Outcomes and failure risks in mid-urethral sling insertion in elderly and old age with urodynamic stress incontinence. Int Urogynecol J. 2020;31:717-726. [PMID: 31832716 DOI: 10.1007/s00192-019-04171-w]

Results of Stress Incontinence Surgery in Octogenarian Women

Stress urinary incontinence (SUI) is common among octogenarian women, often in association with significant comorbidities that can include functional and cognitive impairment. There is limited evidence in the literature on the efficacy and safety of current surgical options for treating SUI in octogenarians. The few studies available on this topic mainly focus on mid-urethral slings and reveal similar efficacy and safety profiles for octogenarian women in comparison to younger women. These studies are mostly retrospective, with small sample sizes and short follow-up. What data there are suggest that greater frailty, not older age, may be associated with complications in the elderly population (>65 yr), a finding that is not specific to octogenarians. Prospective studies with larger sample sizes and longer follow-up are needed to assess the safety and efficacy of the different surgical treatment options for SUI in octogenarians. PATIENT SUMMARY: This mini review discusses the results of surgery for treatment of stress urinary incontinence in women older than 80 years. The limited evidence available suggests that surgical treatments can be safely performed in well-selected octogenarian women after a careful preoperative assessment.

Outcomes of primary transobturator mid-urethral sling surgery in women of different ages

INTRODUCTION

Older age is associated with greater likelihood of urinary incontinence and unmet care needs. It was hypothesized that age might influence clinical and ultrasound outcomes of transobturator mid-urethral sling (TOS) surgery. The aim of this study was to compare 1-year postoperative clinical and ultrasonographic outcomes of TOS surgery among women of different ages.

METHODS

A retrospective analysis of a cohort of women who underwent primary and isolated TOS surgery for uncomplicated urodynamic stress incontinence was undertaken. All women underwent pre-operative and 1-year postoperative evaluations including clinical interview, pelvic examination, urodynamic studies and introital four-dimensional ultrasound. To be eligible for surgery, women needed to be independent in their daily life, and to have an acceptable level of surgical risk on pre-operative assessment. The primary outcome was the rate of stress urinary incontinence (SUI) after surgery. The secondary outcomes comprised postoperative adverse events and ultrasound findings.

RESULTS

In total, 162, 213, 60 and 29 women aged <51, 51-64, 65-74 and ≥75 years, respectively, were included in this study. At 1-year postoperative assessment, older women were more likely to report SUI and bothersome SUI, while the severity of SUI and postoperative adverse events were similar in older women compared with other age groups. Ultrasound revealed that the sling tended to be looser and higher in older women.

CONCLUSION

TOS surgery is effective and safe for women of all ages who are independent in their daily life and who have an acceptable level of surgical risk. The sling tended to be looser and higher in older women.

Predictors and outcomes of Mid-urethral sling continence surgeries for stress urinary incontinence among Taiwanese women: What works best?

Mid urethral sling (MUS) surgery is a widely accepted and safe procedure performed for stress urinary incontinence (SUI) with excellent cure rate besides its minimal complications. There are various types of MUS which can be offered. In this review we collated published data on MUS surgery performed among Taiwanese women with SUI in search for the best techniques and its outcome. We reviewed 77 articles, searched using PubMed platform related to MUS in USI among Taiwanese women from 1998 to 2023.24 articles, total 2733 participants with at least 12 months follow up after MUS. Objective cure rate for trans-obturator tape (TOT), retropubic sling (TVT, tension vaginal tape), single incision sling (SIS) (Solyx) and SIS (MiniArc) are 80%-92%, 88%-94%, 87%-90% and 87%-91% respectively, while subjective cure is 60%-90% in TOT, 86% in SIS (Solyx) and almost 90% in SIS (MiniArc), Predictors for surgical failure analyzed in 5 papers of 1006 women. Identifiable risk includes low maximal urethral closure pressure, intrinsic sphincter deficiency, previous anti SUI or prolapse surgery, presence of neurogenic disease, constipation, decreased bladder sensation, age >65 years, high pad test, Diabetes, detrusor overactivity, post-menopausal, reduced postoperative urethral mobility and tape percentile. Subsequently we dwell into complications of each type of MUS. This review showed the evolution of MUS and its comparable therapeutic efficacy. However, with certain complication rates and predictors for failure. This will add value in preoperative counselling while taking into accounts patients' factors in choosing the appropriate types of MUS. Future research is needed on long term effectiveness and risk of future recurrence.

