported symptoms, respectively. At follow-up, frequency was the most prevalent (56.1%), reduced sensation/bladder pain the less usual (23.1%). ICIQ-FLUTS scores were higher in DUA groups.

CONCLUSIONS

DUA did not have a negative impact on MUS outcomes in a mid-term follow-up. Early postoperative voiding complication rates changed according to the type of DUA urodynamic criteria.

Irreversible Bladder Remodeling Induced by Fibrosis

Underactive bladder and impaired bladder compliance are irreversible problems associated with bladder fibrosis. Remodeling of the extracellular matrix is regarded as an important mechanism associated with bladder fibrosis. However, various risk factors and conditions contribute to the functional impairment of the bladder associated with fibrosis, and there is limited knowledge about bladder fibrosis-associated problems in the field of neurourology. Further studies are thus necessary to elucidate the underlying mechanism of bladder fibrosis and to identify effective treatment.

Management of Urinary Incontinence With Underactive Bladder: A Review

Urinary incontinence is caused by storage function failure, while underactive bladder (UAB) is caused by a decline in detrusor contractility and voiding dysfunction. As the treatment mechanisms for incontinence and UAB are contrary to each other, it is difficult to treat both incontinence and UAB, and the patient's quality of life can be further degraded. Conventional midurethral sling (MUS), such as transobturator tape or retropubic MUS, introduces a risk of postoperative voiding dysfunction in stress urinary incontinence with UAB. However, there have been several reports about the efficacy and safety of conventional MUS. Adjustable sling procedures, such as transobturator adjustable tape or the Remeex system, have better outcomes than conventional MUS because they control tension both during and after surgery. When voiding dysfunction occurs after incontinence treatment with UAB, voiding symptoms can be improved by various therapeutic modalities. Clean intermittent catheterization is recommended for patients with significant increased postvoid residual volumes or urinary retention. Although pharmacotherapy such as with alpha-blockers or parasympathomimetics can be considered for UAB, there is insufficient evidence of their effect on incontinence with UAB. Future therapies, such as stem cell therapy or gene therapy, may be used to treat incontinence with UAB. The possibility of management urgency urinary incontinence that related to detrusor hyperactivity with impaired contractility using sacral neuromodulation has been suggested. Further research is needed to establish evidence for the efficacy and safety of treatments for incontinence with UAB and improve patient quality of life.

Role of videourodynamic study in precision diagnosis and treatment for lower urinary tract dysfunction

Lower urinary tract symptoms (LUTS) are complicated and cannot be used alone to diagnose lower urinary tract dysfunctions (LUTDs) and guide treatment. Patients with bladder outlet obstruction (BOO), impaired detrusor contractility, and hypersensitive bladder might present with voiding predominant symptoms, whereas patients with detrusor overactivity (DO), dysfunctional voiding, or BOO might also present with storage symptoms. To clearly identify the pathophysiology of LUTD, a comprehensive urodynamic study (UDS) including pressure flow and image during the storage and emptying phases, naming videourodynamic study (VUDS), is necessary. This study is especially mandatory in the diagnosis of (1) male LUTS refractory to medical treatment for benign prostatic hyperplasia, (2) female voiding dysfunction and urinary retention, (3) diagnosis of overactive bladder syndrome refractory to first-line medication, (4) management of female stress urinary incontinence and postoperative LUTS, (5) diagnosis and management of neurogenic LUTD, (6) pediatric urinary incontinence and enuresis, (7) geriatric urinary incontinence, and (8) recurrent bacterial cystitis. Although VUDS should not be used as a screening test for any LUTS, it should be considered when the initial management cannot relieve LUTS, or when invasive surgical procedure is planning to undertake for patients with refractory LUTS. VUDS should be recommended as the second-line investigation when the initial diagnosis and treatment based on the symptoms alone or noninvasive tests fail to improve LUTS.

Detrusor Underactivity and Underactive Bladder in Women: What Is New?

Purpose of Review

Detrusor underactivity (DU) and its symptom-based correlation, the underactive bladder (UAB), are common problems encountered in urological practice. Whilst DU has been defined for many years, only recently has UAB received a formal definition and there is now accumulating literature based on this condition. In this article, we reviewed the recent literature on the aetiology, pathogenesis, diagnosis and management of DU/UAB in women.

Recent Findings

Detrusor underactivity is diagnosed on urodynamic studies but there still remains a lack of widely recognised and accepted diagnostic criteria. Commencing treatment based on the diagnosis of UAB, with or without a PVR measurement, is perhaps feasible due to the lower occurrence of BOO in women and specific clinical features that may distinguish this group. Prospective studies attempting to correlate UAB with the underlying DU are needed before this approach could be considered.

