Long-term results of the tension-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incontinence

Bladder neck placement of a synthetic polypropylene sling for the treatment of stress urinary incontinence

INTRODUCTION

Pubo-vaginal sling placed at the bladder neck is the gold standard treatment for stress urinary incontinence (SUI). The synthetic mid-urethral sling (MUS) is now widely used, as morbidity rates with this technique are substantially reduced. This is an initial report on long-term outcomes of a polypropylene sling (PPS) placed in the traditional bladder neck location.

METHODS

A retrospective analysis of all patients who underwent PPS insertion at our institution between 2006 and 2014 was conducted. Patient and urodynamic demographics were recorded. Subjective and objective measures of success were determined by postoperative pad usage and validated incontinence questionnaires.

RESULTS

A total of 170 patients were followed for a median of four years (range 1-8). The mean age was 51 years (±10). Subjective response was assessed in 57% of patients; the overall subjective cure rate was 85.3% (n=145), subjective improvement rate was 4.1% (n=7), and the subjective failure rate was 10.6% (n=18). The mean Urogenital Distress Inventory (UDI)-6 score was 6.5 (±5.6) out of a maximum score of 24 and the Incontinence Impact Questionnaire (IIQ)-7 score was 5.5 (±6.3) out of a maximum score of 28. There was no significant difference in objective outcome measures in those with an abdominal leak-point pressure (ALPP) < or >60 cmH₂O.

CONCLUSIONS

Bladder neck placement of a PPS resulted in cure rates of 85% in this series. SUI secondary to intrinsic sphincter deficiency (ISD) and urethral hypermobility were treated with equal success. Bladder neck PPS placement has a role in the treatment of SUI. Our data may well reassure rectus fascia sling (RFS) surgeons who wish to take advantage of faster postoperative recovery using the less invasive PPS placed at the bladder neck.

Update on complications of synthetic suburethral slings

Synthetic suburethral slings have become the most widely used technique for the surgical treatment of stress urinary incontinence. Despite its high success rates, significant complications have been reported including bleeding, urethral or bladder injury, urethral or bladder mesh erosion, intestinal perforation, vaginal extrusion of mesh, urinary tract infection, pain, urinary urgency and bladder outlet obstruction. Recent warnings from important regulatory agencies worldwide concerning safety issues of the use of mesh for urogynecological reconstruction have had a strong impact on patients as well as surgeons and manufacturers. In this paper, we reviewed the literature regarding surgical morbidity associated with synthetic suburethral slings.

Cumulative Incidence of a Subsequent Surgery After Stress Urinary Incontinence and Pelvic Organ Prolapse Procedure

OBJECTIVE

To assess the 5-year risk and timing of repeat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures.

METHODS

We conducted a retrospective cohort study using a nationwide database, the 2007-2014 MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases (Truven Health Analytics), which contain deidentified health care claims data from approximately 150 employer-based insurance plans across the United States. We included women aged 18-84 years and used Current Procedural Terminology codes to identify surgeries for SUI and POP. We identified index procedures for SUI or POP after at least 3 years of continuous enrollment without a prior procedure. We defined three groups of women based on the index procedure: 1) SUI surgery only; 2) POP surgery only; and 3) Both SUI+POP surgery. We assessed the occurrence of a subsequent SUI or POP procedure over time for women younger than 65 years and 65 years or older with a median follow-up time of 2 years (interquartile range 1-4).

RESULTS

We identified a total of 138,003 index procedures: SUI only n=48,196, POP only n=49,120, and both SUI+POP n=40,687. The overall cumulative incidence of a subsequent SUI or POP surgery within 5 years after any index procedure was 7.8% (95% confidence interval [CI] 7.6-8.1) for women younger than 65 years and 9.9% (95% CI 9.4-10.4) for women 65 years or older. The cumulative incidence was lower if the initial surgery was SUI only and higher if an initial POP procedure was performed, whether POP only or SUI+POP.

CONCLUSIONS

The 5-year risk of undergoing a repeat SUI or POP surgery was less than 10% with higher risks for women 65 years or older and for those who underwent an initial POP surgery.

[Placement of tension-free vaginal tape in women with stress urinary incontinence: Long-term functional outcomes in a prospective series]

PURPOSE

To evaluate the long-term functional outcomes after retropubic tension-free vaginal tape (TVT) placement to treat female stress urinary incontinence (SUI).

METHODS

From September 1998 to September 2000, we prospectively enrolled all consecutive women in our center suffering SUI caused by urethral hypermobility. All women had a retropubic TVT inserted by the same surgeon. Patients were evaluated at 1, 3, 6 and 12 months postoperatively, and annually thereafter. Postoperative assessment included a measurement of post-voiding residual volume, urinalysis, a 1-hour pad test, a urinary symptom questionnaire, and an assessment of quality-of-life. Objective continence (defined as no urine leakage at clinical examination) and subjective continence (defined as no urine leakage, whatever the mechanism, reported by the patient) were reported.

RESULTS

Overall, 58 consecutive women (median age 59; IQR 49-67; min 21-max 78) were evaluated. Median follow-up was 10.2years (IQR 1.4-16.0; min 1-max 13.2). At the last follow-up, objective and subjective continence rates were 93% and 78%, respectively and remained stable in the long run. Pad tests, urinary symptom questionnaire scores and quality-of-life were significantly improved. Self-intermittent catheterisation was required by three women. A section of one TVT and removal of another tape was undertaken in two women with chronic pelvic pain. One patient had a chronic urinary infection. Rate of de novo urgency was 10%.

CONCLUSIONS

TVT implantation offered good and stable functional long-term outcomes. This procedure enhanced quality-of-life and had low morbidity.

LEVEL OF EVIDENCE

3.

Analysis of two sling procedures using polypropylene mesh for treatment of stress urinary incontinence

OBJECTIVES

To evaluate and compare the surgical outcome between the innovative tension-free vaginal tape (TVT) and conventional pubovaginal sling (PVS) procedures using polypropylene mesh.

METHODS

Eighty consecutive women with urodynamic stress urinary incontinence (SUI), who chose to undergo either a TVT (n=23) or a PVS (n=57) procedure using polypropylene mesh based on financial consideration, were recruited for this study. The surgical results were analyzed and compared subjectively and objectively.