One and five-year efficacy of tension-free vaginal tape (TVT) abbrevo and TVT-obturator in the treatment of stress urinary incontinence: a retrospective study

BACKGROUND

Surgical interventions are more effective than nonsurgical approaches in providing a cure for stress urinary incontinence (SUI). In this study, we aimed to assess the benefits of tension-free vaginal tape (TVT) abbrevo by comparing its efficacy and complications to those of TVT obturator.

METHODS AND RESULTS

49 and 47 patients at The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University between January 2013 and December 2016 were included in the TVT-O and TVT-A groups, respectively. We evaluate the success rate and perioperative complications associated with TVT-O and TVT-A. A questionnaire that utilized the Patient Global Impression of Improvement (PGI-I) Scale was employed to assess the impact of surgery. Patients were followed up at 1 year, and 5 years after surgery. There were no statistically significant differences found in the efficacy of the TVT-A group and TVT-O group during both the one-year (p = 0.4) and five-year (p = 0.32) follow-up periods. In the period of one-year follow-up, 95.9% (n = 47) of patients in the TVT-O group and 95.8% (n = 45) of patients in the TVT-A group demonstrated improvement. During the period of five-year follow-up, 87.8% (n = 43) of patients in the TVT-O group and 93.6% (n = 44) of patients in the TVT-A group demonstrated improvement.

CONCLUSIONS

Based on our findings, TVT-A and TVT-O procedures exhibited similarly high success rates and low frequencies of complications.

Single Incision Mini-Sling Versus Mid-Urethral Sling (Transobturator/Retropubic) in Females With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

Stress urine incontinence (SUI) is most common in middle-aged women and the second most common in those over 75. SUI causes significant discomfort and suffering for patients and has a considerable financial impact on the healthcare system. Conservative approaches are recommended as the first step in treatment. However, surgery is often necessary to improve a patient's quality of life due to the high failure rate of conservative treatments. A thorough literature review of studies published before March 2023 was conducted on the safety and effectiveness of single-incision mini slings (SIMS) and standard mid-urethral slings (MUS). PubMed, Embase, Cochrane Library, and Elsevier's ScienceDirect were used to retrieve the studies. Two reviewers independently searched and evaluated the data based on inclusion and exclusion criteria. Review Manager 5.4 software was used for meta-analysis. Included were seventeen studies involving 3,503 female SUI patients without intrinsic sphincter deficiency (ISD) or mixed urinary incontinence. According to the results of our meta-analysis, the clinical efficacy of SIMS is comparable to that of MUS in terms of objective cure rate (RR: 0.99; 95% CI: 0.95 to 1.03, p: 0.66, I2: 29%). In contrast, it increases the post-procedure International Consultation on Incontinence Questionnaire (ICIQ) score (WMD: 0.08; 95% CI: -0.08 to 0.08). CI: -0.02 to 0.18, p: 0.11, I2: 55%) and improves the PGI-I score to a greater extent (RR: 1.04; 95% CI: 0.96 to 1.08, p: 0.36, I2: 76%). In contrast, there is no difference between the two groups regarding patient satisfaction (RR: 0.96; 95% CI: 0.92 to 1.01, p: 0.16, I2: 0%) and Sandvik score reduction (RR: 0.98; 95% CI: 0.94 to 1.02, p: 0.35, I2: 0%). In conclusion, single-incision mid-urethral slings (SIMS) are as effective as mid-urethral slings (MUS) for treating pure stress urinary incontinence (SUI) without intrinsic sphincter deficiency (ISD), with a shorter operation time. However, the SIMS procedure has a higher incidence of dyspareunia. At the same time, bladder perforation, mesh-related complications, pelvic/groin pain, urinary tract infection (UTI), worsening urgency, dysuria, and pain score are less likely to occur with SIMS. Only the decrease in pelvic/groin pain was statistically significant.

