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Tu LM, Gheiler E, Hanson CE, Jalkut M, McCrery R, Parekh M, Parva M, Erickson T. Management of female stress urinary incontinence with single-incision mini-sling (Altis®): 36 month multicenter outcomes. Neurourol Urodyn 2023; 42:1722-1732. [PMID: 37555436 DOI: 10.1002/nau.25256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE To assess noninferiority of the safety and effectiveness of the Altis® Single Incision Sling (SIS) with standard midurethral transobturator and/or retropubic slings through 36 months in a prospective, longitudinal, nonrandomized US Food and Drug Administration (FDA) 522 cohort study. MATERIALS AND METHODS Adult females with confirmed predominant stress urinary incontinence (UI) through cough stress test (CST) or urodynamics and failed two noninvasive incontinence therapies. Effectiveness endpoints included objective dryness, negative CST, adverse events, and revision/resurgery through 36 months. The primary effectiveness endpoint was reduction from baseline in 24-h pad weight of ≥50% at 6 months, as requested by the FDA, and is included as a study point in this paper. Primary safety endpoint was rate of related serious adverse events (SAE) through 36 months. Noninferiority margins of 15% and 10% were prespecified for the effectiveness and safety endpoints. Due to the observational nature of the cohort study, a propensity methodology was conducted to assess the effect of potential confounding variables on the primary endpoints between groups. RESULTS Three hundred fifty-five women underwent the sling procedure (n = 184 Altis; n = 171 Comparator). One hundred fourty (76%) Altis subjects and 101 (59%) Comparator subjects completed follow-up through 36 months. At 36 months, for the effectiveness endpoint, the difference in proportions of -0.005 for Altis versus Comparator (95% confidence interval [CI]: -0.102 to 0.092) was statistically significant (p = 0.002), supporting the hypothesis that Altis is noninferior to Comparator. Furthermore, both groups demonstrated high objective efficacy; in the Altis arm n = 99 (81.8%) subjects were a success, and in the Comparator arm, n = 79 (82.3%) subjects were a success. Additionally, regarding the CST, Altis was found to be noninferior to the Comparator at every study visit, and the rate of negative CST remained above 80% for both groups (p < 0.001). At 36 months, Altis (n = 2; 1.1%) and Comparator (n = 4; 2.3%) subjects experienced a device and/or procedure-related SAE. The difference in proportions of 0.013 for Altis versus Comparator (95% CI: -0.023 to 0.048) was statistically significant (p < 0.001), demonstrating that Altis is noninferior to Comparator with respect to the primary safety endpoint throughout the study. There were 62 (36.3%) retropubic midurethral slings (RMUS), 96 (56.1%) transobturator midurethral slings (TMUS), and 13 (7.6%) SIS slings in the Comparator group. For the 36 month effectiveness endpoint, assessing the noninferiority of Altis versus RMUS and Altis versus TMUS, 99 (81.8%) Altis and 37 (90.2%) RMUS were a success, trending toward statistical significance, however, it cannot be determined to be noninferior (p = 0.092). Ninty-nine (81.8%) Altis and 33 (71.7%) TMUS were a success; this was statistically significant (p < 0.001), demonstrating Altis was noninferior to TMUS. Rates of negative CST were 122 (87.1%) Altis, 40 (93.0%) RMUS (p < 0.001), and 44 (91.7%) TMUS (p < 0.001). CST demonstrated that Altis was noninferior to RMUS and Altis was noninferior to TMUS at 36 months. CONCLUSION Altis single-incision sling was noninferior to standard midurethral sling for treatment of stress UI, throughout the study and at 36 months. Furthermore, adverse event rates were low.