RESULTS

The mean follow-up interval was 23 months for the TVT and 20 months for the PVS procedure (P=0.062). Postoperatively, SUI (91.3% vs. 93.0%), concomitant urge symptoms (85.0% vs. 85.3%) and the negative impact of incontinence and urogenital distress on patients' quality of life (79.8% vs. 77.8%) (77.4% vs. 68.8%) had improved markedly. After a multivariable logistic regression analysis, the treatment outcome of SUI was found to be independent of the main effects of patient age, parity, concurrent gynecological surgeries, intrinsic sphincter deficiency, previous failed incontinence surgeries, and concomitant urge symptoms. However, it was significantly related to treatment procedures (TVT vs. PVS) and their interaction with patient body mass index (BMI). Based on the fitted logistic model, we see that TVT performs better than PVS when BMI is less than 27.27 kg/m2, and the advantage of TVT decreases as BMI increases.

CONCLUSION

Both TVT and PVS procedures using polypropylene mesh are effective treatment modalities for female SUI. However, TVT was not as effective in treating overweight or obese women as PVS.

Long-term efficacy and safety of tension free vaginal tape in a historic cohort of 463 women with stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We report retrospective data on the long-term safety and efficacy of the retropubic midurethral sling (MUS) in a large series of women with stress urinary incontinence.

METHODS

In all, 517 patients were treated during the period January 2005 to June 2012 at a single centre in France. The Urinary Symptoms Profile score was used to identify women who were subjectively cured or improved or in whom treatment had failed. The rates of peroperative, and early (<30 days) and late postoperative complications were recorded.

RESULTS

A total of 463 patients were evaluable at a mean (±SD) follow-up of 71 ± 23 months. At the last follow-up, 344 patients (74.3 %) demonstrated subjective cure, 55 (11.9 %) were improved and 64 (13.8 %) had treatment failure. Bladder perforations occurred in 33 patients (7.1 %); however, this had no effect on cure rate. In the early postoperative period, temporary intermittent self-catheterization was required in 10 patients (2.2 %) due to voiding difficulties. The most frequent long-term postoperative complication was de novo urge incontinence that was reported by 59 patients (12.7 %); seven patients (1.5 %) needed tape excision due to voiding difficulties and six (1.3 %) needed tape removal due to erosion or chronic pain.

CONCLUSIONS

The retropubic MUS was shown to be durable at a mean follow-up of 71 ± 23 months, with a high success/improvement rate and no serious long-term tape-induced adverse effects.

Endopelvic free anchor minisling technique for stress urinary incontinence treatment: 10 years of experience

INTRODUCTION AND HYPOTHESIS

We present our 10-year experience in treating stress urinary incontinence (SUI) using a new minisling technique based on a tension-free vaginal tape band designed by our group. The major advantage of this tape is the use of minibelt polypropylene inserted through a single retropubic incision without the use of needles-the Endopelvic Free Anchor (EFA)-based on its location at the midurethra with a U shape. For insertion, each branch is placed using a simple Pean clamp from the vagina with perforation of the endopelvic fascia to achieve a retropubic insertion.

METHODS

From May 2001 to May 2011, we surgically treated 166 women with primary first- or second-degree SUI due to urethral hypermobility without genital prolapse. All were evaluated according to our study protocol, which included clinical and urodynamic evaluation before and 12 months after surgery.

RESULTS

With a median follow-up of 5 (1-11) years, 152 patients (91.6 %) were fully cured both from urodynamic and subjective points of view. Six patients (3.6 %) had significant improvement, and eight (4.8 %) were identified as technique failure. Complications included one bladder perforation (0.6 %), two cases of postoperative urinary retention (1.24 %), two of retropubic hematoma (1.24 %), and one of de novo urgency (0.6 %). No reinterventions were necessary, and there were no major bleeding complications, no chronic pain or de novo dyspareunia, and no voiding difficulty.

CONCLUSIONS

EFA is a viable, safe, and effective technique for treating UI due to urethral hypermobility.

The surgical management of recurrent stress urinary incontinence: a systematic review

BACKGROUND

Despite a wide spectrum of interventions, surgical treatments of recurrent stress urinary incontinence (SUI) are associated with high failure rates.

OBJECTIVES

To systematically review current evidence on the effectiveness of surgical interventions for recurrent SUI.

DATA SOURCES

An electronic database search was undertaken (1980-2014). Keywords were: "stress urinary incontinence," "failure," "recurrence," "treatment." References of identified studies and abstracts from conferences were considered.

STUDY SELECTION

We restricted the search to female patients and currently used surgical procedures, including studies with five or more cases. After the initial yield, studies were selected following title screening, abstract and full text scrutiny.

RESULTS

The pooled objective cure rates of colposuspension for recurrent SUI are 76% (95% CI ±5.04), whereas rates for midurethral sling procedures are 68.5% (95% CI ±3.11). Repeat midurethral sling procedures have pooled success rates of 66.2% (95% CI ±4) but those of the transobturator approach appear lower than retropubic procedures. Pubovaginal slings for recurrent SUI have pooled success of 79.3% (95% CI ±6.54). Success rates for adjustable continence therapy and adjustable slings for recurrent SUI are 53.8% (95% CI ±5.28), whereas for midurethral sling fixation procedures the pooled success is 61% (95% CI ±10.56). Urethral bulking injections have success rates of 38% (95% CI ±10.7). Laparoscopic two-team sling procedures, salvage spiral slings, and artificial urinary sphincter have shown promising results, but there are limited data on recurrent cases.

CONCLUSION

There is a wide spectrum of surgical interventions reported for secondary or tertiary treatment of SUI. A common characteristic for all recurrent procedures is a lower success rate compared with those reported following primary procedures.

Transvaginal retropubic sling systems: efficacy and patient acceptability

Stress urinary incontinence is a common, disabling, and costly medical problem that affects approximately 50% of women with urinary incontinence. Suburethral retropubic slings have been developed as a minimally invasive and effective surgical option, and they have been used as a first-line treatment for stress urinary incontinence since 1995. However, complications including vaginal extrusion, erosion, pain, bleeding, infections, lower urinary tract symptoms, urinary retention, and incontinence have been reported with use of the slings. Several companies manufacture sling kits, and the sling kits vary with regard to the composition of the mesh and introducer needle. The aim of this review was to determine which sling kit was most effective for patients, had minimal reported side effects, and was best accepted by patients and surgeons. In a review of the literature, it was found that a total of 38 studies were published between 1995 and 2014 that reported on eight tension-free retropubic sling kits: SPARC, RetroArc, Align, Advantage, Lynx, Desara, Supris, and Gynecare TVT. The Gynecare TVT was the most cited sling kit; the second most cited was the SPARC. This review provides a summary of the studies that have examined positive and negative outcomes of the retropubic tension-free suburethral sling procedure using various sling kits. Overall, the results of the literature review indicated that data from comparisons of the available sling kits are insufficient to make an evidenced-based recommendation. Therefore, the decision regarding which sling kit is appropriate to use in surgery is determined by the medical provider’s preference, training, and past experience, and not by the patient.