Liquid crystal elastomer based dynamic device for urethral support: Potential treatment for stress urinary incontinence

Stress urinary incontinence (SUI) is characterized by the involuntary loss of urine due to increased intra-abdominal pressure during coughing, sneezing, or exercising. SUI affects 20-40% of the female population and is exacerbated by aging. Severe SUI is commonly treated with surgical implantation of an autologous or a synthetic sling underneath the urethra for support. These slings, however, are static, and their tension cannot be non-invasively adjusted, if needed, after implantation. This study reports the fabrication of a novel device based on liquid crystal elastomers (LCEs) capable of changing shape in response to temperature increase induced by transcutaneous IR light. The shape change of the LCE-based device was characterized in a scar tissue phantom model. An in vitro urinary tract model was designed to study the efficacy of the LCE-based device to support continence and adjust sling tension with IR illumination. Finally, the device was acutely implanted and tested for induced tension changes in female multiparous New Zealand white rabbits. The LCE device achieved 5.6% ± 1.1% actuation when embedded in an agar gel with an elastic modulus of 100 kPa. The corresponding device temperature was 44.9 °C ± 0.4 °C, and the surrounding agar temperature stayed at 42.1 °C ± 0.4 °C. Leaking time in the in vitro urinary tract model significantly decreased (p < 0.0001) when an LCE-based cuff was sutured around the model urethra from 5.2min ± 1min to 2min ±0.5min when the cuff was illuminated with IR light. Normalized leak point force (LPF) increased significantly (p = 0.01) with the implantation of an LCE-CB cuff around the bladder neck of multiparous rabbits. It decreased significantly (p = 0.023) when the device was actuated via IR light illumination. These results demonstrate that LCE material could be used to fabricate a dynamic device for treating SUI in women.

Bulking agents for the treatment of recurrent stress urinary incontinence: a suitable option?

BACKGROUND

The management of recurrent female stress urinary incontinence (SUI) still needs worldwide standardization. Few data on the role of urethral bulking agents (UBA) for the treatment of recurrent stress urinary incontinence exist. The aim of this study is to assess the efficacy and safety of urethral bulking agents for the treatment of recurrent SUI.

METHODS

A multicenter, prospective study was conducted in four tertiary referral centers in two countries. All consecutive women with urodynamically-proven recurrent SUI, and with a history of previous failed anti-incontinence surgical procedure (mid-urethral sling or single incision sling), treated by UBAs were included. We evaluated only patients who completed at least a 3-year follow-up. Data regarding subjective outcomes (International Consultation on Incontinence Questionnaire-Short Form, Patient Global Impression of Improvement, Urogenital Distress Inventory score and patient satisfaction score), objective cure (stress test) rates, and adverse events were collected during follow-up. Univariable and multivariable analyses was performed to investigate outcomes.

RESULTS

Forty-seven consecutive patients were enrolled. At 3-year follow-up, all women were available for the evaluation. At 3 years after surgery, 38 of 47 patients (81%) declared themselves cured. Similarly, at 3-year evaluation, 39 of 47 patients (83%) were objectively cured. Only five patients (10.6%) required re-operation for UBA failure. The urodynamic diagnosis of preoperative detrusor overactivity and the PDet Max filling phase ≥15 cmH2O (hazard ratio: 2.74; 95% CI, 1.64-10.7; P=0.009 and 1.62; 95% CI, 1.11-3.42; P=0.04, respectively) were the only predictors of failure. Only four complications were reported (8.5%).

CONCLUSIONS

The 3-year results of this study showed that bulking agents is an appropriately effective and safe option for the treatment of recurrent SUI. The presence of preoperative concomitant detrusor overactivity is associated with a significant decrease of the efficacy of this procedure.

Twenty-Five Years of the Midurethral Sling: Lessons Learned

Midurethral slings (MUS) are widely accepted for the surgical treatment of stress urinary incontinence (SUI) in cases where conservative treatment has failed. They have been shown to be a safe and effective surgical treatment for the management of SUI. However, there have recently been growing concerns regarding the safety profile of mesh procedures, generating international debate and leading to national inquiries into the effectiveness and safety of mesh implants. A multitude of clinical, technical, manufacturer-related, and other health jurisdictional factors are involved in the outcomes of MUS. Appropriate patient selection and informed consent to all treatment options, with proper guidance from healthcare providers, are critical for empowering women to choose an appropriate treatment option based on a personalized decision.

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence

OBJECTIVE

To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m2), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

Predictors of cure and overactive bladder syndrome after a mid-urethral sling procedure in women with stress urinary incontinence

OBJECTIVES

To determine predictive factors for the cure of stress urinary incontinence (SUI) or persisting or de novo overactive bladder syndrome (OAB) after a mid-urethral sling procedure (MUS) for women with SUI, especially for menopausal women.

