Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders

Autologous fascial slings for stress urinary incontinence in patients with neuropathic bladder

STUDY DESIGN

Retrospective review.

OBJECTIVES

Stress urinary incontinence in the neurogenic population can have a profound effect on quality of life. It can lead to significant skin breakdown and non-healing pressure sores. Surgical management options for stress incontinence include an autologous pubovaginal sling (PVS). We performed a retrospective review of female patients undergoing PVS insertion in a specialised unit to assess short-term efficacy and safety in this complex neurogenic population.

SETTING

Princess Royal Spinal Injuries Unit, Sheffield, UK.

METHODS

A retrospective review of all patients (n = 22) who had undergone insertion of a PVS was carried out in a single specialised spinal injury unit between 2015 to 2019. Patients were identified from a prospectively maintained database and from the electronic theatre records. Data was collected from the database, electronic patient records and radiological systems. All procedures were carried out by two experienced neurourology consultants.

RESULTS

The majority of patients were continent (n = 19, 86.4%) and 2 (13.5%) patients had an improvement in SUI following PVS insertion at a mean follow-up of 20 months. Pad use decreased from 5 to <1 and mean ICIQ-UI score improved from 17 to 1. One patient had a recurrence of stress urinary incontinence at 28 months. The median length of stay was three days. Three patients (13.6%) had a Clavien-Dindo Grade III-IV complication. One patient developed de-novo neurogenic detrusor overactivity.

CONCLUSION

The autologous PVS is a safe and efficacious procedure for the management of stress urinary incontinence in the neurogenic population with an acceptable morbidity and excellent short-term outcomes.

Knowledge Gaps in Urologic Care of Female Spinal Cord Injury Patients

PURPOSE OF REVIEW

We highlight the substantial gaps in knowledge on urologic care of female spinal cord injury (SCI) patients.

RECENT FINDINGS

Males account for approximately 80% of people living with SCI in developed nations. Although there is a robust body of literature in some aspects of urologic care of individuals with SCI, such as treatments for neurogenic detrusor overactivity, there are relatively few studies focusing specifically on females. There are also few studies focusing on other aspects of urologic care of women with SCI such as sexual dysfunction, pelvic organ prolapse, and bladder cancer. Established guidelines for bladder management exist, generally recommending intermittent catheterization, but the fact remains that a substantial number of women with SCI utilize indwelling catheters for bladder management. There remains a paucity of literature using patient-reported measures regarding both outcomes and experiences of urologic management in the SCI population. Bladder management is challenging for many women with SCI. There are few studies on other urologic concerns in women with SCI.

Management of stress urinary incontinence in spinal cord injured female patients with a mid-urethral tape - a single center experience

Context/Objective Stress urinary incontinence (SUI) affects the quality of life of females with spinal cord injury (SCI), has a negative impact on functional independence and disturbs their psychosocial interaction. Our aim was to assess the efficacy of mid-urethral tapes (MUT) in managing stress urinary incontinence in this population. Design Retrospective cohort study. Participants SCI females with upper motor neuron lesion and urodynamically proven stress or mixed urinary incontinence that was treated with a mid-urethral tape and followed up for at least 12 months. Interventions Mid-urethral tapes such TVT, TOT and mini-Arc. Patient reported outcomes based on the daily use of pads and ICIQ modular questionnaire scores. Outcome measures The primary endpoint was defined as the success rate of MUT surgery in managing stress incontinence at 12. The secondary endpoints included the improvement rate at 12 months, the complication rates and the need for additional treatments. Results 38 females were studied. At 12 months the overall patient reported success rate was 52.6%. 16% reported significant improvement. 68.4% felt the quality of life to improve. Nine patients develop tape related complications (five de novo urgency, one vaginal extrusion, one frequent dysreflexia and one worsening of incontinence). Conclusion Mid-urethral tapes are effective in the management of stress urinary incontinence in female patients with spinal cord injury. There are demonstrable improvements in both continence and quality of life.