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Affiliation(s)
- Le Mai Tu
- Department of Surgery, Division of Urology, Hospital Center of University of Sherbrooke, Sherbrooke, Canada
| | - Edward Gheiler
- Department of Gynecology, Urological Research Network LLC, Nova Southeastern University, Hialeah, Florida, USA
| | - Craig E Hanson
- Department of Urogynecology, Van Wert Health, Van Wert, Ohio, USA
| | - Mark Jalkut
- Associated Urologists of North Carolina, Raleigh, North Carolina, USA
| | - Rebecca McCrery
- Department of Urogynecology, Adult and Pediatric Urology and Urogynecology, Omaha, Nebraska, USA
| | - Mitesh Parekh
- Department of Obstetrics and Gynecology, Ohio University College of Medicine, Athens, Ohio, USA
| | - Mohamad Parva
- Department of Gynecology, The Group for Women, Tidewater Clinical Research, Norfolk, Virginia, USA
| | - Ty Erickson
- Department of Gynecology, UNLV School of Medicine, Las Vegas, Nevada, USA
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Patel T, Sugandh F, Bai S, Varrassi G, Devi A, Khatri M, Kumar S, Dembra D, Dahri S. Single Incision Mini-Sling Versus Mid-Urethral Sling (Transobturator/Retropubic) in Females With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e37773. [PMID: 37214065 PMCID: PMC10194431 DOI: 10.7759/cureus.37773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/18/2023] [Indexed: 05/23/2023] Open
Abstract
Stress urine incontinence (SUI) is most common in middle-aged women and the second most common in those over 75. SUI causes significant discomfort and suffering for patients and has a considerable financial impact on the healthcare system. Conservative approaches are recommended as the first step in treatment. However, surgery is often necessary to improve a patient's quality of life due to the high failure rate of conservative treatments. A thorough literature review of studies published before March 2023 was conducted on the safety and effectiveness of single-incision mini slings (SIMS) and standard mid-urethral slings (MUS). PubMed, Embase, Cochrane Library, and Elsevier's ScienceDirect were used to retrieve the studies. Two reviewers independently searched and evaluated the data based on inclusion and exclusion criteria. Review Manager 5.4 software was used for meta-analysis. Included were seventeen studies involving 3,503 female SUI patients without intrinsic sphincter deficiency (ISD) or mixed urinary incontinence. According to the results of our meta-analysis, the clinical efficacy of SIMS is comparable to that of MUS in terms of objective cure rate (RR: 0.99; 95% CI: 0.95 to 1.03, p: 0.66, I2: 29%). In contrast, it increases the post-procedure International Consultation on Incontinence Questionnaire (ICIQ) score (WMD: 0.08; 95% CI: -0.08 to 0.08). CI: -0.02 to 0.18, p: 0.11, I2: 55%) and improves the PGI-I score to a greater extent (RR: 1.04; 95% CI: 0.96 to 1.08, p: 0.36, I2: 76%). In contrast, there is no difference between the two groups regarding patient satisfaction (RR: 0.96; 95% CI: 0.92 to 1.01, p: 0.16, I2: 0%) and Sandvik score reduction (RR: 0.98; 95% CI: 0.94 to 1.02, p: 0.35, I2: 0%). In conclusion, single-incision mid-urethral slings (SIMS) are as effective as mid-urethral slings (MUS) for treating pure stress urinary incontinence (SUI) without intrinsic sphincter deficiency (ISD), with a shorter operation time. However, the SIMS procedure has a higher incidence of dyspareunia. At the same time, bladder perforation, mesh-related complications, pelvic/groin pain, urinary tract infection (UTI), worsening urgency, dysuria, and pain score are less likely to occur with SIMS. Only the decrease in pelvic/groin pain was statistically significant.
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Affiliation(s)
- Tirath Patel
- Surgery, American University of Antigua, St John, ATG
| | - Fnu Sugandh
- Medicine, Ghulam Muhammad Mahar Medical College, Sukkur, PAK
- Medicine, Civil Hospital Karachi, Sukkur, PAK
| | - Shuaita Bai
- Medicine and Surgery, Peoples University of Medical & Health Science, Nawabshah, PAK
| | | | - Anjuli Devi
- Medicine and Surgery, Ziauddin University, Karachi, PAK
| | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, Karachi, PAK
| | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Deepak Dembra
- Surgery, Ghulam Muhammad Mahar Medical College, Sukkur, PAK
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Safety and Efficacy of Single Incision Sling Versus Midurethral Sling in the Treatment of Stress Urinary Incontinence: A Randomized Controlled Trial. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:113-120. [PMID: 36735422 DOI: 10.1097/spv.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE This study compares the long-term efficacy and safety of an innovative single-incision sling (SIS) with the inside-out transobturator tape (TOT) sling in the treatment of female stress urinary incontinence. OBJECTIVES Women with urodynamic stress urinary incontinence were randomized to either SIS or TOT groups and followed up for 4 years. The primary outcome was objective cure defined with a negative cough stress test result. Secondary outcomes involved subjective cure reported via patient's satisfaction scale, surgery complications, postoperative de novo urgency, and patient's life quality. STUDY DESIGN This is a randomized noninferiority controlled trial. RESULTS A total of 168 women were randomized (84 in both groups). After 4-year follow-up, 130 patients were analyzed (66 in the SIS group and 64 in the TOT group). The objective (86.4% vs 84.4%; risk difference [95% confidence interval], 0.020 [-0.101 to 0.141]; P = 0.807) and subjective cure rates (83.3% vs 81.3%; risk difference [95% confidence interval], 0.020 [-0.111 to 0.151]; P = 0.821) were similar with the SIS and TOT groups. Both procedures were associated with low complication rates. Repeated surgery rates were 7.6% in the SIS group and 6.3% in the TOT groups. The mesh exposure rate was 1.5% for the SIS group and 3.1% for the TOT group. Incidence of de novo urgency did not vary between TOT and SIS patients. Both groups registered significant life quality improvement. CONCLUSION After long-term follow-up, anti-incontinence SIS surgery proved noninferior to the inside-out TOT procedure in terms of objective and subjective cure rates.
