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Yuan AS, Propst KA, Ross JH, Wallace SL, Paraiso MFR, Park AJ, Chapman GC, Ferrando CA. Restrictive opioid prescribing after surgery for prolapse and incontinence: a randomized, noninferiority trial. Am J Obstet Gynecol 2024; 230:340.e1-340.e13. [PMID: 37863158 DOI: 10.1016/j.ajog.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/01/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Opioids are routinely prescribed for postoperative pain control after gynecologic surgery with growing evidence showing that most prescribed opioids go unused. Restrictive opioid prescribing has been implemented in other surgical specialties to combat the risk for opioid misuse and diversion. The impact of this practice in the urogynecologic patient population is unknown. OBJECTIVE This study aimed to determine if a restrictive opioid prescription protocol is noninferior to routine opioid prescribing in terms of patient satisfaction with pain control after minor and major surgeries for prolapse and incontinence. STUDY DESIGN This was a single-center, randomized, noninferiority trial of opioid-naïve patients who underwent minor (eg, colporrhaphy or mid-urethral sling) or major (eg, vaginal or minimally invasive abdominal prolapse repair) urogynecologic surgery. Patients were excluded if they had contraindications to all multimodal analgesia and if they scored ≥30 on the Pain Catastrophizing Scale. Subjects were randomized on the day of surgery to the standard opioid prescription protocol (wherein patients routinely received an opioid prescription upon discharge [ie, 3-10 tablets of 5 mg oxycodone]) or to the restrictive protocol (no opioid prescription unless the patient requested one). All patients received multimodal pain medications. Participants and caregivers were not blinded. Subjects were asked to record their pain medication use and pain levels for 7 days. The primary outcome was satisfaction with pain control reported at the 6-week postoperative visit. We hypothesized that patient satisfaction with the restrictive protocol would be noninferior to those randomized to the standard protocol. The noninferiority margin was 15 percentage points. Pain level scores, opioid usage, opioid prescription refills, and healthcare use were secondary outcomes assessed for superiority. RESULTS A total of 133 patients were randomized, and 127 (64 in the standard arm and 63 in the restrictive arm) completed the primary outcome evaluation and were included in the analysis. There were no statistically significant differences between the study groups, and this remained after adjusting for the surgery type. Major urogynecologic surgery was performed in 73.6% of the study population, and minor surgery was performed in 26.4% of the population. Same-day discharge occurred for 87.6% of all subjects. Patient satisfaction was 92.2% in the standard protocol arm and 92.1% in the restrictive protocol arm (difference, -0.1%; P=.004), which met the criterion for noninferiority. No opioid usage in the first 7 days after hospital discharge was reported by 48.4% of the patients in the standard protocol arm and by 70.8% in the restrictive protocol arm (P=.009). Opioid prescription refills occurred in 8.5% of patients with no difference between the study groups (9.4% in the standard arm vs 6.7% in the restrictive arm; P=.661). No difference was seen in the rate of telephone calls and urgent visits for pain control between the study arms. CONCLUSION Among women who underwent minor and major surgery for prolapse and incontinence, patient satisfaction rates were noninferior after restrictive opioid prescribing when compared with routine opioid prescribing.
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Affiliation(s)
- Angela S Yuan
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Katie A Propst
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - James H Ross
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Shannon L Wallace
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Amy J Park
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Graham C Chapman
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Anglim BC, Tomlinson G, Paquette J, McDermott CD. A risk calculator for postoperative urinary retention (POUR) following vaginal pelvic floor surgery: multivariable prediction modelling. BJOG 2022; 129:2203-2213. [PMID: 35596931 DOI: 10.1111/1471-0528.17225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/07/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the perioperative characteristics associated with an increased risk of postoperative urinary retention (POUR) following vaginal pelvic floor surgery. DESIGN A retrospective cohort study using multivariable prediction modelling. SETTING A tertiary referral urogynaecology unit. POPULATION Patients undergoing vaginal pelvic floor surgery from January 2015 to February 2020. METHODS Eighteen variables (24 parameters) were compared between those with and without POUR and then included as potential predictors in statistical models to predict POUR. The final model was chosen as the model with the largest concordance index (c-index) from internal cross-validation. This was then externally validated using a separate data set (n = 94) from another surgical centre. MAIN OUTCOME MEASURE Diagnosis of POUR following surgery while the patient was in hospital. RESULTS Among the 700 women undergoing surgery, 301 (43%) experienced POUR. Preoperative variables with statistically significant univariate relationships with POUR included age, menopausal status, prolapse stage and uroflowmetry parameters. Significant perioperative factors included estimated blood loss, volume of intravenous fluid administered, operative time, length of stay and specific procedures, including vaginal hysterectomy with intraperitoneal vault suspension, anterior colporrhaphy, posterior colporrhaphy and colpocleisis. The lasso logistic regression model had the best combination of internally cross-validated c-index (0.73, 95% CI 0.71-0.74) and a calibration curve that showed good alignment between observed and predicted risks. Using this data, a POUR risk calculator was developed (https://pourrisk.shinyapps.io/POUR/). CONCLUSIONS This POUR risk calculator will allow physicians to counsel patients preoperatively on their risk of developing POUR after vaginal pelvic surgery and help focus discussion around potential management options.
