Colposuspension or sling for low urethral pressure stress incontinence?

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study

BACKGROUND

There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making.

OBJECTIVE

This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling.

STUDY DESIGN

A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding.

RESULTS

The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00).

CONCLUSION

This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Evaluation and Classification of Stress Urinary Incontinence: Current Concepts and Future Directions

CONTEXT

Stress urinary incontinence (SUI) is a common and bothersome problem that frequently requires operative management. Over the past two decades, novel techniques have been introduced into clinical practice. With the greater variety of surgical options now available, there is an increasing focus on selecting the appropriate procedure for the individual patient based on the likely underlying pathophysiologic mechanism.

OBJECTIVE

To review the methods used in the evaluation of SUI and the proposed classification systems.

EVIDENCE ACQUISITION

A search of the PubMed database for the relevant search terms was conducted, and selected articles were retrieved and reviewed.

EVIDENCE SYNTHESIS

Standardised terminology for the description of SUI has been produced by the International Continence Society describing the problem in terms of symptoms, clinical signs, and urodynamic observations. The two major pathophysiologic theories that have emerged over the past 50 yr, urethral hypermobility and intrinsic sphincteric deficiency, have influenced the development and adoption of surgical techniques. It is now recognised that these two entities are not dichotomous but often coexist. The primary aim of the evaluation of the patient presenting with SUI is to confirm the diagnosis and assess symptom severity before instituting conservative treatments. Secondary evaluation consists of more sophisticated techniques that assess anatomy of the bladder neck and urethra under rest and stress (eg, videourodynamics, ultrasound) or direct or indirect physiologic measures of the integrity of the sphincter mechanism.

CONCLUSIONS

Classification of patients with SUI into distinct groups based on probable pathophysiologic mechanism could help guide the choice of surgical procedure, but current systems are likely too simplistic, and methods of assessment lack standardisation in techniques and sensitivity.

PATIENT SUMMARY

Urinary leakage on exertion, termed stress incontinence, is a common problem that affects many women. There is a need to develop better ways of categorising the underlying causes of leakage to ensure that patients receive the optimal treatments.

The correlation of urethral resistance pressure with maximum urethral closure pressure and stress incontinence

OBJECTIVE

Aim of the study was to correlate urethral retro resistance pressure with the maximum urethral closure pressure (MUCP) and functional urethral length (FUL) in patients with urinary incontinence and healthy individuals.

STUDY DESIGN

Two hundred and twenty patients with the complaint of urinary incontinence had a urodynamic examination including urethral pressure profiles and URP. Additionally, 15 healthy individuals without the complaint of any incontinence had their URP and urethral pressure profiles measured. The correlation of MUCP, FUL and URP were calculated using Graph Pad Instat 4.0 for windows.

RESULTS

URP correlates well with the diagnosis of urodynamic stress incontinence. Correlation coefficient between URP and MUCP is 0.9262. Healthy individuals have significantly higher values for URP and MUCP.

CONCLUSION

URP is a valuable less invasive test than conventional urethral function tests for the diagnosis of urodynamic incontinence with an excellent correlation of MUCP and URP.

A comparative study of water perfusion catheters and microtip transducer catheters for urethral pressure measurements

The aim of this study was to compare the maximum urethral closure pressure (MUCP) measures with two different techniques: water perfused catheter and microtip transducer catheters with respect to reproducibility and comparability for urethral pressure measurements. Eighteen women with stress urinary incontinence had repeat static urethral pressure profilometry on a different day using a dual microtip transducer and water perfused catheter (Brown and Wickham). The investigators were blinded to the results of the other. The microtip measurements were taken in the 45 degrees upright sitting position with the patient at rest at a bladder capacity of 250 ml using an 8 Fr Gaeltec double microtip transducer withdrawn at 1 mm/s, and the transducer was orientated in the three o'clock position. Three different measures were taken for each patient. Three water perfusion measurements were performed with the patient at rest in the 45 degrees upright position at a bladder capacity of 250 ml using an 8 Fr BARD dual lumen catheter withdrawn at 1 mm/s. The mean water perfusion MUCP measure was 26.1 cm H2O, significantly lower than the mean microtip measure of 35.7 cm H2O. The correlation coefficient comparing each water perfusion measurement with the other water perfusion measures in the same patient was excellent, at 0.95 (p = 0.01). Correlation coefficient comparing each microtip measure with the other microtip measure in the same patient was also good, ranging from 0.70 to 0.80. This study confirms that both water perfusion catheters and microtip transducers have excellent or very good reproducibility with an acceptable intraindividual variation for both methods.

