Iatrogenic obstruction after sling surgery

Tunable tension tape versus transobturator tape in treatment of stress urinary incontinence in women: Randomized controlled trial

INTRODUCTION

The synthetic mid-urethral slings are currently considered to be the most widely used technique for the surgical treatment of stress urinary incontinence (SUI). The most challenging aspect of the existing approaches is to achieve the optimal tension of the sling which treatment results are directly dependent on. To solve this problem, sling systems enabling an adjustment of the tension in the early postoperative period were created. A comparative study of the effectiveness and safety of such a system and a nonadjustable sling seems to be a relevant task.

MATERIALS AND METHODS

A double-blind, randomized, multicenter trial enrolled 320 patients with a mean age of 55.2 ± 11.2 years and confirmed SUI. Patients were randomized into two groups: the first group underwent a standard synthetic suburethral sling (transobturator tape [TOT]) procedure and the second group underwent a tunable tension tape sling (TTT) procedure. All patients underwent stress test, uroflowmetry and ultrasound scan to determine the postvoid residual volume. Urinary Distress Inventory Short Form 6, International Consultation on Incontinence Questionnaire-Short Form, Pelvic Organ Prolapse Incontinence Sexual Questionnaire 12 questionnaires were used to assess subjective efficacy.

RESULTS

Enhancement of prosthesis tension in the second group was required in 44 (28%) patients. Due to the possibility of tightening of the sling in the early postoperative period, the operation was effective in 143 (89%) patients in the adjustable sling group and in 109 (68%) patients in Group 1, p < 0.001. Loosening of the sling tension was performed in 25 (16%) patients in Group 2. The signs of obstructive voiding symptoms at the follow-up time of 36 months remained in Group 1 in 13 (8%) patients. Subjective satisfaction with treatment on the PGI-I scale was higher in Group 2: 100 (62%) versus 132 (82%), p < 0.001.

CONCLUSION

A synthetic mid-urethral TTT is superior to a standard nonadjustable sling in long-term effectiveness and safety.

Bladder outlet obstruction in women: Advanced evaluation

INTRODUCTION

Herein, we provide a review of the indications, practical considerations, and interpretation of urodynamics (UDS) with or without fluoroscopy, as well as cystourethroscopy, for women with suspected bladder outlet obstruction (BOO).

METHODS AND RESULTS

A narrative review was performed focusing on the current primary literature and society guidelines around advanced diagnostic modalities for female BOO patients. UDS studies help diagnose BOO by identifying high-pressure low-flow voiding patterns and/or the characteristic radiographic appearance of the bladder neck and urethra during micturition. Cystourethroscopy aids in evaluating structural aberrations of the bladder outlet, and in surgical planning.

CONCLUSIONS

UDS studies and cystourethroscopy are useful adjuncts in carefully-selected female patients with suspected BOO.

Efficacy of single and repeated transurethral bladder neck incisions for female voiding dysfunction

OBJECTIVE

This study aimed to assess the efficacy of single and repeat transurethral bladder neck incision (TUI-BN) for female voiding dysfunction caused by bladder outlet obstruction (BNO). Further, the predictive factors associated with better treatment outcomes were identified.

METHODS

Women with voiding difficulty due to BNO who underwent TUI-BN were included in this research. All patients underwent videourodynamics study at baseline and after TUI-BN. Successful outcome was defined as a voiding efficiency of ≥ 66.7% and a global response assessment score of ≥ 2 after treatment. Repeat TUI-BN was considered for patients with insufficient improvement. The outcomes of repeat surgery, surgical complications, and predictive factors of successful outcomes were evaluated.

RESULTS

In total 158 cases, the success rates were 61.4% and 45.2% after the first and second TUI-BN, respectively, with an overall cumulative rate of 70.3%. The success rates were comparable between patients with detrusor underactivity (DU) and those without (54.9% vs. 68.4%). The absence of a previous history of suburethral sling and a high baseline corrected maximum flow rate were a significant predictor of favorable outcomes. The cumulative rate of regaining self-voiding function was 95.1%. The incidence rates of vesico-vaginal fistula and de novo stress urinary incontinence requiring surgery were 1.2% and 2.5%, respectively.