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Affiliation(s)
- Breffini C Anglim
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network and Mt Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Joalee Paquette
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colleen D McDermott
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Muller P, Gurol-Urganci I, van der Meulen J, Thakar R, Jha S. Risk of reoperation 10 years after surgical treatment for stress urinary incontinence: a national population-based cohort study. Am J Obstet Gynecol 2021; 225:645.e1-645.e14. [PMID: 34509439 DOI: 10.1016/j.ajog.2021.08.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/13/2021] [Accepted: 08/30/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a debate about the safety and effectiveness of surgical treatments for stress urinary incontinence. Controversy about the use of synthetic mesh sling insertion has led to an increased uptake of retropubic colposuspension and autologous sling procedures. Comparative evidence on the long-term outcomes from these procedures is needed. OBJECTIVE To compare the risk of reoperation at 10 years after operation between women treated for stress urinary incontinence with retropubic colposuspension, mesh sling insertion, and autologous sling procedures. STUDY DESIGN The records of admissions to National Health Service hosptials were used to identify women who had first-time stress incontinence surgery between 2006 and 2013 in England. The first incidence of the following outcomes was assessed: further stress incontinence surgery, surgery for a complication (either mesh removal, prolapse repair, or incisional hernia repair), and any reoperation (either further stress incontinence surgery, mesh removal, prolapse repair, or incisional hernia repair). The cumulative incidence of each of these outcomes up to 10 years after surgery was calculated, considering death as a competing event. Multivariable modeling was then used to estimate the reoperation hazard ratios for the different initial surgery types with adjustments for patient characteristics and concurrent prolapse surgery or hysterectomy. RESULTS The analysis included 2262 women treated with retropubic colposuspension, 92,524 treated with mesh sling insertion, and 1234 treated with autologous sling. The cumulative incidence of any first reoperation at 10 years was 21.3% (95% confidence interval, 19.5-23.0) after retropubic colposuspension, 10.9% (10.7-11.1) after mesh sling insertion, and 12.0% (10.2-13.9) after autologous sling procedures. The women who had a retropubic colposuspension were significantly more likely to have a reoperation than women who had an autologous sling (adjusted hazard ratio for any reoperation: 1.79 [1.47-2.17]; for further stress incontinence surgery: 1.64 [1.19-2.26]; for surgery for complications: 1.89 [1.49-2.40]), whereas the women who had mesh slings had a similar hazard (for any reoperation: 0.90 [0.76-1.07]; for further stress incontinence surgery: 0.75 [0.57-0.99]; for surgery for complications: 1.11 [0.89-1.36]). A sensitivity analysis excluding the women who had concurrent prolapse surgery or hysterectomy produced similar results. CONCLUSION Retropubic colposuspension is associated with higher risk of reoperation at 10 years after surgery than mesh sling insertion or autologous sling procedures, with 1 in 5 women requiring reoperation.