Tension-free vaginal tape (TVT) for treatment of stress urinary incontinence in women with low-pressure urethra

OBJECTIVE

To assess the results of TVT in patients with urinary stress incontinence, urethral hypermobility, and low-pressure urethra.

STUDY DESIGN

We retrospectively analysed 265 consecutive women who underwent a TVT procedure for urodynamic stress urinary incontinence over a 31-month period. Women were divided into two groups depending on their preoperative maximum urethral closure pressure (MUCP). Group 1 (61 women with MUCP<or=20 cm H2O) were compared with 204 women (group 2) with a MUCP>20 cm H2O. Subjective and objective outcome data were assessed from routine postoperative visits. Office and hospital records were reviewed to check patients' characteristics, intraoperative findings, and surgical outcomes.

RESULTS

Women with low-pressure urethra were older than those with MUCP>20 cm H2O; they were more likely to have had a hysterectomy or anti-incontinence surgery. The mean duration of follow-up was 31 (+/-11) months. Cure rates among patients with low- or normal-pressure urethra were similar (77% and 86%, P=0.70). Nevertheless, the former were more likely to complain of voiding dysfunction.

CONCLUSION

TVT is a highly effective treatment even in women with intrinsic sphincter deficiency.

Prevalence of persistent and de novo overactive bladder symptoms after the tension-free vaginal tape

OBJECTIVE

The purpose of this study was to assess 1) the proportion of de novo urge incontinence and overactive bladder symptoms after a tension-free vaginal tape (TVT), and 2) the natural history of preoperative urge incontinence and overactive bladder symptoms after a TVT.

METHODS

A chart review was performed on all patients who underwent a TVT without concomitant procedures from November 1998 to November 2002. Preoperative and postoperative stress and mixed urinary incontinence symptoms as well as overactive bladder symptoms were assessed subjectively, as was the use of anticholinergics to treat overactive bladder symptoms. Two preoperative and postoperative validated quality-of-life questionnaires, the Incontinence Impact Questionnaire (IIQ-7) and Urinary Distress Inventory (UDI-6), were also compared.

RESULTS

Ninety-eight patients were included in the study. Postoperatively, de novo urge incontinence symptoms developed in 9.1%, de novo overactive bladder symptoms developed in 4.3%, and 8.7% started taking anticholinergics for the first time. After a TVT, the urge component resolved in 63.1% of those with preoperative symptoms of mixed incontinence, overactive bladder symptoms resolved in 57.3% of those with preoperative overactive bladder symptoms, and 57.7% of those who used anticholinergics preoperatively no longer needed to do so. There was also a statistically significant improvement in comparing the preoperative and postoperative IIQ-7 and UDI-6 scores.

CONCLUSION

The proportion of patients in whom de novo overactive bladder or urge incontinence symptoms developed postoperatively is low, and approximately 57% of patients with preoperative overactive bladder symptoms can expect resolution of these symptoms after a TVT.