CONCLUSIONS

Regardless of the presence of DU, TUI-BN is effective against female voiding dysfunction caused by BNO. Repeat procedures are beneficial and can improve self-voiding function. A high corrected maximum flow rate and the absence of a previous history of suburethral sling can contribute to greater success rates.

Tape-Releasing Suture with "Long Loop" on Mid-Urethral Sling: A Novel Procedure for Management of Iatrogenic Urethral Obstruction

BACKGROUND

To report our experiences of a tape-releasing suture with "long-loop" in women with iatrogenic urethral obstruction following the mid-urethral sling procedure.

METHODS

A total of 149 women underwent a tape-releasing suture with "Long Loop" during the operation. Post-void residual volume was evaluated after Foley removal. Lower urinary tract symptoms and urodynamic studies were assessed before and six months postoperatively.

RESULTS

Nine women out of 149 who underwent mid-urethral sling surgery were found to have iatrogenic urethral obstruction post-operatively based on their urinary symptoms and ultrasound findings. There was no apparent difference between tested groups in mid-urethral sling products and concomitant procedures. 77.8% had successful releases after the first Long-loop manipulation procedure, and 22.2% required two or more releases. However, the SUI cure rate is similar in groups receiving the Long-loop manipulation or not (88.9% and 87.1%, respectively).

CONCLUSIONS

We are convinced of the practicability and efficacy of the tape-releasing suture "Long-loop." We adopted subjective and objective means to evaluate both groups before and after a six-month follow-up. The Long-loop manipulation procedure can successfully resolve the iatrogenic urethral obstruction without compromising the effectiveness of mid-urethral sling for the treatment of SUI.

Double opposite tape incision for obstructive sling

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence affects about 34% of all adult women. The mid-urethral sling (MUS), considered the gold-standard treatment, has widespread use but also potential complications. This study aims to demonstrate a new surgical technique that releases urethral obstruction caused by MUS with urinary continence maintenance.

METHODS

This video presents a 43-year-old patient with acute urinary retention after a suburethral sling procedure treated with a double opposite tape incision through a "U"-shaped inverted incision at the anterior vaginal wall.

RESULTS

The patient resumed her usual activities 1 week later with urinary continence. After 6 weeks, she was allowed to resume physical activities and sexual intercourse. At 3-month follow-up, she is still satisfied without urine leakage recurrence.

CONCLUSIONS

The double opposite tape incision is feasible and effective for urethral loosening after the MUS procedure. Concerned that this is a unique case, further studies are required to compare this technique to other surgical treatment options.

Is bladder outlet obstruction responsible for a successful surgical outcome in women with complicated stress urinary incontinence? Urodynamic results before and after a Remeex® readjustable sling

AIMS

To describe the changes in urodynamic parameters after Remeex® placement in women with recurrent stress urinary incontinence (rSUI) or intrinsic sphincteric deficiency (ISD) and to analyze a potential relationship between postoperative bladder outlet obstruction and a successful surgical outcome.

METHODS

Retrospective analysis of those women who had undergone Remeex® placement due to rSUI or ISD in our department between 2000 and 2017. All patients underwent urodynamic evaluation before and after the surgery. If tension readjustment was required, postoperative urodynamics was performed after the last regulation, once the final continence status had been achieved. The female Bladder Outlet Obstruction Index (BOOIf) was calculated for all patients postoperatively. Obstruction was considered present if BOOIf was >18. Pre- and postoperative urodynamic variables were compared. Postoperative urodynamic changes were also compared between cured and noncured patients.

