Long-term results with tension-free vaginal tape on mixed and stress urinary incontinence

Sonography as a Diagnostic Tool in Midurethral Sling Complications: A Narrative Review

Despite the established safety and efficacy of midurethral slings (MUS), which are the current gold standard treatment for stress urinary incontinence (SUI), the potential for postoperative complications remains a significant concern for both healthcare professionals and patients. Meanwhile, sonography has emerged as a significant diagnostic tool in urogynecology, and one of the applications of this imaging modality may be the evaluation of complications arising from MUS procedures. This review, based on a comprehensive literature search, focuses on the use of pelvic floor ultrasound (US) in the context of MUS complications. It includes analyses of randomized controlled trials, prospective, and retrospective studies, covering preoperative and postoperative investigations, to assess complications such as persistent and recurrent SUI, urinary retention and obstructive voiding, de novo urgency/overactive bladder, vaginal exposure, sling erosion, pain, and hematoma. The review critically examines the existing literature, with a particular focus on recent publications. Despite the variability in findings, it appears that for each of the discussed complications, the application of pelvic floor US can significantly support the diagnostic and therapeutic process. The paper also identifies potential future directions for the development of US applications in diagnosing MUS complications.

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

OBJECTIVES

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

STUDY DESIGN

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Second-Line Surgical Management After Midurethral Sling Failure

Currently, the midurethral sling (MUS) is widely used as a standard treatment in patients with stress urinary incontinence (SUI). Several studies have reported the failure rate of MUS to be approximately 5%–20%. In general, sling failure can be defined as persistent SUI after surgery or a temporary improvement in incontinence followed by recurrence. Failure is also often considered to include cases requiring secondary surgery due to mesh exposure, postoperative voiding difficulty, de novo urgency/urge incontinence, and severe postoperative pain. Because of the lack of large-scale, high-quality research on this topic, no clear guidelines exist for second-line management. To date, transurethral bulking agent injections, tape shortening, repeat MUS, pubovaginal sling (PVS) using autologous fascia, and Burch colposuspension are available options for second-line surgery. Repeat MUS is the most widely used second-line surgical method at present. Bulking agent injections have lower durability and efficacy than other treatments. Tape shortening demonstrates a relatively low success rate, but comparable outcomes if the period from first treatment to relapse is short. In patients with intrinsic sphincter deficiency, PVS and retropubic (RP) MUS can be considered first as second-line management because of their higher success rate than other treatments. When revision or reoperation is required due to prior mesh-related complications, PVS or colposuspension, which is performed without a synthetic mesh, is appropriate for second-line surgery. For patients with detrusor underactivity, a readjustable sling can be a better option because of the high risk of postoperative voiding dysfunction in PVS or RP slings.

Effectiveness of the Remeex system™ in Colombian women with recurrent stress urinary incontinence or intrinsic sphincter deficiency

INTRODUCTION AND HYPOTHESIS

We report our experience with the Remeex system™ in women with recurrent stress urinary incontinence (SUI) or intrinsic sphincter deficiency (ISD).

METHODS

A multicenter retrospective study was conducted in women who underwent an adjustable sling procedure between 2011 and 2016. We used urodynamic studies (UDS) preoperatively and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and cough stress test (CST) pre- and postoperatively. Primary outcomes were subjective (no leakage reported by the patient) and objective (no leakage during CST) cure and improvement rates (reduction of ≥4 points in ICIQ-SF). Descriptive and inferential statistics were employed.

RESULTS

A total of 50 patients were included. Mean age was 62 years (SD ± 11.35). Median follow-up was 19.5 months [interquartile range (IQR) 12.95-41.38]. Urinary incontinence (UI) was described as moderate and severe by 8 (16%) and 42 (84%) patients, respectively, and 25 (50%) had stress-predominant mixed urinary incontinence (MUI). Objective and subjective cure rates were 90% and 48%, respectively, while 82% of patients achieved improvement. Impact of UI on quality of life (QoL) improved from 10 (IQR 9-10) to 2 (IQR 0-5) (p < 0.0001). Clavien-Dindo II complications occurred in 14 (28%) patients, and one (2%) had IIIa. Tape erosion occurred in one (2%) patient, and five (10%) required readjustments. Logistic regression identified MUI [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.02-10.89] and vaginal atrophy (OR 4.2, 95% CI 1.06-16.03) as predictors of low subjective cure rate.

CONCLUSIONS

Adjustable slings represent a valuable and safe option in the management of recurrent SUI or ISD, with improvement in QoL. Results should be carefully interpreted due to our small sample and retrospective design.

Overactive bladder symptoms after midurethral sling surgery in women: Risk factors and management

INTRODUCTION

Overactive bladder syndrome (OAB) including urgency and urgency urinary incontinence (UUI) occurs frequently after stress urinary incontinence (SUI) surgery. It is important to identify the risk factors for the occurrence of OAB symptoms in order to adequately inform the patient before surgery. Furthermore, when facing OAB after sling surgery it is crucial to know how to manage these symptoms.

METHODS

We conducted a literature review in order to assess the risk factors and management of OAB symptoms after SUI surgery. We searched for relevant articles in PubMed that specifically addressed the topic of OAB symptoms after midurethral sling surgery.