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Altis® Adjustable Single Incision Sling System for Treatment of Intrinsic Sphincteric Deficiency: A 3-Year Follow-up Observational Study. Female Pelvic Med Reconstr Surg 2022; 28:500-505. [PMID: 35695733 DOI: 10.1097/spv.0000000000001200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE This article is a long-term follow-up study on the Altis adjustable single incision sling (Coloplast Corp.) in patients with isolated intrinsic sphincteric deficiency (ISD). OBJECTIVES The primary end-points were to evaluate the subjective and objective outcomes of the Altis for the treatment of ISD, with a 3-year follow-up. The secondary end-point was to evaluate the safety of this surgical procedure. STUDY DESIGN This is a retrospective single-arm study. A total of 123 consecutive patients with ISD were selected from our database among women who underwent an Altis implantation for ISD from March 2015 to June 2017, after unsuccessful previous conservative treatment. Of the 123 included patients, 16 were excluded, not meeting inclusion criteria. Cure rate was evaluated objectively, using a standardized cough stress test and urodynamics, and subjectively using the Patient Global Impression of Improvement. Complications were assessed intraoperatively, perioperatively, and postoperatively. Six, 12, and 36 months of follow-ups were analyzed for the study. RESULTS The 3-year objective cure rate was 86.9%, and the subjective cure rate was 81.5%. We observed no intraoperative complications. No women were obstructed. Ten patients reported postoperative complications, although most of them were Clavien-Dindo grade I and self-limited. CONCLUSIONS Altis system could be considered an effective and safe alternative to traditional midurethral slings as treatment for women with ISD.
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Friedman BJ, Nguyen J, Vollstedt A, Diaz M, Hoang Roberts L, Sirls LT. A modified Altis ® mid-urethral sling that allows immediate post-operative adjustment: experience in 197 patients. Int Urol Nephrol 2022; 54:241-247. [PMID: 34981416 DOI: 10.1007/s11255-021-03081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/28/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The transobturator mid-urethral Altis® "mini-sling" uses a static and a dynamic anchor on either end of a pulley suture for intraoperative tension adjustment. Given the potential for incorrect tensioning with sling placement, we adopted a modification for post-operative adjustment should stress urinary incontinence (SUI) persist. The objective is to describe technique, rate of postoperative adjustment driven by patient symptoms, and impact of preoperative/intraoperative variables. METHODS In this single-surgeon experience, retrospective chart review, demographic and clinical data were collected on patients who received the Altis® sling for SUI between 2014 and 2019. We used descriptive statistics and three-group comparison tests to assess difference in variables among tightening, loosening, or no adjustment. RESULTS Altis® sling placement was performed on 197 female patients with an average age of 58.7 years. Eighty-four percent (165/197) did not receive post-operative adjustment. Of the 32 patients with post-operative adjustment, 8 (4.1%) had loosening and 24 (12.2%) had tightening at an average of 10.5 days post-operatively. All tightening procedures were done in the clinic. Of the 8 patients with post-operative loosening, 6 were performed in clinic and 2 in the operating room. Preoperative and intraoperative variables were not significantly different among tightening, loosening, and no adjustment cohorts. CONCLUSIONS This modification of the Altis® sling provides surgeons with the ability to tighten and loosen the sling for persistent SUI. All tightening and most loosening procedures were able to be performed in the clinic. The ability to easily tighten a sling in the early post-operative period may be a critical advantage.