Dynamic maximum urethral closure pressures measured by high-resolution manometry increase markedly after sling surgery

INTRODUCTION AND HYPOTHESIS

The premise of midurethral sling (MUS) surgery is to apply a tension-free vaginal tape in the midurethra that does not constrict the urethra at rest but stabilizes the urethra and prevents downward descent and opening of the urethra during stress maneuvers, but current technology has limitations in measuring urethral pressures during dynamic conditions. Our objective was to describe the change in maximum urethral closure pressures (MUCPs) after MUS surgery using an 8F high-resolution manometry (HRM) system that can measure urethral pressures during cough and strain maneuvers (ManoScan® ESO; Covidien) without migration or withdrawal limitations.

METHODS

We measured rest, cough, and strain MUCPs in 26 women before and after retropubic or transobturator MUS for stress urinary incontinence using the HRM system.

RESULTS

The objective success rate after MUS was 92.3 % based on postoperative cough stress testing. Mean resting MUCPs measured by HRM did not change after surgery (59.3 before vs. 59.7 cm H2O after surgery; p = 1.0). Mean cough MUCPs measured by HRM increased from 36.9 to 100.7 cm H2O (p < 0.001), and strain MUCPs increased from 35.0 to 92.7 cm H2O (p < 0.001).

CONCLUSIONS

Advanced HRM technology to measure MUCPs under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism after tension-free MUS: MUCPs do not change at rest but do increase significantly during cough and strain maneuvers.

5-year longitudinal followup after retropubic and transobturator mid urethral slings

PURPOSE

Few studies have characterized longer-term outcomes after retropubic and transobturator mid urethral slings.

MATERIALS AND METHODS

Women completing 2-year participation in a randomized equivalence trial who had not undergone surgical re-treatment for stress urinary incontinence were invited to participate in a 5-year observational cohort. The primary outcome, treatment success, was defined as no re-treatment or self-reported stress incontinence symptoms. Secondary outcomes included urinary symptoms and quality of life, satisfaction, sexual function and adverse events.

RESULTS

Of 597 women 404 (68%) from the original trial enrolled in the study. Five years after surgical treatment success was 7.9% greater in women assigned to the retropubic sling compared to the transobturator sling (51.3% vs 43.4%, 95% CI -1.4, 17.2), not meeting prespecified criteria for equivalence. Satisfaction decreased during 5 years but remained high and similar between arms (retropubic sling 79% vs transobturator sling 85%, p=0.15). Urinary symptoms and quality of life worsened with time (p <0.001), and women with a retropubic sling reported greater urinary urgency (p=0.001), more negative impact on quality of life (p=0.02) and worse sexual function (p=0.001). There was no difference in the proportion of women experiencing at least 1 adverse event (p=0.17). Seven new mesh erosions were noted (retropubic sling 3, transobturator sling 4).

CONCLUSIONS

Treatment success decreased during 5 years for retropubic and transobturator slings, and did not meet the prespecified criteria for equivalence with retropubic demonstrating a slight benefit. However, satisfaction remained high in both arms. Women undergoing a transobturator sling procedure reported more sustained improvement in urinary symptoms and sexual function. New mesh erosions occurred in both arms over time, although at a similarly low rate.

[Complication management in prolapse and incontinence surgery]

Tension-free alloplastic slings (TFAS) have revolutionized surgery for female stress urinary incontinence for more than 20 years. The procedure is easy to perform, minimally invasive with a short operating time in an outpatient setting and has proven efficacy comparable to retropubic colposuspension. The frequency of surgery for female stress incontinence has tripled within one decade which has to have an impact on the number of complications. In contrast, sacrocolpopexy has remained the gold standard in urological prolapse surgery as none of the new techniques has reached similar efficacy or safety; however, possible complications have to be named and their causes have to be understood to maintain the highest quality of care in the future. Possible complications of TFAS are potentially underestimated with respect to prevalence and manageability. Possible complications of prolapse and incontinence surgery are presented and the underlying causes are identified. Knowledge of the pathophysiology and the cause of complications together with the results of a postoperative diagnostic work-up, allow complication management to be tailored to each individual patient. To prevent complications all conservative treatment options should have been tried preoperatively and a complete evaluation (including urodynamics) should have been carried out for every patient. Postoperative urodynamics may help to document treatment success and to identify and quantify complications.

Prevalence, Risk Factors, Quality of Life, and Health-Care Seeking Behaviors of Female Urinary Incontinence: Results From the 4th Korean National Health and Nutrition Examination Survey VI (2007-2009)

Purpose

There is a lack of information on female urinary incontinence (UI) in South Korea. We investigated the prevalence, risk factors, quality of life (QoL), and healthcare-seeking behaviors of women with UI.

Methods

We included 9,873 women over the age of 20 years who had participated in the Korea National Health and Nutrition Examination Survey IV. The condition of UI was defined as answering "yes" to the question "Do you have UI?" Additionally, health care seeking behavior for UI was defined as answering "yes" to "Have you ever been treated for UI?' The EuroQoL-5 Dimension (EQ-5D) descriptive system was used to evaluate QoL.

Results

The mean age of our sample was 49.7 years. The overall prevalence of UI was 7.9%. The prevalence of UI significantly increased with age. The rate of healthcare-seeking behavior for UI also significantly increased with age. However, the rate of healthcare seeking for UI was significantly lower when compared to the prevalence of UI. In our multivariate analysis, age, body mass index, and marriage were significantly and independently associated with UI. As the severity of all the subscales of EQ-5D increased, the unadjusted odds ratio for UI also increased. After adjusting for potential confounders, the subscales of mobility, usual activities, pain/discomfort, and anxiety/depression from the EQ-5D were significantly associated with UI.

Conclusions

UI is a common disease and is significantly associated with QoL. Our results suggest the need for developing preventive measures and treatment policies for UI.