RESULTS

The incidence of de novo and persistent urgency and UUI is reported around 15% and 30%, respectively. Several studies demonstrated that women with mixed incontinence who have a predominant urge component will have worse outcomes after surgery. Older age was also found to be a predictive factor in three studies. Furthermore, urodynamic signs of overactive bladder (eg, DO, low bladder capacity, elevated detrusor pressure) can predict postoperative urgency or UUI. The management of OAB symptoms after SUI surgery is essentially the same as in idiopathic OAB. However, before commencing therapy it is crucial to rule out other factors than can cause urgency, including bladder outlet obstruction, urinary tract infection, or sling erosion.

CONCLUSIONS

OAB symptoms are frequently reported after sling surgery. Women with mixed incontinence and older women are at risk of developing post-operative OAB symptoms. We have proposed an algorithm for the treatment of these symptoms which can be useful in clinical practice.

Management of patients with stress urinary incontinence after failed midurethral sling

Surgical failure rates after midurethral sling (MUS) procedures are variable and range from approximately 8-57% at five years of followup. The disparity in long-term failure rates is explained by a lack of long-term followup and lack of a clear definition of what constitutes failure. A recent Cochrane review illustrates that no high-quality data exists to recommend or refute any of the different management strategies for recurrent or persistent stress urinary incontinence (SUI) after failed MUS surgery. Clinical evaluation requires a complete history, physical examination, and establishment of patient goals. Conservative treatment measures include pelvic floor physiotherapy, incontinence pessary dish, commercially available devices (Uresta^®, Impressa^®), or medical therapy. Minimally invasive therapies include periurethral bulking agents (bladder neck injections) and sling plication. Surgical options include repeat MUS with or without mesh removal, salvage autologous fascial sling or Burch colposuspension, or salvage artificial urinary sphincter insertion. In this paper, we present the available evidence to support each of these approaches and include the management strategy used by our review panel for patients that present with SUI after failed midurethral sling.

Clinical epidemiological insights into urinary incontinence

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is very common and heterogeneous among women with limited knowledge of progression or prognosis. Evidence based on clinical epidemiology can help to better understand the natural history of UI.

METHODS

We examine the challenges of UI definition and its subtypes, its impact on quality of life and health-seeking behavior. We review the proposed pathophysiology of UI subtypes and known risk factors as they relate to our current knowledge of the disease state. Finally, we emphasize the role of epidemiology in the process of acquiring new insight, improving knowledge, and translating this information into clinical practice.

RESULTS

Stress UI is most common overall, but mixed UI is most prevalent in older women. The three UI subtypes have some common risk factors, and others that are unique, but there remains a significant gap in our understanding of how they develop. Although the pathophysiology of stress UI is somewhat understood, urgency UI remains mostly idiopathic, whereas mixed UI is the least studied and most complex subtype. Moreover, there exists limited information on the progression of symptoms over time, and disproportionate UI health-seeking behavior. We identify areas of exploration (e.g., epigenetics, urinary microbiome), and offer new insights into a better understanding of the relationship among the UI subtypes and to develop an integrated construct of UI natural history.

CONCLUSION

Future epidemiological strategies using longitudinal study designs could play a pivotal role in better elucidating the controversies in UI natural history and the pathophysiology of its subtypes leading to improved clinical care.

Mixed urinary incontinence- what should we treat first?

Mixed urinary incontinence (MUI) is defined as ‘the involuntary loss of urine associated with urgency and also with effort or physical exertion, or on sneezing or coughing’. It is highly prevalent, increases with age and affects women more than men. It has a significant negative impact on health-related quality of life (HRQL). Additionally, treatment of mixed urinary incontinence places a large financial burden on both individuals and the NHS. Optimal management of this common condition is contested – should we treat the urge urinary incontinence (UUI), stress urinary incontinence (SUI) or predominant symptom first? At the 2015 BAUS Section of Female, Neurological and Urodynamic Urology this subject was debated. Based on a common scenario, the authors of the debate present the arguments for treating the urge urinary incontinence component, stress urinary incontinence component or the predominant symptom of mixed urinary incontinence first, before making recommendations for current practice.

The Long-Term Outcomes of the Tension-free Vaginal Tape Procedure for Treatment of Female Stress Urinary Incontinence: Data from Minimum 13 Years of Follow-Up

OBJECTIVES

To evaluate the long-term outcomes from the tension-free vaginal tape (TVT) procedure, we investigated the data from a minimum 13-year follow-up and predictive risk factors affecting efficacy for treatment of female stress urinary incontinence (SUI).

METHODS

A total of 206 (mean age, 59.2 ± 8.8 years) women who underwent the TVT procedure for SUI were selected and followed up for at least 13 years (mean, 162.4 months; range, 156-174) after TVT procedure. We analyzed the long-term results and the predictive parameters for success rates and patients' satisfaction.

RESULTS

At 13 years after surgery, the overall cure rate was 82.5%, with a satisfaction rate of 67.5%. Univariable analysis demonstrated an association of symptom grade of SUI with cure rates, while the presence of frequency, urgency, and urge incontinence showed an association with patients' satisfaction. However, in multivariable logistic regression model, none of those variables were identified as an independent risk factor related to the cure and satisfaction rate. Twenty one patients (10.2%) had postoperative complications at 1-year follow-up after surgery. However, at 13 years follow-up after surgery, only three patients (1.5%) had postoperative complications, including mesh exposure in one patient and de novo urgency in two patients.