STUDY DESIGN

All women who had consecutively received MUS for SUI between January 2008 and July 2019 in a tertiary referral center were reviewed.

MAIN OUTCOME MEASURES

Multivariable Cox proportional hazards model or logistic regression analysis was used to assess the predictors of cure and persisting or de novo OAB after MUS.

RESULTS

A total of 385 women had undergone MUS, of whom 265 (68.8%) were menopausal. The multivariable Cox proportional hazards model revealed that age (hazard ratio = 1.04), and preoperative detrusor overactivity (hazard ratio = 2.26) were independent predictors of persisting/recurrent SUI. Among the 216 women with preoperative OAB, 109 (50.5%) experienced resolution of their OAB after MUS; and among 169 women without preoperative OAB, twenty-five (14.8%) women developed de novo OAB after MUS (p < 0.0001). Preoperative OAB (hazard ratio = 3.97), small voided volume (hazard ratio = 0.83), and preoperative detrusor overactivity (hazard ratio = 1.62) were predictors of postoperative OAB. In addition, six (1.6%) women had mesh extrusion. Parity (odds ratio = 2.08) was the sole predictor of mesh extrusion. Menopause (hazard ratio = 1.69) was a predictor of postoperative OAB in the univariate analysis. However, menopause was not a predictor of cure or OAB in the multivariable analysis.

CONCLUSIONS

Age and preoperative detrusor overactivity were independent predictors of persisting/recurrent SUI. In addition, preoperative OAB, small voided volume, and preoperative detrusor overactivity were predictors of postoperative OAB. These findings could serve as a guide for preoperative consultation for MUS.

Surgical outcomes of tension-free vaginal tape (TVT)- abbrevo® and TVT-obturator® for the treatment of stress urinary incontinence: a retrospective study

OBJECTIVE

We compared the efficacy and postoperative complications of tension-free vaginal tape (TVT)-abbrevo® (TVT-A) and TVT-obturator® (TVT-O) surgeries for the treatment of stress urinary incontinence (SUI).

METHODS

We retrospectively analyzed the medical records of 143 female patients with SUI who underwent TVT-A or TVT-O surgery between January 2010 and December 2019 at the Asan Medical Center in Seoul. We evaluated intra- and postoperative complications such as bladder injury, groin pain, urinary retention, and mesh exposure. We also checked the success rate at 6 months after surgery.

RESULTS

There were no complications, including fever, hematuria, hematoma of the vulva, or bladder injury, immediately after surgery in either group. Postoperative complications 2 weeks post-surgery were groin pain (11.3%), urinary retention (4.9%), and mesh exposure (0.7%). Groin pain was not significantly different between the two groups at 2 weeks, 3 months, and 6 months after surgery (TVT-O vs. TVT-A after 2 weeks: 12.5% vs. 10.3%, P=0.791; 3 months: 0.0% vs. 1.4%, P=0.999; and 6 months: 0.0% vs. 0.0%, P=0.999). Over 90% of the patients reported cure or improved symptoms in both groups. In the univariate logistic analysis, the type of TVT (TVT-O or TVT-A) was not associated with the success rate (odds ratio, 3.21; 95% confidence interval, 0.59-17.40; P=0.175).

CONCLUSION

TVT-A surgery is comparable with TVT-O in terms of high success rate and low frequency of complications, including bladder injury and groin pain.

Management and Follow-Up Practices of Women With Recurrent Stress Urinary Incontinence Following Transobturator Mid-urethral Synthetic Sling Procedure: A 6-Year Retrospective Monocentric University-Based Study

Purpose: The purpose of this study is to evaluate the efficacy of management and follow-up practices in repeat retropubic mid-urethral synthetic sling (MUS) procedure after transobturator tape/tension-free vaginal tape-obturator (TOT/TVT-O) failure, and to clarify the possible etiology of recurrent stress urinary incontinence.

Methods: The charts of all women patients who underwent tension-free vaginal tape (TVT) slings after previous failed transobturator MUS procedures between February 2012 and November 2018 at a single center were reviewed retrospectively. The transperineal ultrasound was performed to assess the pre-operative or post-operative urethral mobility and location of the slings. Furthermore, some essential evaluations were also made, mainly including medical history, physical examination, 1 h pad test, and urodynamic study. Finally, primary outcomes were evaluated according to the above items at 3, 6, and 12 months after the second operation, respectively.