Management and rehabilitation of neurologic patients with lower urinary tract dysfunction

Diverse lower urinary tract problems arise in neurologic disease, caused by dysfunctions of the bladder and outlet, both during urine storage and voiding. Most neurologic diseases cause some lower urinary tract dysfunction (LUTD), and the type of dysfunction is related to the location of the nervous system lesion. Clinical evaluation requires identification of risk factors for major morbidity, particularly renal dysfunction, and mechanisms underlying symptoms. A holistic approach is needed to cover influential aspects (e.g., cognitive function, mobility, and urinary tract infections) and related issues (e.g., sexual function, bowel function, and autonomic dysreflexia), requiring a multidisciplinary team. Comprehensive history and examination are supported by a bladder diary, urinalysis, and renal assessment, supplemented by urodynamic tests. The simplest classification of neurogenic LUTD describes both bladder and sphincter function, cataloging each structure as normal, overactive, or underactive. Treatment aims to protect life expectancy and improve quality of life, noting the possibility of neurologic disease progression and comorbid disorders. Conservative measures include fluid advice and assessment of suitable containment products. Urine storage can be improved with antimuscarinic medications, bladder injections with botulinum neurotoxin A, and less established methods such as nerve stimulation, intravesical instillations, and beta-3 agonist. For severe storage dysfunction, sacral neuromodulation or surgery to improve reservoir function, increase outlet resistance, or divert the urinary tract may be needed. Voiding is usually replaced by intermittent or indwelling catheterization, which has largely superseded triggered reflex voiding, bladder expression, or sphincterotomy. Treatment selection is hampered by a limited, low-quality evidence base.

A retrospective study on female urological surgeries over the 10 years following spinal cord lesion

OBJECTIVES

To evaluate the efficacy and safety over a 10-year period of any urological operations required by female patients with spinal cord lesions (SCLs).

METHODS

Retrospective study of urological surgeries from our database performed on females with SCLs from 2001 to 2002. Surgery efficacy for neurogenic lower urinary tract dysfunctions (N-LUTDs) was evaluated by comparing 7-day voiding diaries pre- and post-surgeries, while individual investigations were done pre- and post-surgery to evaluate urological complications. Drawbacks were assessed.

RESULTS

Thirty-eight out of 69 patients underwent one or more urological procedures. Twenty-one out of 42 patients with suprasacral lesions underwent interventions for N-LUTD. The main surgical treatment was endoscopic detrusor infiltration of botulinum-A (Botox 300 UI or Dysport 750 UI) performed 107 times on 15 subjects using aseptic intermittent catheterizations for neurogenic overactive bladder. Mean efficacy duration was 9.2 months. Six females with infrasacral lesions underwent at least one intervention for N-LUTD. Two females in each group underwent tension-free vaginal tape for stress urinary incontinence (SUI), reducing episodes per week of SUI by >90% after 5 years. The most serious urological complication was active vesico-ureteral reflux (VUR) in three patients, treated endoscopically with submucosal injection of Macroplastique. No VUR recurrence was detected during a 6-year follow-up. All bladder stones (five cases) and renal calculi (five cases) were treated with endoscopic transurethrally electrohydraulic lithotripsy and extracorporeal shock-wave lithotripsy, respectively. Overall, no serious drawbacks were observed.

CONCLUSIONS

Mini-invasive surgeries were exclusively used to address urological issues in chronic SCL patients.

Clinical usefulness of the transobturator sub-urethral tape in the treatment of stress urinary incontinence in female patients with spinal cord lesion

OBJECTIVES

To evaluate the clinical usefulness of transobturator sub-urethral tapes for the treatment of stress urinary incontinence in women with spinal cord injury.

METHOD AND SUBJECTS

Chart review for all female patients with spinal cord injury who underwent implantation of a transobturator sub-urethral tape for treatment of stress urinary incontinence at our institution.