RESULTS

A total of 205 women were included. After a follow-up of 89 ± 36 months, 165 women (80.5%) were continent. A significant impairment in the majority of the urodynamic parameters was observed. Mean postoperative BOOIf was -11.8 ± 21.5 in cured patients and -15.3 ± 23.1 in noncured patients (p = 0.365); 15 (9.1%) patients in the cured group had a postoperative BOOIf >18, whereas all (100%) patients in the noncured group had a postoperative BOOIf <18.

CONCLUSIONS

Most urodynamic parameters may worsen after the Remeex® system placement. Postoperative urodynamic parameters may not differ substantially between cured and noncured patients, although a certain grade of bladder outlet obstruction could be related to postoperative continence status in some patients.

Reliability of Symptoms and Dipstick for Postoperative Catheter-Associated Urinary Tract Infections

OBJECTIVE

The aim of the study was to determine the diagnostic reliability of patient symptoms and urine dipstick results, including blood, leukocyte esterase, and nitrite, in diagnosing postoperative catheter-associated urinary tract infections (CAUTIs) after gynecologic surgery.

METHODS

A prospective cohort study of patients undergoing gynecologic surgeries who required short-term (>24 hours) postoperative catheterization was conducted. Patients completed a questionnaire regarding symptoms. Urine dipstick analysis was completed on catheterized urine samples and urine was sent for culture for all patients. Positive likelihood ratios (LRs) were used to examine diagnostic reliability of patient symptoms and urine dipstick results in diagnosing postoperative CAUTIs.

RESULTS

Fifty-seven patients with postoperative short-term indwelling catheterization were recruited, 25 (44%) of whom had CAUTIs diagnosed by urine culture at recruitment and 32 (56%) of whom did not have CAUTIs. Urine dipstick parameters were found to successfully diagnose CAUTIs, with positive LRs of 1.44 (95% confidence interval [CI], 1.04-1.99), 6.77 (95% CI, 2.23-20.52), and 9.47 (95% CI, 1.23-72.69) for blood, leukocyte esterase, and nitrite, respectively. The combination of leukocyte esterase and nitrite yielded a positive LR of 9.48 (95% CI, 2.62-34.25). Individual symptoms, alone or in combination, did not successfully diagnose positive urine culture (positive LRs <1.8).

CONCLUSIONS

Urine dipstick parameters are reliable diagnostic tests for diagnosing postoperative CAUTIs after gynecologic surgery, particularly when in combination. Patient symptoms have little diagnostic value for positive urine cultures in catheterized patients after gynecologic surgery.

Does Pharmacological Treatment Reduce the Incidence of Lower Urinary Tract Symptoms (LUTS) after Transobturator Sling?

Aim

Lower urinary tract symptoms (LUTS) frequently affect patients immediately after midurethral sling (MUS) placement. The objective of the study was to assess if solifenacin or mirabegron decreases incidence of LUTS in women who underwent transobturator MUS.

Methods

A prospective randomized trial was conducted on patients undergoing ambulatory transobturator midurethral sling due to stress urinary incontinence (SUI). All participants were questioned before and after surgery for occurrence of bothersome LUTS. A total of 328 patients who underwent transobturator MUS were randomly assigned to one of three groups: prophylaxis with 10 mg of solifenacin, prophylaxis with 50 mg of mirabegron, or without any additional treatment. LUTS evolution and efficacy of solifenacin and mirabegron were analyzed based on results of assessments made during follow-up visits at 1 and 6 weeks after surgery. Comparison of the prevalence of LUTS was done using chi² test.

Results

Prevalence of urgency and frequency episodes increased notably 1 week after sling placement and then came down to baseline levels. Solifenacin and mirabegron significantly reduced the incidence of urgency after 1 week, but after 6 weeks the beneficial effect was observed only in case of solifenacin. Treatment with mirabegron reduced the percentage of patients suffering from frequency after 6 weeks. Although prevalence of nocturia did not raise after sling placement, both treatments significantly reduced the incidence of this complaint after 6 weeks. Pharmacological treatment did not modulate the course of hesitancy and terminal dribbling.