Summary

Detrusor underactivity/UAB in women requires a separate consideration from men due to the anatomical and functional differences in the lower urinary tracts between both genders and consequent differences in pathologies affecting them. The aetiology of DU remains largely unknown, but is probably multifactorial, including myogenic, neurogenic and vasculogenic factors. There remains a lack of any simple effective drug treatments, whilst apart from sacral neuromodulation for the specific subgroup with non-obstructive urinary retention, no safe and effective surgical treatment is currently available. Often, permanent or intermittent bladder drainage with a catheter is the final solution.

Surgical results in women with detrusor underactivity and stress urinary incontinence undergoing suburethral sling procedure-Predictive factors for successful outcome

OBJECTIVES

To elucidate the treatment results and predictors for successful outcome in women with detrusor underactivity (DU) and stress urinary incontinence (SUI) undergoing suburethral sling procedure.

METHODS

Medical records of women with coexistent SUI and DU treated with a suburethral sling were retrospectively reviewed and we analyzed the association between treatment outcome and baseline demographics including etiology of DU and urodynamic variables. Patients who were dry and could urinate spontaneously were considered successful. Treatment failure was considered in those who were dry but needing clean intermittent catheterization (CIC) and patients who were still wet. Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) scores were used to assess the impact of surgery on the quality of life.

RESULTS

Among 71 patients, a successful outcome was noted in 39 (55%), failed outcome with CIC in 15 (21%), and totally treatment failure in 17 (24%). Treatment outcome did not differ among the etiology subgroups. Overall, UDI-6 and IIQ-7 scores significantly improved after surgery. Multivariable logistic regression analysis revealed that the IIQ-7 and maximum flow rate (Qmax) were two independent predictors for improvement after surgery. An IIQ-7 score ≤6, and Qmax ≥6 mL/s can predict improvement by receiver operating characteristic analysis. Qmax ≤6 mL/s can predict needing CIC after surgery.

CONCLUSIONS

For women with SUI and coexistent DU who underwent suburethral sling procedure, low IIQ-7 (≤6) scores and higher Qmax (≥6 mL/s) are predictors for improvement of surgical outcome. A Qmax of <6 mL/s was the only predictor for CIC after surgery.

3-Year follow-up of tension-free vaginal tape-ABBREVO procedure for the treatment of pure urodynamic stress urinary incontinence: efficacy and adverse effects

INTRODUCTION AND HYPOTHESIS

The tension-free vaginal tape ABBREVO (TVT-A) is a new surgical procedure for the treatment of female stress urinary incontinence (SUI). However, data reporting medium- and long-term outcomes are lacking. The aim of the study was to assess the efficacy and safety of TVT-A in patients with at least a 3-year follow-up.

METHODS

All consecutive women who complained of pure SUI symptoms with urodynamically proven SUI undergoing a TVT-A procedure were prospectively enrolled. Data regarding subjective outcomes (International Consultation on Incontinence Questionnaire-Short Form, Patient Global Impression of Improvement and patient satisfaction scores), objective cure (stress test) rates and adverse events were collected during follow-up. Univariate analysis was performed to investigate outcomes.

RESULTS

A total of 41 women underwent TVT-A implantation. At 3-year follow-up, 40 women (97.5%) were available for the evaluation. We did not find any significant change in surgical outcomes during this time. At 3 years after surgery, 36 of 40 (90%) patients were subjectively cured (p for trend 0.18) and 37 out of 40 (92.5%) patients were objectively cured (p for trend 0.22). The univariate analysis did not find any risk factor statistically associated with the recurrence of SUI. A significant trend of de novo overactive bladder (OAB) occurrence was registered at the 3-year follow-up (p for trend = 0.03). No serious late complications or groin-thigh pain were reported.

CONCLUSIONS

TVT-A implantation is a highly effective option for the treatment of women with pure SUI.

The autologous pubovaginal fascial sling: An update in 2019

The contemporary management of stress urinary incontinence (SUI) has seen renewed interest in the use of autologous fascia for the formation of a retropubic suburethral sling. Traditionally, it has been used in only the most severe of incontinence cases, such as those women with intrinsic sphincter deficiency, or in patients requiring concomitant reconstructive procedures. In the current climate surrounding transvaginal mesh, many doctors and patients are shying away from the less morbid synthetic midurethral sling. International literature has demonstrated that the fascial sling is a safe and efficacious procedure for all patients with SUI, adequately treating both urethral hypermobility and intrinsic sphincter deficiency. This paper will discuss the indications, technique, and outcomes of autologous fascial slings. We will explore the use of fascial slings following failed synthetic slings and also the troubleshooting of commonly encountered issues intra- and postoperatively.