CONCLUSION

Our long-term data, which illustrate the absence of long-term adverse events secondary to TVT procedure and the high success rate both in subjective and objective goals regardless of any independent predictive factors, suggest the TVT procedure as a recommendable method for the management of female SUI.

Diagnosis, Evaluation, and Treatment of Mixed Urinary Incontinence in Women

Mixed urinary incontinence (MUI) is a common clinical problem in the community and hospital setting. The broad definition of the term makes it difficult to diagnose, as well as determine effective treatment strategies. There are no current guidelines recommended for physicians. The estimated prevalence of this condition is approximately 30% in all women with incontinence. It has also been suggested that patients with MUI report more bothersome symptoms than either stress or urge incontinence; approximately 32% of 40- to 64-year-olds with MUI report symptoms of depression. The authors examine the diagnosis, evaluation, and treatment of patients with MUI.

Pelvic artery embolization in the management of pelvic arterial bleeding following midurethral sling surgery for stress urinary incontinence

The transobturator tape (TOT) method is the recent minimally invasive midurethral sling surgery. The TOT method was invented to reduce complication rate of surgical technique for female stress urinary incontinence. Pelvic bleeding following TOT procedure, although extremely rare, could be occurred. We presented three cases which treat pelvic arterial bleeding after midurethral sling (TOT and tension-free vaginal tape Secur) surgery via pelvic artery embolization. Therefore we report our cases with brief review of the literature.

10 years follow-up after mid-urethral sling implantation: high rate of cure yet a re-occurrence of OAB-symptoms

AIMS

To assess the long-term outcome of mid-urethral slings regarding urinary incontinence (UI) and lower urinary tract symptoms and to identify risk factors for an unsatisfactory outcome.

METHODS

Analysis of a prospective institutional database. For the current analysis only women who reached the 10 years follow-up were eligible. Outcome was assessed using a detailed, non-validated questionnaire on continence status and on several aspects of lower urinary tract function.

RESULTS

A total of 256 women were operated during 1999-2004, in 139 (54.3%), a 10 years follow-up was available and these patients were included. Mean age at surgery was 63 years. At the 2, 5, and 10 years follow-up, the percentages of women reporting 0-1 pads/day were 96.4%, 97.1% and 88.5%, respectively. More than 95% of the patients reported no stress UI at the 2, 5, and 10 years follow-up. At baseline, urgency was reported by 61.2%, this figure dropped to 17.3% at 2 years and increased thereafter to 32.4% (5 years) and 41.7% (10 years). De novo urgency was present in 3.6% after 2 years, in 10.8% after 5 years, and 14.4% after 10 years. The percentage of patients with a high degree of treatment satisfaction declined from 79.1% at 2 years to 70.5% at 5 years, and 62.6% at 10 years. Risk factors for an unsatisfactory long-term outcome were advanced age, the presence of urgency, nocturia, and decreased bladder capacity at baseline.

CONCLUSIONS

This study confirms the excellent long-term efficacy of mid-urethral slings regarding the management of stress UI. A substantial number of women develop OAB-symptoms after the procedure that largely contribute to outcome dissatisfaction. Neurourol. Urodynam. 36:614-619, 2017. © 2016 Wiley Periodicals, Inc.

Change in Overactive Bladder Symptoms After Surgery for Stress Urinary Incontinence in Women

OBJECTIVE

To assess change in overactive bladder (OAB) symptoms up to 5 years after surgery and to identify associated predictors of change from baseline.

METHODS

This is a secondary analysis of data from three multicenter urinary incontinence (UI) surgical trials of women with stress-predominant mixed UI assigned to Burch colposuspension, autologous fascial sling, or retropubic or transobturator midurethral slings. The primary outcome was improvement of 70% or greater from baseline in symptoms measured by the Urinary Distress Inventory-Irritative subscale. Surgical groups were compared within respective trials. Generalized linear models were fit using 1-year and up to 5-year data.

RESULTS

Significant improvements in Urinary Distress Inventory-Irritative scores were reported by each surgical group 1 year after surgery (P<.001). Most women (50-71%) reported improvement in OAB symptoms. Improvements were similar between midurethral sling groups at 1 year (65.5% compared with 70.7%, P=.32; odds ratio [OR] 0.83, 95% confidence interval [CI] 0.57-1.20 for retropubic compared with transobturator sling) and throughout the 5-year follow-up period. More women reported OAB symptom improvement after Burch compared with pubovaginal sling (67.9% compared with 56.6%, P=.01; OR 1.59, 95% CI 1.10-2.31 for Burch compared with sling); this group difference at 1 year persisted throughout the 5-year follow-up. At 1-year, 50.0-64.3% of patients reported 70% greater improvement in UI. This proportion declined to 36.5-54.1% at 5 years (P<.001). Preoperative use of anticholinergics and urodynamic parameters was not predictive of OAB symptom change after surgery.

CONCLUSION

Most women with stress-predominant mixed UI experienced significant improvement in OAB symptoms after incontinence surgery although this initial improvement diminished over time. Obesity blunted symptom improvement.

LEVEL OF EVIDENCE

II.