Conclusions

Treatment with solifenacin or mirabegron may significantly reduce the incidence of undesired LUTS after MUS.

Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion

Voiding dysfunction following midurethral sling procedures is not a rare event. There is no current consensus regarding management of this complication. Although it is often transient and self-limiting, chronic post-midurethral sling voiding dysfunction may lead to irreversible changes affecting detrusor function. Initial management includes intermittent catheterization, and addressing circumstantial factors interfering with normal voiding, such as pain. Early sling mobilization often resolves the dysfunction, and is associated with minimal morbidity. Sling incision or excision at a later stage, although fairly effective, could be associated with recurrence of stress urinary incontinence. There is insufficient evidence to justify urethral dilatation in this context.

Transobturator midurethral sling: What should patients expect after surgery?

INTRODUCTION AND HYPOTHESIS

Midurethral sling (MUS) surgeries are minimally invasive procedures; however, they are not free of postoperative complications. The aim of the study was to assess the occurrence of lower urinary tract symptoms (LUTS) (urgency, nocturia, frequency, splitting/spraying, hesitancy, terminal dribbling, and subjective feeling of postvoid residual) in patients suffering from stress (SUI) or mixed (MUI) urinary incontinence with a predominant SUI component before and after transobturator MUS placement.

METHODS

The study group consisted of 88 women with SUI and 18 with MUI who underwent transobturator MUS. All participants were questioned with a self-developed questionnaire before and after surgery regarding the presence of LUTS.

RESULTS

Seven days after surgery, 62 patients (58.5%) noted voiding and postmicturition symptoms, whereas 67 (63.2%) reported problems in storage. The more commonly reported LUTS at week 1 after surgery were urgency (52.8%), splitting/spraying (41.5%), and feeling of incomplete bladder emptying (34.0%). Patients perceived that splitting/spraying was the most bothersome. After 6 months, the most common LUTS reported were hesitancy (14.1%), terminal dribbling (10.4%), and splitting/spraying (9.4%). We noticed a decrease in the number of urgency episodes >2.7 times (p < 0.001) compared with baseline. After 6 months, 97 (91.5%) patients reported the lack of incontinence episodes.

CONCLUSIONS

A vast majority of patients after MUS suffer from LUTS in the early postoperative period; however, the majority of undesired symptoms resolve spontaneously within the first 6 months postsurgery.

Suprameatal urethrolysis with Martius flap for refractory bladder outflow obstruction following stress incontinence surgery in females

AIMS

To present our technique of suprameatal urethrolysis with Martius flap (SMUM) and outcomes of this procedure for refractory female bladder outflow obstruction (BOO).

METHODS

A retrospective chart review was performed to identify female patients who underwent SMUM between January 2010 and August 2016 after failed transvaginal urethrolysis (TVU) for BOO due to prior stress urinary incontinence (SUI) surgery. The primary outcome measure was surgical success defined as patient ability to void volitionally without need for catheterization or additional surgery for BOO. Secondary outcomes assessed included perioperative outcomes, intraoperative and 30-day complications, change in post-void residual volume (PVR), resolution of urge urinary incontinence (UUI), incidence of recurrent SUI, and treatment for any urinary incontinence.

RESULTS

Eleven patients were identified. After a median follow-up of 10.8 months (range 3.1-20.1), the procedure was successful in nine patients (82%). Postoperative median PVR was 29 cc (range 0-425) and median change in PVR was a 280 cc (range 29-1050) decrease (P < 0.01). Among the seven patients who required catheterization preoperatively, five patients (71%) recovered volitional voiding. Two patients (18%) continued to require indwelling or intermittent catheterization and underwent additional surgery for BOO. SUI recurred in one patient (9%). UUI persisted in all four patients who reported this preoperatively.