Assessing outcome after a modified vaginal wall sling for stress incontinence with intrinsic sphincter deficiency

Forty women with stress incontinence, intrinsic sphincter deficiency (ISD), associated or not with urethral hypermobility, a Valsalva leak point pressure (VLLP)<60 cmH(2)0 and a maximum urethral closure pressure<30 cmH(2)0 underwent in situ vaginal wall sling. The main modification to the technique was the use of two small Marlex meshes placed at the lateral edges of the sling. Outcome was assessed by pad use, surgical results and patients' satisfaction. Data of 39/40 patients were analyzed after a minimum follow-up of 1 year. After surgery 30/39 patients were completely dry (no pads), stress incontinence disappeared in 22/39, and 30/39 patients were satisfied with outcome. Reasons for dissatisfaction included recurrence of stress incontinence in three, infections in one and urge incontinence in five. Overall results are good given this category of patients. The vaginal wall sling can be recommended for patients with ISD because the results are promising, it corrects urethral hypermobility and, in our experience, it does not cause obstruction if correctly performed.

Sling failures: What’s next?

The pubovaginal sling has been used to treat anatomic, functional, and recurrent stress urinary incontinence for decades with excellent results. Nevertheless, enthusiasm for the pubovaginal sling is tempered by the surgical morbidity and postoperative voiding dysfunction associated with it. New modifications such as alternative sling materials, bone anchor suspension, and midurethral slings have been developed to reduce operating time and surgical morbidity. The less invasive approaches are now well recognized and midurethral slings have become the most common procedure performed for stress urinary incontinence. Despite the ubiquity of sling procedures in all of their forms, there is no consensus on the management of sling failures. Recent literature suggests that similar to primary genuine stress incontinence, recurrent stress urinary incontinence as a result of sling failure is being successfully managed with less invasive techniques.

Pubovaginal sling in the treatment of stress urinary incontinence for urethral hypermobility and intrinsic sphincteric deficiency

PURPOSE

This study was undertaken to evaluate the use of pubovaginal sling for the treatment of female stress urinary incontinence in patients with intrinsic sphincteric deficiency and patients with urethral hypermobility.

MATERIALS AND METHODS

Sixty-two patients aging 22 to 73 years-old (mean = 49.6) with a median parity of 4.1 (range 0 - 14) who underwent pubovaginal autologous fascial sling procedures for stress urinary incontinence from August/1999 to August/2002 were prospectively analyzed. Objective pre and postoperative urodynamic evaluation was performed in all cases. The patients were divided into 2 groups: thirty-nine patients (62.9%) with urethral hypermobility (Valsalva leak point pressure equal or superior to 60 cm of H(2)O) and twenty-three patients (37.1%) with intrinsic sphincteric insufficiency (Valsalva leak point pressure below 60 cm of H(2)O).

RESULTS

The average follow-up period was 24.8 months, ranging from 3 to 38 months. Three patients (4.8%) had detrusor overactivity before the operation, and 36 patients (58.1%) had voiding dysfunction before surgery. The postoperative objective cure rate was 88.7% for stress urinary incontinence. The study also showed that 32.2% of the patients had voiding dysfunction and 11.3% had detrusor overactivity. The mean hospital stay was 3.1 days (range 2 - 4). No difference in the above parameters was noticed between patients with intrinsic sphincteric deficiency and those with urethral hypermobility.

CONCLUSION

Construction of a pubovaginal sling is an effective technique for the relief of severe stress urinary incontinence, for both patients with urethral hipermobility and with intrinsic sphincteric deficiency, having a cure rate of 88.7%. The high frequency of postoperative voiding urgency was not related to the detrusor overactivity as evaluated by urodynamic studies.

Laparoscopic Two-Team Slings for Women with Stress Urinary Incontinence

STUDY OBJECTIVE

To review long-term success and complication rates of laparoscopic two-team sling procedures in women with stress urinary incontinence or mixed incontinence confirmed by urodynamic testing and cystoscopy.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Tertiary urogynecology unit at a university-affiliated teaching hospital.

PATIENTS

One hundred seventy-five women.

INTERVENTIONS

Laparoscopic two-team sling procedure.