Autologous mid-urethral sling for stress urinary incontinence: Preliminary results and description of a contemporary technique

Objective:

The objective of this article is to describe the preliminary results of a contemporary technique for autologous rectus fascial sling insertion for stress urinary incontinence (SUI).

Methods:

We retrospectively reviewed the case notes of all patients who underwent autologous mid-urethral sling (aMUS) insertion by a single surgeon at our institution over a four-year period (2008–2012). Our novel technique utilises a minimal suprapubic incision, a specially designed reusable retropubic needle and mid-urethral sling positioning in a tension-free fashion as opposed to a tensioned bladder neck sling.

Results:

Thirty-eight patients were identified. Fifty per cent reported pure SUI whilst 47% had mixed urinary incontinence. Patients used an average of four pads per day (one to eight), and 26% of patients had at least one previously failed SUI procedure. Post-operative symptom questionnaires revealed mean Patient Global Impression of Improvement (PGI) scores of 1.8 (1–4), indicating that the majority of patients were very much or much improved. Only 8% of patients reported de novo OAB symptoms. Intraoperative bladder perforation occurred in only two patients. There was no incidence of chronic pain, sexual dysfunction or erosion.

Conclusion:

In a heterogeneous group of women with primary or recurrent stress urinary incontinence, the aMUS was found to have good subjective short-term cure rates with acceptable patient-reported satisfaction scores. We report a low rate of de novo OAB symptoms, no cases of erosion and no chronic pelvic, groin, or vaginal pain. We believe that aMUS is a good alternative to synthetic mid-urethral sling surgery and could be offered to women contemplating surgery for SUI.

Short-term outcomes of adjustable single-incision sling (Ajust™) procedure for stress urinary incontinence: a prospective single-center study

OBJECTIVES

Slings have become the most widely performed surgical procedure for stress urinary incontinence (SUI) in last two decades. As the third generation sling, the efficacy of the early single-incision mini-sling was controversial. The aim of this study was to determine whether the new adjustable single-incision sling (Ajust™) is safe and effective in management of female SUI at 6-18 months follow-up.

STUDY DESIGN

69 patients with SUI according the inclusion and exclusion criteria were considered adjustable single-incision sling (Ajust™) from September 2012 to September 2013. 67 patients finished 6-18 months follow-up. The data about clinical parameter, operation, complication, Urogenital Distress Inventory-Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7) and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) in Chinese were collected in preoperative, 6-month and 12-month follow-up.

RESULTS

All patients underwent successful adjustable single-incision sling (Ajust(TM)) placement. The subjective cure rate and objective cure rate was 82.0%, 92.5% in 6-month follow-up and 82.3%, 91.2% in 12-month follow-up respectively. There were no significant perioperative complications such as bladder perforation, major bleeding requiring blood transfusion in the present study. Sling exposure was observed in two patients (3.2%).

CONCLUSIONS

Adjustable single-incision sling (Ajust(TM)) was a safe and effective option for treating female SUI and was associated with comparable subjective and objective success rates when compared to standard midurethral slings (TVT-O) at a 6-18 months follow-up.

[Female incontinence surgery: state of the art]

Female urinary incontinence represents a medical and social problem with huge impact regarding both patient's quality of life and social costs. The diagnosis is important for therapeutic choice and should consider some factors: the degree of urethral mobility, urodynamics parameters, patient's will and expectations, information about surgical complications and risks. Nowadays suburethral sling evolution and bulking therapy for selected cases consent to perform miniinvasive surgery; the most relevant problem concerns the management of postoperative complications: in this sense autologous slings are used after urethrolisis. In most difficult cases, it is possible to consider artificial sphincter as the best option.

Short-term outcomes of Altis single-incision sling procedure for stress urinary incontinence: a prospective single-center study

INTRODUCTION AND HYPOTHESIS

Data on Altis® (Coloplast), a new adjustable single-incision sling (SIS) procedure for the treatment of female stress urinary incontinence (SUI), are scarce. Our aim was to evaluate the efficacy and complication rates of this procedure.

METHODS

In this prospective observational study, a total of 52 women with SUI were implanted with an Altis sling in an ambulatory setting. Before and after intervention (3, 6, and 12 months), women completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF). In addition, patients underwent a cough stress test at each evaluation and a post-voiding residual urine volume estimation at 3 months. The main outcomes measured were subjective cure (ICIQ-SF = 0), subjective improvement (ICIQ-SF >0 and < preoperative ICIQ-SF), and objective cure (negative cough stress test and no pad usage) rates. De novo overactive bladder (OAB) symptoms, changes in voiding habits and adverse events were also analyzed.

RESULTS

The subjective cure rate at 12 months was 84.0%, with an additional improvement rate of 8.0%. The objective cure rate was 90.2%. Later postoperative complications included 1 case of vaginal extrusion (requiring surgical removal of the eroded mesh segment), 3 cases of vaginal exposure of the adjustment thread (managed conservatively), de novo urgency in 3 patients, and mild dyspareunia in 2 patients.

CONCLUSIONS

The Altis sling is a safe and effective SIS procedure for the treatment of SUI with a short-term follow-up.