CONCLUSIONS

SMUM is successful in improving or relieving refractory BOO in this challenging patient population. After TVU, we believe that Martius flap interposition is critical to preventing recurrent fixation of the urethra to the pubic bones and thus achieving improved voiding.

Female Bladder Outlet Obstruction

The non-specific symptoms the patients express upon the presentation of female bladder outlet obstruction make it a challenge to diagnose. There are subtle differences between the obstructed patient and those whose bladders are underactive and/or fail to mount a detrusor contraction. These disparities can be extracted through a thorough history and examination. At times, the clinician may utilize nomograms, non-invasive uroflow, and urodynamics with the addition of fluoroscopy to establish the diagnosis of obstruction. Management of the obstruction depends on the nature of the condition, whether functional or anatomical. The increase in the number of sling procedures performed to treat stress urinary incontinence has resulted in a rise in the number of iatrogenic obstructions. The temporal relationship between surgery and obstruction is the key to identifying the problem.

Anatomic Outcomes of Robotic Assisted Supracervical Hysterectomy and Concurrent Sacrocolpopexy at a Tertiary Care Institution at Initial Adaptation of the Procedure

OBJECTIVE

The aim of the study was to review anatomic and surgical outcomes of robotic-assisted supracervical hysterectomy (RASCH) with concurrent sacrocolpopexy in the treatment of primary pelvic organ prolapse (POP) on initial adaption of this procedure.

STUDY DESIGN

A retrospective chart review of patients undergoing RASCH with concurrent sacrocolpopexy between 2009 and 2012 was performed at a tertiary care academic institution, after initial adaption of this procedure. The primary outcome was change in vaginal support (assessed with the pelvic organ prolapse quantification [POP-Q]) at 3 months and 1 year postoperatively. Secondary measures assessed included estimated blood loss, operative times, hospital length of stay, and operative complications.

RESULTS

Forty patients (N = 40) underwent RASCH with concurrent sacrocolpopexy. Twenty-six patients (65%) had preoperative stage II POP, and 35% had stage III POP. Three months after undergoing the procedure, 55% had achieved stage 0 POP. An additional 35% were categorized as stage I POP. At 1 year, 72.7% were stage I POP or lower. The mean (SD) operating time was 275 (82.3) minutes. Estimated blood loss and mean (SD) length of hospital stay were 163 (114.9) mL and 1.3 (0.8) days, respectively. There were no intensive care unit admissions. The most common postoperative complication was immediate urinary retention in 10% of patients; all cases resolved with time-limited intermittent self-catheterization.

CONCLUSIONS

Even with initial adaptation of the procedure, RASCH with concurrent sacrocolpopexy for the repair of primary POP is effective in restoring anatomic support in the short term. Operative complications are minimal.

Analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence

Purpose

The definition of posttransobturator tape procedure (post-TOT) voiding dysfunction (VD) is inconsistent in the literature. In this study, we retrospectively investigated the risk factors for post-TOT VD by applying various definitions in one cohort.

Materials and Methods

The medical records of 449 patients were evaluated postoperatively. Acute urinary retention requiring catheterization, subjective feeling of voiding difficulty during follow-up, and postoperative postvoid residual (PVR) greater than 100 mL or PVR greater than 50% of voided volume (significant PVR) were adopted for the definition of VD. With these categories, multivariate analysis was performed for risk factors of postoperative VD.

Results

Ten patients (2.2%) required catheterization, 47 (10.5%) experienced postoperative voiding difficulty, and 63 (14.7%) showed significant PVR. In the multivariate logistic analysis, independent risk factors for postoperative retention requiring catheterization were previous retention history (p=0.06) and preoperative history of hysterectomy. Risk factors for subjective postoperative voiding difficulty were underactive detrusor (p=0.04) and preoperative obstructive voiding symptoms (p<0.01). Previous urinary retention history (p<0.01)) was an independent risk factor for concomitant postoperative voiding difficulty and significant PVR. Spinal anesthesia (p=0.02) and previous urinary retention history (p=0.02) were independent risk factors for significant postoperative PVR.