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Affiliation(s)
- Brett J Friedman
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
| | - Jennifer Nguyen
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Annah Vollstedt
- Department of Urology, University of Iowa, Iowa City, Iowa, USA
| | | | - Ly Hoang Roberts
- Department of Urology, Beaumont Health System, Royal Oak, MI, USA
| | - Larry T Sirls
- Department of Urology, Beaumont Health System, Royal Oak, MI, USA
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Gromicho A, Dias J, Araújo D, Rodrigues R, Kheir GB, Ferraz L. Long-term outcomes of Altis® single-incision sling procedure for stress urinary incontinence. Int Urogynecol J 2021; 33:717-722. [PMID: 34338824 DOI: 10.1007/s00192-021-04936-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/30/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS In women with predominant stress urinary incontinence (SUI), recent data are still controversial regarding the short-term outcomes of mini-slings and there is a lack of evidence about the outcomes in the long term. Our aim was to evaluate the long-term effectiveness and complication rates of Altis® (Coloplast). METHODS A total of 145 women with clinical SUI were implanted with an Altis® sling between April 2012 and December 2015. Women completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) before the intervention and in the following consultations. A telephone interview was performed in January 2021 and 131 women (90%) were available for re-evaluation. The main outcome was treatment success, defined as no self-reported SUI symptoms and no reintervention. Secondary outcomes included response to ICIQ-SF (cure defined as ICIQ-SF = 0) and Patient Global Impression of Improvement (PGI-I) questionnaires, de novo overactive bladder (OAB) symptoms and adverse events. RESULTS The overall treatment success was 73.3% at a median follow-up of 8 years. The ICIQ-SF cure rate was 66.1%. In the PGI-I, 70.4% answered that they were much better or very much better. Later postoperative complications included 2 cases (1.5%) of vaginal extrusion (requiring surgical removal of the eroded mesh segment), 3 (2.3%) cases of infravesical obstruction (which led to sling section), de novo urgency in 20 patients (15.3%), and mild dyspareunia in 2 (1.5%) patients. CONCLUSIONS The Altis® sling was safe and effective in a long-term follow-up, improving the quality of life in patients with SUI.
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Affiliation(s)
- Alexandre Gromicho
- Urology Department, Centro Hospitalar do Funchal, Av. Luís de Camões 57, 9000-177, Funchal, Portugal.
| | - Jorge Dias
- Urology Department, Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | - Débora Araújo
- Urology Department, Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | - Raquel Rodrigues
- Urology Department, Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | - George Bou Kheir
- Urology Department, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Luís Ferraz
- Urology Department, Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
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Erickson T, Roovers JP, Gheiler E, Parekh M, Parva M, Hanson C, McCrery R, Tu LM. A Multicenter Prospective Study Evaluating Efficacy and Safety of a Single-incision Sling Procedure for Stress Urinary Incontinence. J Minim Invasive Gynecol 2020; 28:93-99. [PMID: 32320798 DOI: 10.1016/j.jmig.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 01/10/2023]
Abstract
STUDY OBJECTIVE The aim of the Altis 522 study was to compare the safety and efficacy of the Altis Single-Incision Sling System (SIS) (Coloplast, Minneapolis, MN) with standard midurethral transobturator and/or retropubic slings through 36 months. In this report, we present data through 12 months of follow-up. DESIGN Postmarket, prospective, multicenter, nonrandomized cohort design. SETTING The study was performed at 23 hospitals in the United States and Canada. PATIENTS Adult female patients with stress urinary incontinence (SUI) clinically indicated for an incontinence sling were treated (n = 355). INTERVENTIONS Altis SIS was compared with any Food and Drug Administration-cleared transobturator or retropubic sling. MEASUREMENTS AND MAIN RESULTS Collected measures included device- and/or procedure-related serious adverse events, relevant nonserious and all adverse events, and revision surgery. Objective efficacy measures included 24-hour pad weight, dryness (defined as pad weight ≤4.0 g), and cough stress test. Subjective outcome measures included patient global impression of improvement, urogenital distress inventory, Incontinence Impact Questionnaire-Short Form, Surgical Satisfaction Questionnaire, and visual analog scale for pain. At 12 months, 24-hour pad weight success (≥50% reduction), negative cough stress test, patient global impression of improvement, urogenital distress inventory, and Incontinence Impact Questionnaire-Short Form appeared similar between groups. Through 12 months, 2 subjects in the Altis group and 3 subjects in the comparator group experienced a serious device- and/or procedure-related adverse event. In the Altis group, 1 subject (0.5%) experienced a device revision, and 1 subject (0.5%) had the device explanted. In the comparator group, 7 subjects (4.1%) experienced a device revision, and 1 device (0.6%) was explanted before the 12-month visit. The occurrence of relevant nonserious procedure and/or device-related adverse events was similar between groups. CONCLUSION At 12-months follow-up, safety and efficacy appeared similar between Altis SIS and standard transobturator and retropubic midurethral slings.