Effectiveness of retropubic tension-free vaginal tape and transobturator inside-out tape procedures in women with overactive bladder and stress urinary incontinence

PURPOSE

We compared the effectiveness of the retropubic tension-free vaginal tape (TVT) and the transobturator inside-out tape (TVT-O) in treating symptoms of overactive bladder (OAB) in women with stress urinary incontinence (SUI).

METHODS

Women with urodynamic SUI and OAB (mean urgency episodes ≥1 and frequency ≥8/24 hours on a 3-day voiding diary) were assigned to the TVT or TVT-O group. Preoperative measures were based on a urodynamic study, 3-day voiding diary, the Bristol Female Lower Urinary Tract Symptoms questionnaire (BFLUTSSF), and the urgency perception scale (UPS). At 12 postoperative months, the 3-day voiding diary, symptoms questionnaire, patient satisfaction, and standing stress test were assessed. The primary endpoint was change in the number of urgency episodes/24 hours from baseline to 12 months.

RESULTS

In this group of 132 women, 42 received TVT and 90 received TVT-O. The mean urgency episodes/24 hours decreased from 6.3±5.5 to 1.6±3.2 in the TVT group and from 5.1±4.4 to 1.8±3.0 in the TVT-O group. The mean percent change was significantly greater after TVT than after TVT-O (73% vs. 60%, P=0.049). All subscales of BFLUTSSF and UPS were significantly improved using either method, with significantly greater improvement seen in the quality of life (QoL) domain after TVT (P=0.002). There were no significant differences in the cure and satisfaction rates between the two groups.

CONCLUSIONS

Intervention with the TVT or the TVT-O significantly improved symptoms of OAB in women with SUI and OAB. Urgency and QoL significantly improved after TVT compared with that after TVT-O.

Risk factors for long-term failure of the retropubic tension-free vaginal tape procedure

AIMS

To investigate potential risk factors for long-term (10-year) subjective and objective failure of the retropubic tension-free vaginal tape procedure (TVT).

METHODS

Secondary risk analysis was performed using data from a recently published multi-center study that were merged with additional preoperative and operative data individually stored in the Norwegian Female Incontinence Registry (NFIR). Subjective data from 483 women and objective data from 327 women were obtained 10 years after retropubic TVT surgery. A validated questionnaire was used for subjective outcome data and a stress test for objective outcome data. Uni- and multivariate logistic regression analyses were performed using preoperative and operative variables extracted from the NFIR. The outcomes were 10-year subjective failure defined as women stating not cured, and objective failure was defined as ≥1 g urinary leakage during stress testing.

RESULTS

Age ≥56 years at the time of TVT surgery was associated with both long-term subjective failure (adjusted OR: 2.15, CI: 1.40-3.30) and long-term objective failure (adjusted OR: 2.81, CI: 1.30-6.09). Mixed incontinence was associated with subjective, but not objective failure if the urgency incontinence component was severe (adjusted OR: 2.33, CI: 1.27-4.28). Surgical complications occurring at or immediately following surgery were associated with both outcomes in the univariate analyses, but were only an independent risk factor for subjective failure in the multivariate analysis (adjusted OR: 3.02, CI: 1.53-5.95).

CONCLUSIONS

Age ≥56 years, a severe preoperative urgency incontinence component and surgical complications seem to represent independent risk factors for long-term (10-year) failure.

Surgical management of female SUI: is there a gold standard?

Many surgical options exist for women with stress urinary incontinence (SUI). The traditional gold standards of Burch retropubic colposuspension and pubovaginal slings are still appropriate treatment options for some patients, but randomized controlled trials have demonstrated that synthetic midurethral slings are just as effective as these traditional procedures but with less associated morbidity. Thus, midurethral slings--inserted via a retropubic or transobturator approach--have become the new gold standard first-line surgical treatment for women with uncomplicated SUI. Retropubic midurethral slings are associated with slightly higher success rates than transobturator slings, but at the cost of more postoperative complications. Pubovaginal slings remain an effective option for women with SUI who have failed other procedures, have had mesh complications, or who require concomitant urethral surgery. Single-incision slings have a number of benefits, including decreased operative times and early return to regular activities, but they are yet to be shown to be as effective as midurethral slings. Both retropubic and transobturator midurethral slings are effective for patients with mixed urinary incontinence, but the overall cure rate is lower than for patients with pure SUI. Based on the literature a new gold standard first-line surgical treatment for women with SUI is the synthetic midurethral sling inserted through a retropubic or transobturator approach [corrected].

Mixed Incontinence: How Best to Manage It?

Although common in women, mixed urinary incontinence (MUI) is under-reported and under-treated. It is linked to concomitant disturbances, which may be due to childbirth, ageing, or other medical conditions, in the complex bladder-urethra coordinated system of urine storage and emptying. Primary care physicians can evaluate MUI through history and simple clinical assessment or they can avail of more complex device and tools, such as urodynamic assessment. There is a wide range of therapeutic options. The recent proliferation of new drug treatments and surgical devices for urinary incontinence offers innovative strategies for therapy but products risk being introduced without long-term safety and efficacy assessment. Direct-to-consumer advertising has increased public awareness of MUI.