Implantation of autologous adipose-derived cells reconstructs functional urethral sphincters in rabbit cryoinjured urethra

We investigated the ability of autologous adipose-derived cells injected into cryoinjured rabbit urethras to improve urinary continence and explored the possible mechanisms by which it occurred. Adipose tissue was harvested from the perivesical region of nine 10-week-old female New Zealand White rabbits and cultured for 7 days. Immediately after harvesting the tissue, we injured the internal urethral orifice by spraying liquid nitrogen for 20 s. The cultured cells expressed the mesenchymal cell marker STRO1, but not muscle cell markers myoglobin or smooth muscle actin (SMA). Just before implantation, the adipose-derived cells were labeled with the PKH26 fluorescent cell linker. Autologous 2.0×10(6) adipose-derived cells (five rabbits) or a cell-free control solution (four rabbits) was injected around the cryoinjured urethras at 7 days after injury. Fourteen days later, the leak point pressure (LPP) was measured, and the urethras were harvested for immunohistochemical analyses. At 14 days after implantation, LPP of the cell-implanted group was significantly higher compared with the cell-free control group (p<0.05). In immunohistochemical examination, the reconstructed skeletal and smooth muscle areas in the cell-implanted regions were significantly more developed than those in controls (p<0.01). Implanted PKH26-labeled adipose-derived cells were immunohistochemically positive for myoglobin, SMA, and Pax7 antibodies, which are markers for skeletal muscles, smooth muscles, and myoblast progenitor cells, respectively. In addition, these implanted cells were positive for the nerve cell markers, tubulin β3, S100, and the vascular endothelial cell marker, von Willebrand factor. Furthermore, some of the implanted cells were positive for the transforming growth factor β1, nerve growth factor, and vascular endothelial growth factor. In conclusion, implantation of autologous adipose-derived cells into the cryoinjured rabbit urethras promoted the recovery of urethral function by myogenic differentiation, neuroregeneration, and neoangiogenesis of the implanted cells and/or the surrounding tissues as well as by bulking effects. Thus, treatment of human radical prostatectomy-related stress urinary incontinence by adipose-derived cell implantation could have significant therapeutic effects.

Effect of preoperative flow rate on postoperative retention and voiding difficulty after transobturator tape operation

Purpose

Controversy exists over the preoperative risk factors for postoperative urinary retention after the midurethral sling procedure for stress urinary incontinence (SUI). We intended to analyze the effect of preoperative flow rate on postoperative urinary retention after the transobturator tape (TOT) operation.

Materials and Methods

A total of 322 patients who underwent TOT from June 2006 to May 2012 were included in this retrospective study. All patients were preoperatively investigated for urinary symptoms and underwent preoperative urodynamic studies including urine flow rate. Postoperative urinary retention, voiding difficulty, and uroflowmetry were checked. Urinary retention was defined as the need for additional catheterization longer than 1 day. Patients were divided by preoperative peak flow rate (Qmax) of 15 mL/s (low Qmax group and normal Qmax group).

Results

There were 3 cases of postoperative urinary retention (0.9%) and 52 cases of voiding difficulty (16.1%). The low Qmax group included 40 patients (12.4%) and the normal Qmax group included 282 patients (87.5%). Between the two groups, there were no significant differences in age, previous pelvic surgery history, or past medical history. The low Qmax group had higher scores for voided volume and detrusor pressure at Qmax. However, there was no significant difference in postoperative voiding difficulty between the two groups. Furthermore, three patients who experienced postoperative retention showed high flow rates preoperatively.

Conclusions

Our results suggest that voiding difficulty in the group with low preoperative flow was tolerable and the treatment success rate was comparable to that in patients in the normal flow group. According to our analysis, patients with a low flow rate preoperatively can be safely treated with TOT for SUI.

Tension-free vaginal tape, transobturator tape, and own modification of transobturator tape in the treatment of female stress urinary incontinence: comparative analysis

INTRODUCTION

This study is a comparative evaluation of the TVT, TOT, and our own modification of TOT (mTOT) in the treatment of female stress urinary incontinence from a single center experience.

MATERIAL AND METHODS

The study was conducted on 527 patients with SUI diagnosed on the basis of urodynamic studies. They were divided into three groups--TVT: n=142, (TOT): n=129, and mTOT: n=256. All of the patients underwent evaluation at 1, 3, and 6 months after surgery. Results were statistically analysed and compared.

RESULTS

Objective and subjective effectiveness after the surgery were not significantly different in the study groups and ranged from 90.1% to 96.4%. Mean surgery time was 32.3, 28.2, and 26.4 in the TVT, TOT, and mTOT, respectively. Mean hospitalization time was 2.51 days. Mean catheter maintenance time was significantly higher in the TVT than in other groups. In the TVT group total incidence of complications was 13.4%, and it was significantly higher than that in TOT and mTOT (9.3% and 8.6%, resp.).

CONCLUSIONS

TVT, TOT, and mTOT are highly effective and safe methods in the treatment of SUI. There are no differences in the efficacy between the methods with a little higher percentage of complications in the TVT group.

Long-term Outcome of the Readjustable Sling Procedure for Female Stress Urinary Incontinence With Intrinsic Sphincter Deficiency or Recurrence

Purpose

We evaluated the long-term outcome of a readjustable midurethral sling system (Remeex) in the treatment of recurrence of stress urinary incontinence (SUI) after surgical treatment or SUI with intrinsic sphincter deficiency (ISD).

Materials and Methods

This study included 19 patients who underwent the Remeex procedure with a mean of 45.6 months of follow-up. The patients had responded to a telephone questionnaire. Thirteen patients had ISD, four patients had SUI recurrence, and two patients had both. The questionnaire included subjective cure and satisfaction surveys and also recommended surgery to some patients.

Results

The mean patient age was 69.1 years (range, 50-85 years), the mean parity was 2.79 times (range, 2-5 times), and the mean follow-up period was 45.6 months (range, 21-72 months). The long-term follow-up cure rate was 79%, the improvement rate was 21%, and the fail rate was 0%. The long-term follow-up "very satisfactory" rate was 26.3%, the "satisfactory" rate was 73.7%, and the "usual" and "unsatisfactory" rates were both 0%. In addition to these results, 16 patients (84.2%) would recommend the Remeex procedure to other patients with SUI recurrence or ISD. After the procedure, four patients had urinary retention, three patients had difficulty emptying, and one patient had SUI recurrence. Furthermore, all of the patients subsequently endured sling readjustments.