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Affiliation(s)
- Ty Erickson
- Department of Gynaecology, Rosemark Women Care Specialists, Idaho Falls, Idaho (Dr. Erickson)
| | - Jan-Paul Roovers
- Department of Gynaecology, Amsterdam UMC, Amsterdam, Netherlands (Dr. Roovers).
| | - Edward Gheiler
- Department of Gynaecology, Nova Southeastern University/Urological Research Network LLC, Hialeah, Florida (Dr. Gheiler)
| | - Mitesh Parekh
- Department of Gynaecology, Genesis Healthcare, Zanesville, Ohio (Dr. Parekh)
| | - Mohamad Parva
- Department of Gynaecology, The Group for Women, Tidewater Clinical Research, Norfolk, Virginia (Dr. Parva)
| | - Craig Hanson
- Department of Gynaecology, Women's Health Advantage, Fort Wayne, Indiana (Dr. Hanson)
| | - Rebecca McCrery
- Department of Gynaecology, Adult and Pediatric Urology and Urogynecology, Omaha, Nebraska (Dr. McCrery)
| | - Le Mai Tu
- Department of Surgery, Division of Urology, Hospital Center, University of Sherbrooke, Sherbrooke, Quebec, Canada (Dr. Tu)
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Lau HH, Enkhtaivan S, Su TH, Huang WC. The Outcome of a Single-Incision Sling versus Trans-Obturator Sling in Overweight and Obese Women with Stress Urinary Incontinence at 3-Year Follow-Up. J Clin Med 2019; 8:jcm8081099. [PMID: 31349577 PMCID: PMC6723533 DOI: 10.3390/jcm8081099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 07/19/2019] [Accepted: 07/23/2019] [Indexed: 11/18/2022] Open
Abstract
Background: Being overweight or obese is a risk factor for incontinence and has negative impacts on the surgical outcomes. Compared with trans-obturator sling (TOS), single incision sling (SIS) is a new generation of anti-incontinence surgery. However, the data on SIS in overweight and obese women remains limited. Methods: This retrospective study analyzed the objective and subjective cure rate of overweight and obese women who underwent sling surgeries. Other evaluations included valid questionnaires to assess quality of life and 1-hour pad test to quantify urine leakage. Surgical characteristics and adverse events were also analyzed. Results: A total of 217 patients were analyzed with a median follow-up period of 37.3 months (range, 9–84 months). For overweight and obese patients, the objective and subjective cure rate were comparable (all p > 0.05). However, the SIS group had worse post-operative incontinence-related symptom distress (p < 0.001) and 1-hour pad test (p = 0.047). On the other hand, SIS had a shorter surgery time (p = 0.017) and lower pain score (p < 0.001). Conclusions: Compared with TOS, SIS had non-significant cure rates in the overweight and obese women. SIS had worse urine leakage and incontinence symptoms, but less surgical and wound pain in obese women. Thorough pre-operative counseling is necessary.
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Affiliation(s)
- Hui-Hsuan Lau
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei 104, Taiwan
- Mackay Medicine, Nursing and Management College, New Taipei City 251, Taiwan
- Department of Obstetrics and Gynecology, Hsinchu Mackay Memorial Hospital, Hsinchu 300, Taiwan
| | | | - Tsung-Hsien Su
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei 104, Taiwan
- Mackay Medicine, Nursing and Management College, New Taipei City 251, Taiwan
- Department of Obstetrics and Gynecology, Hsinchu Mackay Memorial Hospital, Hsinchu 300, Taiwan
| | - Wen-Chu Huang
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan.
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei 104, Taiwan.
- Mackay Medicine, Nursing and Management College, New Taipei City 251, Taiwan.
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