RESULTS

Nine women, median age 45.1 years, received a sub-urethral transobturator tape in the period November 2007 to September 2010. Four patients had paraplegia and five had tetraplegia. Seven women performed intermittent catheterization. At follow up, three of the nine patients were either cured or vastly improved. One major late complication (urethral erosion) occurred. Five of the six patients without treatment success underwent second-line treatment (artificial sphincter or urinary diversion).

CONCLUSION

In our case series, implantation of transobturator sub-urethral tapes in women with stress urinary continence due to intrinsic sphincter deficiency and a low leak point pressure led to unfavorable results.

EAU guidelines on neurogenic lower urinary tract dysfunction

CONTEXT

Most patients with neurogenic lower urinary tract dysfunction (NLUTD) require life-long care to maintain their quality of life (QoL) and to maximise life expectancy.

OBJECTIVE

To provide a summary of the 2008 version of the European Association of Urology (EAU) guidelines on NLUTD and to assess the effectiveness of currently available diagnostic tools, particularly ultrasound imaging and urodynamics.

EVIDENCE ACQUISITION

The recommendations provided in the 2008 EAU guidelines on NLUTD are based on a review of the literature, using online searches of Medline and other source documents published between 2004 and 2007. A level of evidence and/or a grade of recommendation have been assigned to the guidelines where possible.

EVIDENCE SYNTHESIS

NLUTD encompasses a wide spectrum of pathologies, and patients often require life-long, intensive medical care to maximise their life-expectancy and to maintain their QoL. Treatment must be tailored to the needs of the individual patient and, in many cases, involves a multidisciplinary team of experts. Timely diagnosis and treatment are essential if irreversible deterioration of both the upper and lower urinary tracts are to be avoided. Therapeutic decisions are made on the basis of a comprehensive medical assessment, including urodynamics to identify the type of dysfunction. Advances in investigative technologies have facilitated the noninvasive and conservative management of patients who have NLUTD.

CONCLUSIONS

The diagnosis and treatment of NLUTD, which is a highly specialised and complex field involving both urology and medicine, requires up-to-date expert advice to be readily available. The current guidelines are designed to fulfil this need.

The artificial urinary sphincter in patients with spinal cord lesion: description of a modified technique and clinical results

BACKGROUND

The artificial sphincter is the method of choice in patients with stress urinary incontinence due to neurogenic bladder dysfunction. However, long-term studies reveal a high revision rate.

OBJECTIVE

To determine the success and revision rates of a modified implant.

DESIGN, SETTING, AND PARTICIPANTS

In a retrospective analysis, the results of 51 consecutive patients presenting at a private paraplegic center with neurogenic bladder dysfunction (meningomyelocele: n=8; spinal cord injury: n=37; others: n=6) who underwent implantation of an artificial sphincter at the bladder neck using a port instead of a pump were evaluated.

MEASUREMENTS

Subjective and objective cure rates were assessed by video-urodynamics and a standardized interview.

RESULTS AND LIMITATIONS

After a mean follow up of 95.9 mo, 70.6% of the patients were objectively and subjectively cured; 90.2% were completely continent in everyday life. Mean bladder capacity (465 ml) and compliance (41.7 ml/cm H(2)O) were normal. Sixteen patients underwent 18 revisions (35.3%). One implant had to be permanently removed. This is a single-centre study; thus, the results have to be confirmed.

CONCLUSIONS

With a long follow up of 8 yr, the modification presented by our group proved to be highly successful, reliable, safe, and even cost-effective. Therefore, it seems to be a valuable tool for the treatment of this group of patients.

Chapitre C-2 D - Bandelettes sous-uréthrales et incontinence urinaire d’effort par insuffisance sphinctérienne neurologique chez la femme

The management of stress urinary incontinence in patients with neurogenic bladder raises specific problems. This treatment is guided by the preoperative clinical and urodynamic assessment focussing on the characteristics of incontinence and on the potential for progression of the neurological disease. Retropubic insertion of suburethral tape is probably the preferred technique in the case of predominant urethral hypermobility.