Conclusions

After long-term follow-up, the Remeex system showed good cure rates and subjective satisfaction rates that were similar to the results found at the 1-year follow-up, and minimal complications were reported. Therefore, the Remeex system is effective in treating patients with SUI recurrence or ISD.

Involuntary detrusor contraction is a frequent finding in patients with recurrent urinary tract infections

OBJECTIVE

To check whether subtle voiding dysfunction is related to recurrent urinary tract infection (rUTI).

METHODS

254 consecutive patients with at least four episodes of urinary tract infection (UTI) were studied. At least three repeat urodynamic evaluations with an additional ice water test to maximize the detection of involuntary detrusor contraction (IDC) were used. Stress urinary incontinence cases were used as controls. Nonparametric univariate and multivariate analyses were used for statistics.

RESULTS

IDC was detected in 83.6% of patients in the rUTI group and in 31.7% in the control group. IDC was <15 cm H2O in 54.7% whereas high-amplitude (>50 cm H2O) IDC was observed in 6.8% in the rUTI group. Female urinary tract obstruction was diagnosed in 16.8% of patients in the rUTI group and in 7.9% in the control group. Residual volume, PdetQmax and Qmax were not predictive of UTI recurrence. Symptoms were similar in both groups.

CONCLUSIONS

Patients with rUTI present with covert bladder dysfunctions represented by detrusor overactivity.

Randomized clinical trial comparing TVT Secur system and trans vaginal obturator tape for the surgical management of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

This prospective randomized study aimed to compare the safety and efficacy of the TVT-Secur (TVT-S) with the trans vaginal obturator tape (TVT-O) for the treatment of stress urinary incontinence.

METHODS

We set out to enroll 136 patients in our study. 106 patients with stress urinary incontinence were randomized to either the TVT-S (n = 56) or TVT-O (n = 50) procedure. Patients were evaluated postoperatively at 2 months and 1 year. Our primary outcome was objective cure measured by the cough test. Secondary outcomes of subjective symptoms, questionnaires, pain scores, complications, and urodynamic studies were also included. Statistical analysis was by Chi-squared, Kruskal-Wallis, Wilcoxon, and Fisher's exact tests as appropriate. P values of <0.05 were considered significant.

RESULTS

Objective cure rates were better for TVT-O compared with TVT-S at 1 year (86 % and 63 % respectively, p = 0.01). Subjective cure rates were 88 % for TVT-O and 63 % for TVT-S. Quality of life scores through questionnaires improved in both groups and were not statistically different. Initial post-operative groin pain was more prevalent in the TVT-O group; however, this resolved quickly with time.

CONCLUSION

TVT-O was superior to TVT-S in the objective cure of stress urinary incontinence at 1-year follow-up.

Labhardt's colpoperineocleisis: subjective results of an alternative treatment for genital prolapse in patients who are not sexually active--2-year follow-up

INTRODUCTION AND HYPOTHESIS

Genital prolapse affects up to 50 % of multiparous women and has an impact on quality of life (QoL) for many. Vaginal obliterative techniques are relevant in older patients who are not sexually active. We performed Labhardt's colpoperineocleisis in such patients. The objective was the evaluation of subjective outcomes of this technique using PGI-I.

METHODS

Retrospective cohort analysis of patients. We performed a bivariate, multivariate analysis, and survival curves for subjective improvement.

RESULTS

Seventy-four cases were analyzed. Average age of the patients was 72 years, median parity 4, 95.9 % POP-Q stage III or IV, anterior leading edge defect in 61.1 %. Operating time: 54 min, estimated blood loss 70 ml, no intraoperative complications, 12 patients had protocol deviations with changes in the recommended type of suture. Median hospital stay was 2 days and average follow-up 24.9 months. There was 13.5 % anatomical recurrence, 3 of which (30 %) were in patients with protocol deviations. 1.9 % developed clinically significant de novo stress urinary incontinence (SUI).

PGI-I

64 (86 %) reported subjective improvement and 10 did not. In the subjective improvement group, 98.4 % reported being very much or much better. In the non-subjective improvement group 80 % reported that they were the same as before surgery and 20 % were worse. In bivariate analysis anatomical recurrence showed significance and persisted after multivariate analysis with an OR of 8322 for subjective failure.

CONCLUSION

Labhardt's colpoperineocleisis is a safe technique with good subjective results. It has few complications, an acceptable recurrence rate, and a low rate of de novo SUI. It may be important to use the #0 or #1 polydioxanone sutures, as these are associated with better outcomes in this series. Comparative studies with other obliterative techniques are needed.

[Tethered tape or the fourth factor. A new cause of recurrent stress incontinence after midurethral tape procedures vaginal tape insertion]

BACKGROUND

This is the first report of a newly identified cause of recurrent stress urinary incontinence (SUI) after midurethral tape insertion.

PATIENTS AND METHODS

This article reports a series of cases with primary or secondary tape failure including clinical presentation and findings, the results of pelvic floor (PF) ultrasound, and the (surgical) correction of malpositioned vaginal tapes.

RESULTS

A vaginal tape for treating SUI must be accurately placed under the mid-third of the urethra and at a distance of 3-5 mm from the urethra. Alignment parallel to the urethra in the urethrovaginal septum is also essential for adequate function. A tethered tape refers to the adhesion of a tape edge to the anterior vaginal wall either during primary wound closure or due to secondary ingrowths and is typically associated with recurrent SUI during activities or changes in posture. Less common is SUI through an increase in pressure from cranially, which occurs when coughing or laughing. "Vaginal polyps" may point to imminent vaginal erosion of the tape. In the sagittal plane, the PF examination will identify an oblique orientation of the tape at rest, an abnormal closeness of the tape to the transducer, and changes in tape shape upon manipulation of the vaginal probe. Once the diagnosis has been established, a tethered tape is easy to correct by realignment or tightening to accomplish correct positioning parallel to the urethra. This measure restores tape function and continence.

CONCLUSION

Primary or secondary failure of a tension-free vaginal tape may be caused by a tethered tape. This complication can be diagnosed on the basis of characteristic findings at PF ultrasound. In most women, the tape position can be corrected and there is no need for tape removal.

The fate of synthetic mid-urethral slings in 2013: A turning point

INTRODUCTION

Since the introduction of the first retropubic tension-free synthetic sling to treat stress urinary incontinence (SUI), newer approaches, different techniques and new devices have been created. Transobturator and single-incision sling (SIS) techniquespara-were developed with the goal of diminishing the rate of complications andspeeding the recovery phase.