MEASUREMENTS AND MAIN RESULTS

The extraperitoneal approach to the space of Retzius was accomplished using a balloon device, and the intraperitoneal approach involved a transverse incision through the anterior parietal peritoneum 6 cm above the symphysis. A 1.5- to 2.0-cm wide strip of polypropylene mesh was inserted through a vertical incision along the anterior vaginal wall, perforating the urogenital diaphragm under laparoscopic guidance. The mesh was sutured to Cooper's ligaments bilaterally with 0 polypropylene sutures. Mean operating time was 80.1 +/- 30.0 minutes, mean estimated blood loss was 160 +/- 146 ml, and mean hospital stay was 2.4 +/- 1.2 days. Patients were followed at 6 weeks, 6 months, 1 year, and yearly (mean 17.8 mo, range 1-5 yrs).

CONCLUSION

Laparoscopic two-team sling procedures can be performed safely in women with recurrent stress incontinence and those with risk factors for failure of retropubic urethropexy. Long-term success rates are excellent (91.1%) with few complications.

De novo urge syndrome and detrusor instability after anti-incontinence surgery: current concepts, evaluation, and treatment

The onset of de novo irritative voiding symptoms after anti-incontinence surgery for stress urinary incontinence is troubling to both patient and physician alike. At present, mechanisms responsible for the development of these symptoms are incompletely elucidated. Although bladder outlet obstruction may certainly be a cause, correct diagnosis and treatment of this condition in its more insidious manifestation may be difficult. In addition, alternative etiologic factors related to surgical technique during outlet enhancing surgery may play a role, prompting a rethinking of these procedures. In this discussion, we review changes in voiding physiology and mechanisms for voiding dysfunction after anti-incontinence surgery, emphasizing de novo urge syndrome and detrusor instability. In addition, we present our approach to the evaluation, diagnosis, and treatment of these challenging patients.

A comparison of urethral pressure profilometry using microtip and double-lumen perfusion catheters in women with genuine stress incontinence

OBJECTIVE

To compare urethral pressure profilometry measurements using microtip transducer and double-lumen perfusion catheters.

DESIGN

Prospective study.

SETTING

Tertiary referral urogynaecology unit.

SAMPLE

Three hundred and ninety two non-pregnant women with various lower urinary tract symptoms.

METHODS

Multichannel urodynamic investigations were performed using double-lumen perfusion catheters with external pressure transducers in 392 women. For those 301 (76.8%) diagnosed as having genuine stress incontinence, an investigation with microtip transducers followed. For data analysis, a mixed-effects model was used to evaluate changes in the urethral profilometry and an approach proposed by Bland and Altman was applied to access agreement between the two techniques.

RESULTS

Of the 301 women with genuine stress incontinence, 272 were eligible for this study. In resting status, the differences between the two techniques were statistically significant (48.9cm H2O vs 73.4cm H2O, P = 0.0001) after adjusting for age. Moreover, the agreement study also confirmed that these two techniques do not agree sufficiently.

CONCLUSION

Maximum urethral closure pressure obtained from the double-lumen catheter was significantly higher than that obtained from the microtip catheter. Use of the double-lumen catheter for the measurement of maximum urethral closure pressure can be considered a reliable technique since its reproducibility is as good as that of the microtip catheter. Therefore, the diagnosis of 'low pressure urethra' will be different between the two techniques.

Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence?

Urethral pressure profilometry is commonly used as a diagnostic test for stress urinary incontinence. The objective of this article is to review the published literature on urethral pressure profilometry to summarize its usefulness. MEDLINE was used to search the published English literature from 1966 to October 2000 for full-length original research articles on urethral pressure profilometry and stress urinary incontinence in women. Terms related to urethral pressure profilometry are defined consistently but techniques are not standardized, introducing variation in test results. Reproducibility of urethral pressure profilometry parameters is poor, both because of biological variation and variation within the test procedure itself (related in part to lack of standardization). Parameters of urethral pressure profilometry do not distinguish between continent and incontinent women and do not characterize the severity of incontinence or urethral incompetence. It is, therefore, concluded that urethral pressure profilometry is not a useful diagnostic test for stress urinary incontinence in women. Its use in clinical management is not supported by current evidence.