Persistent and recurrent stress urinary incontinence following mid-urethral tape surgery in women: a UK perspective

Stress urinary incontinence is a common health problem that affects a large proportion of women in Britain. It poses physical and psychological implications for the affected women and is a frequent indication for referral to tertiary urology centres. Midurethral tape surgery (MUTS) has established itself as the standard first-line surgical treatment as a result of its low morbidity, short hospital stay and high long-term success. Failure of the initial surgery can present as persistent or recurrent symptoms. This is a major challenge to the treating urologists as a result of the complicated nature of the condition and the lack of strong evidence supporting individual treatment modalities. In this article we discuss the factors associated with MUTS failure and the surgical options for its treatment.

Predictors of postoperative antimuscarinics in women with mixed urinary incontinence after transobturator surgery

INTRODUCTION AND HYPOTHESIS

The study sought to identify the risk factors of postoperative use of antimuscarinics after transobturator surgery in women with mixed urinary incontinence (MUI) displaying both urodynamic stress urinary incontinence (SUI) and involuntary detrusor contraction (IDC) with leakage in urodynamic study.

METHODS

The clinical data of 103 patients with MUI who underwent transobturator tape (TOT) sling surgery were retrospectively reviewed. The patients were followed at least a year. To determine risk factors for postoperative use of antimuscarinics, variables of only those with P values < 0.05 on univariate analysis were included in the multivariate logistic regression analysis with forward stepwise building.

RESULTS

Eight-four (81.6 %) of 103 patients were included in this study. The cure rate of urge urinary incontinence (UUI) was 69.0 % (58/84). Antimuscarinics were prescribed postoperatively in 22 (26.2 %) of 84 patients. Variables affecting postoperative use of antimuscarinics were age, parity, episode of any UUI, preoperative use of antimuscarinics, predominant urgency incontinence type, detrusor pressure at maximum flow, and Urogenital Distress Inventory 6. Increasing age and preoperative use of antimuscarinics increased the odds of postoperative use of antimuscarinics following TOT surgery.

CONCLUSION

Patients who were older and had taken antimuscarinics preoperatively were significantly associated with postoperative use of antimuscarinics.

Demographic and clinical predictors of treatment failure one year after midurethral sling surgery

OBJECTIVE

To identify clinical and demographic factors predictive of midurethral sling failure.

METHODS

Overall treatment failure was defined by one or more of the following objective outcomes: a positive stress test, positive 24-hour pad test or retreatment for stress urinary incontinence (SUI); subjective outcomes: self reported SUI by the Medical, Epidemiologic and Social Aspect of Aging questionnaire, incontinent episodes by 3-day diary, or retreatment for SUI, or a combination of these. Logistic regression models adjusting for sling type and clinical site were used to predict odds of overall treatment failure after univariable analysis. Models were also fit to compare factors associated with objective failure and subjective failure only.

RESULTS

Previous UI surgery (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.14-3.47); maximum Q-tip excursion<30° (OR 1.89, 95% CI 1.16-3.05); Medical, Epidemiologic and Social Aspect of Aging questionnaire urge score per 10 points (OR 1.97, 95% CI 1.21-3.21); and pad weight per 10 g (OR 1.06, 95% CI 1.02-1.10) were predictors of overall failure. Having concomitant surgery (OR 0.44, 95% CI 0.22-0.90) was predictive of subjective failure only rather than objective failure. Age per 10 years (OR 1.48, 95% CI 1.14-1.90); Urogenital Distress Inventory score per 10 points (OR 1.09, 95% CI 1.02-1.17); pad weight per 10 g (OR 1.05, 95% CI 1.01-1.10) were predictive of objective failure compared with subjective failure only. Associations of risk factors and failure were similar independent of sling type (retropubic or transobturator).

CONCLUSION

Twelve months after surgery, risk factors for overall and objective treatment failure were similar in women undergoing retropubic and transobturator sling procedures. This information may assist in counseling patients regarding efficacy of sling procedures and in setting expectations for women at increased odds for treatment failure.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00325039.

LEVEL OF EVIDENCE

II.

Ajust single incision transobturator sling procedure for stress urinary incontinence: results after 1-year follow-up

INTRODUCTION AND HYPOTHESIS

Data on the Ajust, a new single-incision sling procedure for female stress urinary incontinence (SUI) management, remain scarce and limited to a 1-year follow-up. Our goal was to assess the efficacy of this procedure after a 1-year follow-up.

METHODS

This prospective evaluation involved 95 consecutive patients implanted with Ajust at a single centre. All patients had SUI on urodynamics due to urethral hypermobility, 33 % had preoperative overactive bladder (OAB) symptoms and none had detrusor overactivity. Ninety-two patients were treated on an outpatient basis, and 3 patients had general anaesthesia. Postoperative assessment was conducted at 1, 6, 12 months, and yearly thereafter. The main outcome measure was pad usage. Secondary parameters were self-reported SUI episodes, OAB symptoms, data of clinical examination, satisfaction using the Patient Global Impression of Improvement (PGI-I) scale, postoperative pain, and adverse events.

RESULTS

After a mean follow-up of 21 ± 6 months (12-32), 76 out of 95 patients used no pads or one dry security pad, showing a success rate of 80 %. Seventy-nine out of 95 patients had no more SUI-related leakage. Only 6 patients experienced late recurrence of SUI after 6 months' follow-up. Perioperative complications included 1 case of vaginal hematoma, 1 case of acute urinary retention, 2 cases of urinary tract infection, all managed conservatively. Half of the patients had no pain after day 1, free of medications. Late complications were vaginal erosion in 1 case, and pain during exertion in 2 cases.

