Operations for stress urinary incontinence in the United States, 1988-1992

Burch colposuspension versus fascial sling to reduce urinary stress incontinence

BACKGROUND

Many surgical procedures are available for women with urinary stress incontinence, yet few randomized clinical trials have been conducted to provide a basis for treatment recommendations.

METHODS

We performed a multicenter, randomized clinical trial comparing two procedures--the pubovaginal sling, using autologous rectus fascia, and the Burch colposuspension--among women with stress incontinence. Women were eligible for the study if they had predominant symptoms associated with the condition, a positive stress test, and urethral hypermobility. The primary outcomes were success in terms of overall urinary-incontinence measures, which required a negative pad test, no urinary incontinence (as recorded in a 3-day diary), a negative cough and Valsalva stress test, no self-reported symptoms, and no retreatment for the condition, and success in terms of measures of stress incontinence specifically, which required only the latter three criteria. We also assessed postoperative urge incontinence, voiding dysfunction, and adverse events.

RESULTS

A total of 655 women were randomly assigned to study groups: 326 to undergo the sling procedure and 329 to undergo the Burch procedure; 520 women (79%) completed the outcome assessment. At 24 months, success rates were higher for women who underwent the sling procedure than for those who underwent the Burch procedure, for both the overall category of success (47% vs. 38%, P=0.01) and the category specific to stress incontinence (66% vs. 49%, P<0.001). However, more women who underwent the sling procedure had urinary tract infections, difficulty voiding, and postoperative urge incontinence.

CONCLUSIONS

The autologous fascial sling results in a higher rate of successful treatment of stress incontinence but also greater morbidity than the Burch colposuspension. (ClinicalTrials.gov number, NCT00064662 [ClinicalTrials.gov] .).

Intra-abdominal pressure measurement during ultrasound assessment of women with stress urinary incontinence: a novel model

PURPOSE

To determine the influence of intra-abdominal pressure on the ultrasonographic evaluation of the urethrovesical junction (UVJ) and proximal urethra (PU) in women with stress urinary incontinence (SUI).

METHODS

This is a prospective cross-sectional study undertaken at the Urinary Incontinence Research Unit (UIRU) of the Universidade Federal de Pernambuco (UFPE). Thirty-six women complaining of SUI underwent perineal ultrasound assessments of the UVJ and PU having the bladder barely empty (< 50 ml of urine) with simultaneous measurement of the intra-abdominal pressure (IAP). An ALOKA ultrasound machine with a 7 MHz vaginal probe was used for the assessments. In order to measure the IAP, an Uromaster MPX616 urodynamic equipment, connected to a 10Fr rectal catheter with a pressure sensitive balloon, was used.

RESULTS

The participants' mean age was 46.4 +/- 10.2 years. On maximum straining, the mean IAP was 99.3 +/- 51.8 cm H(2)0, varying from 7 to 193 cm H(2)0, and the median was 99.5 cm H(2)0. Twenty-eight of 31 patients with UVJ hypermobility (90.3%) easily showed it with an IAP over 40 cm H(2)0. There was no significant association between the mean IAP measurements on maximum straining and the parameters studied. The IAP did induce a significant elongation of the proximal urethra length over 14 mm up to a cut-off over 80 cm H(2)O, most likely to increase urethral resistance and pressure profile, thus avoiding urine leakage. However, all 19 women with such a characteristic already presented so with an IAP > 40 cm H(2)O.

CONCLUSION

There is no need to measure IAP routinely on perineal ultrasound assessments of the UVJ and PU in women with SUI having a barely empty bladder.

SPARC Sling System for Treatment of Female Stress Urinary Incontinence in the Elderly

OBJECTIVE

To investigate the safety and efficacy of the suprapubic arch (SPARC) sling procedure for the management of stress urinary incontinence (SUI) in elderly women.

METHOD

Forty-three women, aged 65-91 yr, underwent the SPARC procedure for urodynamic SUI. Before surgery, a complete medical history was obtained and a urogynecology examination and urodynamic test were performed. The objective cure rate was evaluated by clinical and urodynamic examination at 3, 6, and 12 mo and the subjective cure rate was assessed using a visual analogue score and a global patient impression questionnaire.

RESULTS

No severe intraoperative or postoperative complications occurred. No patient referred de novo urge incontinence. Significant differences were found between the preoperative and postoperative number of daytime voidings (p < 0.001), the pad weights and numbers of pads used (p < 0.001), and the visual analogue score (p = 0.021). No significant differences in preoperative and postoperative urodynamic parameters were reported. At the mean follow-up of 36+/-14 mo (range, 12-54 mo), objective and subjective cure rates were 91% and 95%, respectively.

CONCLUSIONS

The SPARC procedure is effective and offers a satisfactory cure rate without significant morbidity in elderly women with SUI.