METHODS

For this review we searched Medline for relevant papers, with an emphasis on meta-analysis and randomised controlled trials (RCTs). Specially selected reports were identified to address both 'index patients' (defined as those with genuine SUI and no previous anti-incontinence procedure or other genitourinary sign or symptom that might affect her SUI) and, briefly, non-index patients. Two authors independently reviewed papers for eligibility.

RESULTS

Level 1 evidence from a Cochrane review and two meta-analyses indicated that subjective outcomes with the mid-urethral sling (MUS) were similar to those from colposuspension. However, the MUS was better than colposuspension when assessing objective outcomes (Level 1). MUS are equally effective as autologous pubovaginal slings (Level1). Two meta-analyses suggest that retropubic MUS (RMUS) might be better than transobturator MUS when assessing objective outcomes. Five more recent RCTs with longer term outcomes showed high success rates and only one reported a significant advantage for the RMUS in women with intrinsic sphincteric deficiency. One meta-analysis addressing the SIS showed inferior outcomes to the MUS (Level 1). New and improved SIS techniques have been used, but long-term outcomes are limited and results are still controversial when compared to the MUS.

CONCLUSION

MUS are still the standard to treat the index patient as previously stated by the American and European Associations of Urology. Currently data are lacking to define which sling and what approach works best. Complications are significantly different between sling types and are dependent on technique.

Value of Maximum Urethral Closure Pressure in Predicting the Outcome of Tension-Free Vaginal Tape and Transobturator Tape Procedure

OBJECTIVES

The short-term results for the tension-free vaginal tape procedure (TVT) and the transobturator tape procedure (TOT) for stress urinary incontinence (SUI) were compared using the preoperative maximum urethral closure pressure (MUCP).

METHODS

A total of 278 patients treated for SUI was considered: 165 who underwent TVT and 113 who underwent TOT retrospectively. The MUCP in a preoperative urodynamic study before and 3 months after surgery were evaluated.

RESULTS

At 3 months after TVT, 159 patients (96.4%) were cured and four patients failed. The mean MUCP of the patients who failed was 22.5 ± 5.3 cmH2 O, which was significantly lower than that among the cured patients (P < 0.007). At 3 months after TOT, 100 patients (88.5%) were cured and seven patients failed. The mean MUCP of the patients who failed was 27 ± 6.3 cmH2 O, which was significantly lower than that among the cured patients (P < 0.001). Furthermore, the mean MUCP among the patients who were cured after TOT was significantly higher than that among the patients who were cured after TVT (P < 0.01). A further analysis using a ROC curve indicated that the MUCP value in the successful patients after TVT was ≧ 24 cmH2 O and that in the failures after TOT was ≦ 30 cmH2 O with selection sensitivity at 80%.

CONCLUSION

These results suggest that the failure cases after TVT or TOT are often found in SUI with a low MUCP and that TVT might be superior to TOT in SUI with a MUCP ≦ 30 cmH2 O.

Seventeen years' follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The minimally invasive tension-free vaginal tape (TVT) operation has become the "gold standard" of incontinence surgery. The aim of the present study was to evaluate the long-term effect of the tape material and to assess the continence status 17 years after surgery

METHODS

A cohort of 90 women operated upon with the TVT procedure at three Nordic centers has been prospectively followed for 17 years. All of the women alive according to national registries were contacted and invited to visit the clinics for evaluation. Pelvic examination was performed to reveal any adverse effects of the tape material. Objective and subjective continence status were assessed by a cough stress test and the patients' global impression of improvement as well as by condition-specific quality of life questionnaires.

RESULTS

Seventy-eight percent of the potentially assessable women were evaluated either by a clinic visit or by a telephone interview. One case of a minimal, symptom-free tape extrusion was seen. No other tape complications occurred. Over 90 % of the women were objectively continent. Eighty-seven per cent were subjectively cured or significantly improved.

CONCLUSION

The TVT operation is durable for 17 years, with a high satisfaction rate and no serious long-term tape-induced adverse effects.

Outcome of midurethral tape continence surgery in patients with and without urodynamically confirmed stress incontinence

OBJECTIVE

To compare the outcomes of midurethral tape continence surgery in patients with urodynamically confirmed stress incontinence (USI) and patients with symptoms of stress urinary incontinence but normal urodynamic studies (NUDS) and a positive 1-h pad test.

STUDY DESIGN

Analysis of data collected prospectively from 356 women who underwent tension-free vaginal tape (TVT) surgery from June 1998 to September 2009. There were 25 women with NUDS but a positive pad test. Outcome measures in these 25 women were compared with 65 women with urodynamically confirmed stress incontinence. These 65 women were chosen as suitable controls from the group of 331 potential controls. All the women underwent TVT surgery under local or spinal anaesthesia.

RESULTS

The outcome measures were: (1) absence of stress urinary incontinence symptoms, (2) new occurrence of lower urinary tract irritative symptoms (LUTS), (3) persistent voiding dysfunction (VD), and (4) recurrent urinary tract infections (UTIs). Following TVT, stress incontinence was absent in 100% and 97% of patients in the NUDS and USI groups respectively. The occurrence of LUTS was 4% and 4.6% in the NUDS and USI groups, while VD was found in 4% and 4.6% and recurrent UTIs in 8% and 6.1% of the groups respectively.

CONCLUSION

There were no significant differences in outcomes following TVT in patients with and without urodynamically confirmed stress urinary incontinence.

Laparoscopic sacrocolpopexy versus transvaginal mesh for recurrent pelvic organ prolapse

Both expert surgeons agree with the following: (1) Surgical mesh, whether placed laparoscopically or transvaginally, is indicated for pelvic floor reconstruction in cases involving recurrent advanced pelvic organ prolapse. (2) Procedural expertise and experience gained from performing a high volume of cases is fundamentally necessary. Knowledge of outcomes and complications from an individual surgeon's audit of cases is also needed when discussing the risks and benefits of procedures and alternatives. Yet controversy still exists on how best to teach new surgical techniques and optimal ways to efficiently track outcomes, including subjective and objective cure of prolapse as well as perioperative complications. A mesh registry will be useful in providing data needed for surgeons. Cost factors are also a consideration since laparoscopic and especially robotic surgical mesh procedures are generally more costly than transvaginal mesh kits when operative time, extra instrumentation and length of stay are included. Long-term outcomes, particularly for transvaginal mesh procedures, are lacking. In conclusion, all surgery poses risks; however, patients should be made aware of the pros and cons of various routes of surgery as well as the potential risks and benefits of using mesh. Surgeons should provide patients with honest information about their own experience implanting mesh and also their experience dealing with mesh-related complications.