CONCLUSIONS

The Ajust single incision transobturator sling is a safe and effective procedure, with durable results after 1 year.

Miniarc single-incision sling for treatment of stress urinary incontinence: 2-year clinical outcomes

INTRODUCTION AND HYPOTHESIS

We report 2-year data on the effectiveness and safety of the MiniArc single-incision sling in women with stress urinary incontinence.

METHODS

This multi-center, prospective, single-arm, industry-sponsored study measured the effectiveness of the MiniArc sling via quantitative (cough stress test and 1-h pad weight test) and qualitative (Urogenital Distress Inventory-Short Form and Incontinence Impact Questionnaire-Short Form) measurements. The objective efficacy rate was defined as the number of patients with a negative cough stress test or 1-h pad weight test ≤ 1 g at 2 years. The subjective efficacy rate was determined by patient responses to the UDI-6 question # 3, "Do you experience, and if so, how much are you bothered by urine leakage related to physical activity, coughing, or sneezing?" Secondary objectives were to evaluate procedural variables of implantation and long-term safety.

RESULTS

One hundred and eighty women with a mean age of 51.1 years were implanted in the study. Mean procedure time, blood loss, and length of stay were 11.0 min, 41.7 mL and 9.5 h respectively. At 2 years, 142 patients were available for analysis. The objective efficacy rates for the cough stress test (CST) and pad weight test (PWT) were 84.5 % and 80.1 % respectively and the subjective efficacy rate was 92.9 %. Median Urogenital Distress Inventory-Short Form and Incontinence Impact Questionnaire-Short Form scores showed statistically significant improvement (p < .001). The most common adverse events included UTI (4.8 %), constipation (3.7 %), and temporary urinary retention (3.2 %).

CONCLUSION

MiniArc is a safe and effective surgical procedure for the treatment of SUI in women with follow-up through 2 years.

Complications Following Outside-in and Inside-out Transobturator-Tape Procedures with Concomitant Gynecologic Operations

This study was undertaken to compare the complications of outside-in transobturator tape procedures (TOT) and inside-out transobturator tape procedures (TVT-O) with concomitant gynecologic surgery for the treatment of female stress urinary incontinence (SUI). A retrospective review of 206 consecutive patients who underwent either TOT or TVT-O with concomitant gynecologic operations between March 2008 and February 2011 was conducted. The incidence of perioperative complications was compared. For statistical analysis, chi-squared tests were used. There were no reports of intraoperative complications such as vaginal injury or bladder perforation. Postoperative complications were noted in 23 procedures (11.2%). These included 6 cases of urinary retention (2.9%), 2 cases of vulva hematoma (1.0%), 7 cases of urinary tract infection (3.4%), 4 cases of de novo urgency (2.9%), and 4 cases of vaginal erosion (2.9%). There were no significant differences in complication rates between the two groups. Our results suggest that inside-out and outside-in procedures are simple and safe techniques that may have a low rate of complications when used with a concomitant gynecologic operation.

The MiniArc sling for female stress urinary incontinence: clinical results after 1-year follow-up

Introduction and hypothesis

The objective of this study was the assessment of the efficiency of the MiniArc for curing stress urinary incontinence.

Methods

Seventy-seven patients, operated on from March 2008 to November 2009, were evaluated in this study. One-year post-operative data are presented. All patients suffered from predominant stress urinary incontinence. After 1 year, response was 74%. Evaluation was performed using a questionnaire consisting of the EuroQol-5 Dimensions, the Patient Global Impression of Improvement, the Incontinence Impact Questionnaire, the Urinary Distress Inventory, the Prolapse/Urinary Incontinence Sexual Questionnaire, short form, and the Defecation Distress Inventory.

Results

One year after surgery, 68% of the patients stated an improvement in their incontinence status, while only 44% stated to be completely dry.

Conclusion

The 1-year follow-up suggests that the MiniArc is less effective in the treatment of stress urinary incontinence than the TVT.

Treatment of mixed urinary incontinence

INTRODUCTION

Mixed urinary incontinence (MUI) is a prevalent condition and imposes a significant impact on a woman's quality of life. Treatment is often challenging, as a single modality may be inadequate for alleviating both the urge and stress component.

MATERIALS AND METHODS

A MEDLINE search was conducted regarding English-language literature pertaining to the pathophysiology, diagnosis of, and treatment for MUI. Non-English language articles were considered if they could be translated into English using GOOGLE translator.

RESULTS

The identification of an ideal single treatment has also been made more challenging by the poor characterization of the pathophysiology of MUI. Behavioral and lifestyle modification, as well as pelvic floor muscle therapy, should be considered first-line options for all women with MUI. Treatment of the urge component with anti-muscarinics is effective; however the stress component is likely to persist after therapy. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI, with emerging evidence suggesting that transobturator MUS may be associated with lower rates of de novo and persistent urge component compared to other procedures. The presence of concomitant, preoperative detrusor overactivity has not been consistently associated with postoperative outcomes.