Conclusions

With the use of several definitions of VD after the midurethral sling procedure, postoperative peak flow rate and PVR were significantly different between groups. Although there were no independent risk factors consistent with various definitions of VD, preoperative obstructive voiding symptoms and objective parameters suggesting impaired detrusor tend to have predictive power for post-TOT VD.

Urodynamics: examining the current role of UDS testing. What is the role of urodynamic testing in light of recent AUA urodynamics and overactive bladder guidelines and the VALUE study?

Urodynamics testing is a diagnostic assessment of the lower urinary tract system composed of multiple tests to obtain physiologic data regarding lower urinary tract function (detrusor and outlet) during storage and emptying. The necessity of urodynamics has been both supported and challenged in various urologic conditions such as urinary incontinence, neurogenic bladder, lower urinary tract symptoms, and bladder outlet obstruction. This review discusses the most recent studies with regards to the utility of urodynamics in current practice, highlighting the recent American Urologic Association Adult Urodynamics and Overactive Bladder Guidelines and the Value of Urodynamic Evaluation study.

Management of complications after tension-free midurethral slings

Since their introduction in 1996, tension-free midurethral slings (MUS) have been proven to have long-term efficacy and safety. They are considered the gold standard treatment of female stress urinary incontinence, especially in cases that are associated with urethral hypermobility. However, they are not free of complications and, although rare, some of these complications can be challenging for both patients and physicians. Some complications occur intraoperatively, whereas others appear in the early or late postoperative period. There is less controversy in the diagnosis and treatment of complications such as vaginal extrusion or urinary system erosion, whereas de novo voiding problems are at best not completely understood. Voiding dysfunction after MUS placement may vary in a wide range from urinary frequency or urgency to retention and is usually attributed to the obstructive or irritative effect of the sling. However, present urodynamic criteria for the diagnosis of female infravesical obstruction are not satisfactory, and the best management policy for de novo voiding dysfunction remains controversial. In the majority of cases, the diagnosis of obstruction leading to a urethral release surgery depends on a combination of several clinical findings. The timing of urethral release surgery varies depending on the preferences of the surgeon, and the outcome of this surgery is not always predictable. The purpose of this review was to assess the diagnosis and management of the immediate, short-term, and long-term complications of MUS in light of the current literature in an attempt to determine the best management policy.

Risk of repeat anti-incontinence surgery following sling release: a review of 93 cases

PURPOSE

Sling procedures are the most common surgery for stress urinary incontinence in women. Lower urinary tract symptoms are well documented complications of these procedures that develop in 5% to 20% of patients. A common treatment for postoperative urinary retention and bothersome obstructive voiding symptoms after anti-incontinence surgery is sling release. While previous studies indicated the risk of recurrent stress urinary incontinence after surgical release of slings, there is a paucity of data on how many patients require repeat anti-incontinence procedures.

MATERIALS AND METHODS

After receiving institutional review board approval we retrospectively reviewed the records of 143 consecutive female sling release procedures performed by 2 subspecialized urologists at our clinic from January 2000 through August 2012. A total of 121 patients underwent documented followup at our clinic, of whom 93 were treated with sling release for obstruction or retention after sling placement. We identified the characteristics of this patient population, specifically the incidence of subsequent anti-incontinence procedures.

RESULTS

Mean ± SD patient age was 58 ± 13.2 years and median patient followup after surgical sling release was 32 months (IQR 6, 67). Of the 93 patients 13 (14%) required a repeat anti-incontinence procedure after sling release at a median of 3 months.

CONCLUSIONS

Sling release remains an important treatment option in patients with obstruction after anti-incontinence surgery. Only a small percent of patients require repeat anti-incontinence surgery for recurrent stress urinary incontinence.