Results: Thirty-five patients were included in the primary transobturator MUS sling procedure. At the 6 months follow-up, 32 (91.42%) patients were socially continent and negative in 1 h pad test. The transperineal ultrasound measurement results revealed that the bladder neck descent (BND) values were significantly decreased after the repeat sling operation, and better urinary continence function was observed according to the post-operative urodynamic study. Multifactorial etiologies resulted in recurrent stress urinary incontinence (SUI), including poor surgical technique, inadequate sling tension when treating ISD, and inappropriate sling position. Then the detail of the surgical procedure varied with the results of pre-operative evaluations, affecting the validity of the second sling.

Conclusion: Recurrent SUI has resulted from multi factors, pre-operative urodynamic study and transperineal ultrasound might be valuable tools to guide repeat sling operation and predict post-operative outcomes. A repeat TVT procedure may be regarded as a remedial measure for a failed transobturator MUS operation.

De novo detrusor overactivity and urgency after mid-urethral slings for urodynamic stress incontinence

INTRODUCTION AND HYPOTHESIS

The objective was to identify incidence and risk factors of de novo urgency and detrusor overactivity (DO) following mid-urethral slings (MUS) in patients with urodynamic stress incontinence (USI) without urgency.

METHODS

A total of 688 women between January 2004 and July 2017 were reviewed retrospectively. De novo urgency was established with a positive response to question 2 on the Urogenital Distress Inventory-6 questionnaire (UDI-6). Objective cure of USI is no involuntary urine leakage during filling cystometry and pad test < 2 g. Subjective cure of stress urinary incontinence (SUI) is defined as a negative response to question 3 on UDI-6. Multivariate logistic regression was used to identify risk factors for failure.

RESULTS

Forty-four out of 688 women (6.4%) developed de novo urgency, with 16 out of 688 (2.3%) demonstrating de novo DO. Subjective cure for women with de novo urgency was significantly lower at 35 out of 44 (79.5%) compared with 556 out of 644 (86.3%) in those with no urgency (p < 0.001). Objective cure for women with de novo DO was significantly lower at 8 out of 16 (50%) compared with 599 out of 672 (89.1%) in those with detrusor stability (p < 0.001). Quality of life improved for all. Age ≥ 66 (OR, 1.23; 1.07), increased bladder sensation (OR, 4.18; 3.80), lower bladder capacity (OR, 5.28; 4.97), lower maximum urethral closure pressure (OR, 2.32; 5.20), and pad test > 100 g (OR, 1.08; 1.15) were independent risk factors for de novo urgency and DO. Diabetes (OR, 1.32) was an independent predictor of de novo urgency.

CONCLUSION

Cure is significantly reduced in women who report symptoms of de novo urgency or demonstrate DO after MUS at 1 year. Independent risk factors include age ≥ 66, increased bladder sensation, lower bladder capacity, lower maximum urethral closure pressure, greater pad loss, and diabetes.

What to do after a mid-urethral sling fails

PURPOSE OF REVIEW

After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated.

RECENT FINDINGS

Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling.

SUMMARY

MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.

Clinical value of needleless sling in treatment of female stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a common disease in women. The emergence of the needle-free sling has led to a new clinical treatment for SUI in women.

AIM

To explore the clinical value of the needleless sling without acupuncture in the treatment of SUI in women.

METHODS

From February 2017 to November 2018, according to the order of admission, 44 patients (mid-suspension group) were treated by tension-free transobturator urethral suspension, and 44 patients (non-acupuncture group) were treated with a needleless non-acupuncture band. The clinical effects of the two treatments were evaluated.

RESULTS

There was no significant difference between the two groups in the total clinical effectiveness rate (P = 0.374), but intraoperative blood loss and visual analogue scale score at postoperative day 1 were significantly lower in the non-acupuncture suspension group than in the middle urethral suspension group (P = 0.396). The incidence of complications in the needle-free sling group was significantly lower than that in the middle urethral suspension group (P = 0.025).

CONCLUSION

The clinical effectiveness of acupuncture-free suspension in treating SUI in female patients is better than that of traditional tension-free transobturator mid-urethral suspension.