CONCLUSIONS

The optimum treatment of MUI may often require multiple treatment modalities. While surgery may have a positive impact on both the urge and stress component, its implementation should be approached with caution and patients should be carefully selected. Detailed informed consent in women with MUI cannot be overstated.

Transobturator vaginal tape in comparison to tension-free vaginal tape: A prospective trial with a minimum 12 months follow-up

BACKGROUND

The tension-free vaginal tape (TVT) procedure is based on the integral theory that the midurethra has an important role in the continence mechanism. Transobturator vaginal tape (TOT) is the same in concept as TVT but it differs from TVT in that, rather than passing through the retropubic space, sling materials are drawn through the obturator foramina. We prospectively compared TVT with TOT with respect to operation-related morbidity and surgical outcomes at a minimum follow up of 12 months.

MATERIALS AND METHODS

A total of 36 women with stress urinary incontinence (SUI) were alternatively assigned to the TVT group (18) or the TOT group. Preoperative evaluation included urodynamic study and I-QOL questionnaire. One year after operation the surgical result, patient satisfaction, incontinence quality-of-life questionnaire, long-term complications, and uroflowmetry were evaluated in both groups.

RESULTS

The patient characteristics in both the TVT and TOT group were similar. Mean operating time was significantly shorter in the TOT group likened to the TVT group.

CONCLUSIONS

Both the TVT and TOT procedures are minimally invasive and similar in operation-related morbidity. TOT appears to be as effective as TVT, and safer than TVT for the surgical treatment of SUI in women at 12 months follow-up.

Preoperative and postoperative predictors of satisfaction after surgical treatment of stress urinary incontinence

OBJECTIVE

The purpose of this study was to assess which preoperative and postoperative variables correlated with satisfaction after surgical treatment of urinary incontinence.

STUDY DESIGN

We conducted a retrospective cohort study of 371 women who underwent rectus fascial or midurethral sling procedure. Satisfaction was defined as a questionnaire response of "completely satisfied." Incontinence symptoms were based on responses to validated questionnaires. Associations between preoperative and postoperative variables and satisfaction were assessed with the use of logistic regression models.

RESULTS

Increasing patient age (odds ratio [OR], 0.8; P = .002), body mass index (OR, 0.8; P = .003), and an autologous rectus fascial sling (compared with a midurethral sling; OR, 0.5; P = .003) were associated with decreased odds of satisfaction in a multivariate model. Furthermore, patients who required urethrolysis or had severe lower-urinary tract symptoms were significantly less likely to report satisfaction.

CONCLUSION

Increasing age, body mass index, and type of operation were associated with decreased odds of satisfaction.

Review article: Mid-urethral synthetic slings for female stress urinary incontinence

• Mid-urethral synthetic slings (MUSS) have grown in acceptance and popularity to gain a foremost position in stress urinary incontinence (SUI) surgery. • There are numerous studies that provide a large amount of Level 1 and 2 evidence that support the concept of a sling placed at the level of the mid-urethra. • Long-term follow-up has been published for the original tension-free vaginal tape (TVT) procedure with the most recent publication providing Level 2 evidence with mean follow-up of 11.5 years of 69/91 (77%) of patients from the original series. There was objective cure was in 90% of women and 77% considered themselves subjectively cured, based on the Patient Global Impression of Improvement. • Level 1 evidence with long-term follow-up has been provided comparing colposuspension to TVT at 2 and 5 years. At 5 years for the primary efficacy variable of a negative 1 h stress pad test, there was no difference in success (81% vs 90%). • Two recent meta-analyses provide Level 1 evidence comparing outcomes for retropubic vs transobturator MUSS. One included 18 studies, randomized and cohort: cohort studies had a 12.3% failure rate for transobturator and 13.7% failure for the retropubic approach, randomized studies showed 5.7% failure in the transobturator vs 7.8% in the retropubic group. The other meta-analysis included 11 studies published 2008-2009, which found that the short-term cure rate was borderline inferior for the transobturator tape group (odds ratio 0.62; 95% confidence interval 0.37-1.00), nearly reaching statistical significance (P= 0.05). • This review details further comparator evidence and evidence for use in specific patient groups (elderly, obese, intrinsic sphincter deficiency, mixed UI).

[Sub-urethral sling in the treatment of female urinary incontinence: which? how?]

Review of the literature that formed the basis for drafting the guideline on the sub-uretral sling in the first-line surgical treatment of female stress urinary incontinence. Medline database query since the introduction of TVT on the questions of various chapters and sub-chapters of the present article. The use of tapes made of polypropylene monofilament exclusively, knitted, is recommended to the exclusion of any other material. Regarding the choice of procedure, the objective cure rate of transobturator and retro-pubic routes cannot be evaluated clearly because of vague evaluation criteria from one study to another. Without adequate clinical trials proving their efficacy and safety, the mini-bands can so far be recommended to treat female stress urinary incontinence. Moderate overweight does not affect the results of laying tape. In patients with severe obesity, surgery to correct obesity is even better than surgery for incontinence. Age is not a contra-indication. If the patient is young and nulliparous, it is reasonable to advise her to postpone surgery after her last pregnancy. In case of multiparous patient, the risk of vaginal delivery does not seem sufficient to suggest a cesarean section. To conclude, sub-urethral slings are the first-line surgical treatment of female stress urinary incontinence.