Trans-vaginal total pelvic floor repair using customized prolene mesh: A safe and cost-effective approach for high-grade pelvic organ prolapse

AIMS

To assess safety, efficacy, and cost-effectiveness of trans-vaginal total pelvic floor repair with customized prolene mesh in patients with high-grade pelvic organ prolapse.

MATERIALS AND METHODS

A total of 32 patients, who underwent trans-vaginal total pelvic floor repair using a customized prolene mesh from January 2007 to June 2010 for grade III and IV pelvic organ prolapse, were analyzed retrospectively. Prolapse was graded using Pelvic Organ Prolapse Quantification system of International Continence Society. Patients were evaluated for symptoms associated with prolapse pre- and postoperatively.

RESULTS

Of the 32 patients, 18 were grade IV uterine prolapse, 10 were grade III uterine prolapse, and 4 were grade IV vault prolapse. Twenty-eight patients underwent vaginal hysterectomy at the time of repair. All the patients had associated anterior and posterior prolapse of varying degree. Follow-up ranged from 6 to 42 months. All patients had symptomatic relief after surgery. There were no intraoperative rectal or bladder injuries. Early complications were perineal pain (30), de novo urgency (4), vaginal discharge (3), vaginal wall hematoma (2), and failure to void (2). Two patients had vaginal erosion of mesh.

CONCLUSIONS

Trans-vaginal total pelvic floor repair using a customized prolene mesh is safe and effective treatment for comprehensive repair of high-grade pelvic organ prolapse. The use of this custom-made prolene mesh makes the procedure very cost-effective and affordable. The reduction in cost is about 25-30 times with the use of this mesh when compared with commercially available variety.

Minimally invasive treatment for female stress urinary incontinence (SUI): a review including TVT, TOT, and mini-sling

Treatment for female stress urinary incontinence (SUI) has progressed rapidly over the past ten years in the search for less invasive methods to treat this disease. There have been over 100 procedures described in the literature to date to treat female SUI; however, only two procedures have stood the test of time and have adequate cure rates: the retropubic colposuspension (Burch, MMK) and the sling. The laparoscopic approach to minimize the Burch procedure was described in the 1990s, but the evolution of the retropubic tension-free vaginal tape sling (TVT) in the late 1990s revolutionized the treatment of female SUI. More recently, the transobturator technique (TOT) and the single-incision mini-sling have been reported in attempts to further reduce the risks of sling placement. The current chapter reviews the history of treatment of female SUI and the development of these newer, less-invasive techniques. The procedures themselves are described, the risks of mesh complications reviewed, and the literature reviewed for current data on the different approaches and procedures.

Revisions of mid urethral slings can be accomplished in the office

PURPOSE

Mid urethral slings occasionally require revision for obstructive voiding symptoms or vaginal extrusion. Our approach has been to offer revision in office or resection done under local anesthesia when the patient is agreeable and deemed an appropriate candidate. The results and complications of these procedures are presented.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients from January 2003 to October 2010 to determine the subset with mid urethral sling insertion who subsequently underwent revision in the office or operating room, as identified through the Northwestern Medical Enterprise Data Warehouse. The CPT code for female sling insertion (57288) or revision/removal (57287) was used.

RESULTS

A total of 41 revisions were performed in 28 of the 118 patients (23.7%) who underwent synthetic sling insertion. Reasons for adjustment were an intravesical sling (1 operating room case), extruded vaginal mesh (7 operating room and 19 office) and obstructive voiding symptoms (7 operating room and 7 office). Obstructive voiding symptoms in 6 of 7 operating room and 6 of 7 office patients improved immediately after sling release. There were no complications in either group but 3 office patients required repeat revision in the operating room due to inability to tolerate the procedure in 2 and to nonrelief of symptoms in 1. A total of 13 operating room adjustments were made according to surgeon preference while 2 patients elected the operating room, although adjustment in office was offered.

CONCLUSIONS

Sling adjustment due to vaginal mesh extrusion or obstructive voiding symptoms can be successfully performed in the office with good result. When greater adjustment is needed, the operating room may be preferable. Surgeons should make these decisions based on their comfort level and patient preference.

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

INTRODUCTION AND HYPOTHESIS

Midurethral slings (MUS) are the gold standard primary procedure for the surgical treatment of stress urinary incontinence (SUI). There is no robust evidence on the success with MUS in the treatment of recurrent SUI. Our objective was to evaluate the effectiveness and complications of MUS in women with recurrent SUI by systematic review and meta-analysis of the literature.

METHODS

A systematic literature search was carried out (up to August 2011) using relevant search terms in MEDLINE, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis of cure stated in prospective cohort studies was performed with a random effects model using Stata 8.

RESULTS

There was 1 randomised trial and 11 good quality prospective studies included in this systematic review. The overall subjective cure rate per meta-analysis of prospective cohort studies following MUS for recurrent SUI after any previous surgery was found to be 78.5 % [95 % confidence interval (CI) 69-88] at the follow-up of 29.72 ± 29.49 months. The subjective cure rate following MUS after previous failed MUS was 73.3 % (95 % CI 55-97) at the follow-up of 15.7 ± 7.7 months.

CONCLUSIONS

The studies report good cure rates of SUI after MUS surgery following previous incontinence surgery (62-100 %). There seems to be a lower cure rate with transobturator compared to the retropubic tape for recurrent SUI after previous surgery.

Randomized controlled study of MONARC® vs. tension-free vaginal tape obturator (TVT-O®) in the treatment of female urinary incontinence: comparison of 3-year cure rates

Purpose

Transobturator approaches to midurethral sling surgery are one of the most commonly performed operations for female stress urinary incontinence throughout the world. However, very few results of randomized clinical trials of transobturator midurethral sling surgery (MONARC vs. TVT-O) for the treatment of female urinary incontinence have been reported. In this study, we compared the 3-year follow-up cure rates of these two procedures.

Materials and Methods

From July 2006 to June 2008, 74 patients who had undergone MONARC (35 patients) or TVT-O (39 patients) were included in the study and were analyzed prospectively. The mean follow-up duration of both groups was 39.2 months. Preoperative and postoperative evaluations included physical examination, uroflowmetry and postvoid residual measurement, involuntary urine loss with physical activity, and urinary symptoms. Cure of female urinary incontinence was defined as patient report of no loss of urine upon physical activity. The patients' satisfaction after treatment was rated as very satisfied, satisfied, equivocal, and unsatisfied. Very satisfied and satisfied were considered as the satisfied rate.