Healthcare utilization among women who undergo surgery for stress urinary incontinence

This study examined patterns of care for women undergoing surgery for stress urinary incontinence (SUI). A retrospective analysis of administrative claims data was performed and we identified 12520 women with a diagnosis of SUI and a subset of 3735 women with a surgical procedure code for SUI. For the main types of surgeries, we examined length of stay, pharmaceutical use, complications, and healthcare utilization related to incontinence greater than 6 months after surgery. Approximately 30% of women with a coded SUI diagnosis underwent surgery. Of the initial procedures, 40% were retropubic suspensions and 25% were sling procedures. Almost 4% of women underwent an additional surgery, and 14.1% had claims related to incontinence 6 or more months after the initial procedure. We examined medical care and pharmaceutical use for women undergoing continence surgery. This information may be important to patients and physicians discussing treatment options.

Prevalence and outcomes of continence surgery in community dwelling women

PURPOSE

Published outcomes of continence surgery are based largely on cohort studies and a smaller number of randomized trials. There is no consensus on the outcomes that should be considered and patient reported outcomes have not always been included. We determined the prevalence of continence surgery as well as patient reported outcomes in community dwelling women.

MATERIALS AND METHODS

We performed a 2-stage national cross-sectional mailed survey. A short questionnaire used to identify women with a history of continence surgery was sent to 45,000 representative American households. Eligible women with a history of continence surgery received a followup questionnaire to assess patient reported outcomes, including current symptom frequency, bother and overall satisfaction.

RESULTS

Of the 24,581 women 967 (4%) had a history of continence surgery, including 73% who currently reported incontinence in the preceding month, 58% who reported incontinence in the preceding week and 53% who reported current use of pads or other absorbent material. Of those who reported incontinence 83% reported current stress incontinence symptoms, including 62% with stress and urge symptoms. A third of the women had been treated with surgery in the last 5 years. The proportion of women satisfied with the results of surgery decreased from 67% who recalled initial satisfaction to 45% who reported current satisfaction.

CONCLUSIONS

Almost 4% of women had undergone continence surgery and continence rates were lower than most published figures. However, some women reported satisfaction with surgery even when they did not achieve continence. Patient satisfaction and other patient reported outcomes might be considered with continence rates when determining surgical success rates.

A survey of physician efficacy requirements to plan clinical trials

PURPOSE

Eliciting physician efficacy requirements for utilizing medical treatments can be a useful means of helping plan a clinical trial. Efficacy requirements were studied for female stress urinary incontinence, where an experimental treatment (collagen injection) was compared to the standard therapy (surgery).

METHODS

A self-administered questionnaire was sent to 223 North American urologists, gynecologists, and urogynecologists. An interviewer also administered a similar questionnaire to 20 other clinician-specialists.

RESULTS

The response rate for the self-administered questionnaire was 48.4% (108/223). All 20 clinician-specialists who were approached for an interview consented. On average, respondents to the self-administered questionnaire indicated they would consider using collagen as the first line treatment if the absolute reduction in efficacy of collagen versus surgery was no larger than 23%. The corresponding result for the interview-questionnaire was 22%. Efficacy was measured as patient satisfaction with treatment. In the opinion of the physicians, surgery would remain the standard therapy if the reduction was greater than 34% (self-administered questionnaire), or 37% (interviewer-administered questionnaire).

CONCLUSIONS

The elicitation of physician efficacy requirements provides an idea of the treatment effect that would be needed for a clinical trial to have an impact on medical practice. These requirements can be used to calculate a relevant sample size.

Rectocele repair: when and how?

Pelvic organ prolapse repair poses a unique challenge to the reconstructive pelvic surgeon. Traditional levator plication has been promoted for the past century and has recently been shown to create unsatisfactory functional results, among them dyspareunia. In an attempt to improve both functional and quality-of-life outcomes, new methods for posterior vaginal wall defect repair have been developed and are now undergoing critical evaluation. We present a review of posterior vaginal wall repair with a focus on new anatomic concepts and site-specific rectocele repair.

The second stage of labor and stress urinary incontinence

OBJECTIVE

This study was undertaken to investigate the potential association between prolonged second stage of labor and stress urinary incontinence.

STUDY DESIGN

A retrospective, population-based study was performed. A random, case-controlled sample of 85 cases and 88 controls was identified by means of a standard computerized patient database. Subjects were identified by International Classification of Diseases, Ninth Revision codes, and medical records were reviewed. The median follow-up time from delivery was 7.8 years for cases and 7.2 years for controls. Multiple logistic regression was performed to test for an association between stress urinary incontinence and variables of interest.

RESULTS

The data suggest that for all women who labored the length of the second stage of labor for the first delivery was not associated with stress urinary incontinence (odds ratio, 1.07; P =.42; 95% confidence interval, 0.9-1.3). However, forceps delivery was associated with a significant increase in stress urinary incontinence risk (odds ratio, 10.4; P =.04; 95% confidence interval, 1.2-93.4).

CONCLUSION

Length of second stage of labor was not associated with stress urinary incontinence. However, the odds of having a later diagnosis of stress urinary incontinence was 10 times higher for women who underwent forceps delivery.