Results

There were no significant differences in preoperative patient characteristics, postoperative complications, or success rate between the two groups. The cure rate of the MONARC and TVT-O groups was 85.7% and 84.6%, respectively. The patient satisfaction (very satisfied, satisfied) rate of the MONARC and TVT-O groups was 82.8% and 82.1%, respectively.

Conclusions

The MONARC and TVT-O procedures were equally efficient for the treatment of female urinary incontinence, with maintenance of high cure rates for 3 years. Longer follow-up is needed to confirm these results.

Three-dimensional ultrasonographic assessment of compression effect on urethra following tension-free vaginal tape and transobturator tape procedures

OBJECTIVE

To compare the anatomical difference using three-dimensional (3D) ultrasound between the urethra at rest and during straining, in women who have undergone a tension-free vaginal tape (TVT) or TVT-obturator tape (TVT-O) procedure for stress urinary incontinence (SUI).

METHODS

We reviewed retrospectively 48 women with SUI who had undergone either a TVT (n = 24) or a TVT-O (n = 24) procedure. All women underwent urinalysis, pelvic examination, pad test, 3D perineal ultrasonography and personal interview about urinary symptoms within 1 year after surgery.

RESULTS

After both TVT and TVT-O procedures, the area and longest and shortest diameters of the hypoechoic core of the mid-urethra were significantly smaller during straining than during resting (P < 0.01). The distance between tape and urethra was similarly smaller during straining in both groups. Analysis of ultrasound measurements in women reporting success (n = 40) and those reporting failure (n = 8) of the procedure showed the area and longest and shortest diameters of the hypoechoic core of the mid-urethra to be significantly smaller during straining than during resting in both groups (P < 0.01). However, the shortest diameter of the proximal and distal urethra during straining were significantly smaller only in the successful group (P < 0.01).

CONCLUSION

There are differences in urethral morphology during straining compared with during resting in women with TVT and those with TVT-O, regardless of tape procedure. A urethral compression effect of slings may have an important role in the continence mechanism.

Tension-free vaginal tape for the treatment of urodynamic stress incontinence: efficacy and adverse effects at 10-year follow-up

BACKGROUND

One of the most effective and popular current procedures for the surgical treatment of stress urinary incontinence (SUI) is tension-free midurethral slings.

OBJECTIVE

To evaluate the outcomes of women with retropubic tension-free vaginal tape (TVT) for urodynamic stress incontinence (USI) after 10-yr follow-up.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective observational study. Consecutive women with proven USI were treated with TVT. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded.

INTERVENTION

Standard retropubic TVT.

MEASUREMENTS

Patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. Multivariable analyses were performed to investigate outcomes.

RESULTS AND LIMITATIONS

A total of 63 women were included. After 10 yr, 5 patients (8%) were lost or no longer evaluable. The 10-yr subjective, objective, and urodynamic cure rates were 89.7%, 93.1%, and 91.4%, respectively. These rates were stable across the whole study period (p>0.99). De novo overactive bladder was reported by 30.1% and 18.9% of patients at 3-mo and 10-yr follow-up, respectively (p for trend = 0.19). A total of 84.2% of women with detrusor overactivity received antimuscarinic drugs, but 43.8% were nonresponders 12 wk later. At multivariable analysis, maximum detrusor pressure during the filling phase >9cm H(2)O (hazard ratio [HR]: 16.2; p=0.01) and maximum detrusor pressure during the voiding phase ≤29cm H(2)O (HR: 8.0; p=0.01) were independent predictors for the recurrence of SUI, as well as obesity was for the recurrence of objective SUI (HR: 17.1; p=0.01) and of USI (HR: 8.9; p=0.02), respectively. Intraoperatively, bladder perforation occurred in two cases; no severe bleeding or other complications occurred.

CONCLUSIONS

The 10-yr results of this study seem to demonstrate that TVT is a highly effective option for the treatment of female SUI, recording a very high cure rate with low complications after a 10-yr follow-up.

Prevalence of urinary urgency symptoms decreases by mid-urethral sling procedures for treatment of stress incontinence

INTRODUCTION AND HYPOTHESIS

Conflicting opinions on the effect of incontinence surgery on the prevalence of postoperative urgency symptoms exists. Our aim was to evaluate the prevalence of urgency symptoms preoperatively and during 3-year of follow-up in women undergoing mid-urethral sling procedures for stress incontinence.

METHODS

Two hundred and sixty-seven women were randomly assigned to a retropubic or a transobturator operation. Detrusor instability score (DIS) and Urogenital Distress Inventory-6 (UDI-6) questionnaires were used to assess prevalence of urgency symptoms. The Incontinence Impact Questionnaire-7, visual analog scale, urinary incontinence severity score, and the EuroQol-5D assessed overall quality of life changes.

RESULTS

A significant decrease in the DIS and UDI-6 score was seen postoperatively. Signs of de novo urgency symptoms were low.

CONCLUSIONS

Mid-urethral sling procedures can be recommended in cases of mixed incontinence, and the procedures seems to decrease prevalence of urgency symptoms.

Trends in inpatient urinary incontinence surgery in the USA, 1998-2007

INTRODUCTION AND HYPOTHESIS

This study was conducted to assess national rates in stress urinary incontinence (SUI) surgery in the USA from 1998 to 2007.

METHODS

We utilized the 1998-2007 Nationwide Inpatient Sample and assessed women aged 20 years and older who underwent SUI surgery based on the International Classification of Diseases, 9th Revision (ICD-9) procedure and diagnosis codes.

RESULTS

The total number of SUI surgeries performed during this 10-year period was 759,821. The annual number of procedures increased from 37,953 in 1998 to 94,910 in 2007. The type of SUI surgery performed also changed (p < 0.001). In 1998, retropubic suspensions represented 52.3%, decreasing to 13.8% in 2007. "Other repair of SUI" (ICD-9 59.79) comprised 22.4% in 1998, increasing to 75.2% in 2007, likely representing midurethral slings.

CONCLUSIONS

The total number and incidence rates of SUI surgeries have increased from 1998 to 2007. The type of SUI surgery performed has also changed significantly, likely secondary to adoption of midurethral slings.