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Affiliation(s)
- Patrick Muller
- London School of Hygiene & Tropical Medicine, London, United Kingdom; Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
| | - Ipek Gurol-Urganci
- London School of Hygiene & Tropical Medicine, London, United Kingdom; Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - Jan van der Meulen
- London School of Hygiene & Tropical Medicine, London, United Kingdom; Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - Ranee Thakar
- Royal College of Obstetricians and Gynaecologists, London, United Kingdom; Croydon University Hospital, Croydon, London, United Kingdom
| | - Swati Jha
- The British Society of Urogynaecology, London, United Kingdom; Sheffield Teaching Hospitals, London, United Kingdom
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Parry MG, Skolarus TA, Nossiter J, Sujenthiran A, Morris M, Cowling TE, Berry B, Aggarwal A, Payne H, Cathcart P, Clarke NW, van der Meulen J. Urinary incontinence and use of incontinence surgery after radical prostatectomy: a national study using patient-reported outcomes. BJU Int 2021; 130:84-91. [PMID: 34846770 DOI: 10.1111/bju.15663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate whether patient-reported urinary incontinence and bother scores after radical prostatectomy result in subsequent intervention with incontinence surgery. METHODS Men diagnosed with prostate cancer in the English National Health Service between April 2014 and January 2016 were identified. Administrative data were used to identify men who had undergone a radical prostatectomy and those who subsequently underwent a urinary incontinence procedure. The National Prostate Cancer Audit database was used to identify men who had also completed a post-treatment survey. These surveys included the Expanded Prostate Cancer Composite Index (EPIC-26). The frequency of subsequent incontinence procedures, within 6 months of the survey, was explored according to EPIC-26 urinary incontinence scores. The relationship between "good" (≥75) or "bad" (≤25) EPIC-26 urinary incontinence scores and perceptions of urinary bother was also explored (responses ranging from 'no problem' to 'big problem' with respect to their urinary function). RESULTS We identified 11,290 men who had undergone a radical prostatectomy. The 3-year cumulative incidence of incontinence surgery was 2.5%. After exclusions, we identified 5,165 men who had also completed a post-treatment survey after a median time of 19 months (response rate 74%). 481 men (9.3%) reported a "bad" urinary incontinence score and 207 men (4.0%) also reported that they had a big problem with their urinary function. 47 men went on to have incontinence surgery within 6 months of survey completion (0.9%), of whom 93.6% had a "bad" urinary incontinence score. Of the 71 men with the worst urinary incontinence score (zero), only 11 men (15.5%) subsequently had incontinence surgery. CONCLUSION In England, there is a significant number of men living with severe, bothersome urinary incontinence following radical prostatectomy, and an unmet clinical need for incontinence surgery. The systematic collection of patient-reported outcomes could be used to identify men who may benefit from incontinence surgery.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA.,Flatiron, UK
| | - Melanie Morris
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | | | - Brendan Berry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ajay Aggarwal
- Department of Radiotherapy, NHS Foundation Trust, Guy's & St Thomas, UK.,Department of Cancer Epidemiology, KCL, Population & Global Health, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Paul Cathcart
- Department of Urology, NHS Foundation Trust, Guy's & St Thomas, UK
| | - Noel W Clarke
- Department of Urology, Salford Royal NHS Foundation Trusts, The Christie &, UK
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Muller P, Gurol-Urganci I, Thakar R, Ehrenstein MR, Van Der Meulen J, Jha S. Impact of a mid-urethral synthetic mesh sling on long-term risk of systemic conditions in women with stress urinary incontinence: a national cohort study. BJOG 2021; 129:664-670. [PMID: 34524725 PMCID: PMC9292923 DOI: 10.1111/1471-0528.16917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
Objective To compare the incidence of systemic conditions between women who had surgical treatment for stress incontinence with mesh and without mesh. Design National cohort study. Setting English National Health Service. Population Women with no previous record of systemic disease who had first‐time urinary incontinence surgery between 1 January 2006 and 31 December 2013, followed up to the earliest of 10 years or 31 March 2019. Methods Competing‐risks regression was used to estimate hazard ratios (HR), adjusted for patient characteristics, with HR > 1 indicating increased incidence following mesh surgery. Main outcome measures First postoperative admission with a record of autoimmune disease, fibromyalgia or myalgic encephalomyelitis up to 10 years following the first incontinence procedure. Results The cohort included 88 947 women who had mesh surgery and 3389 women who had non‐mesh surgery. Both treatment groups were similar with respect to age, socio‐economic deprivation, comorbidity and ethnicity. The 10‐year cumulative incidence of autoimmune disease, fibromyalgia or myalgic encephalomyelitis was 8.1% (95% CI 7.9–8.3%) in the mesh group and 9.0% (95% CI 8.0–10.1%) in the non‐mesh group (adjusted HR 0.89, 95% CI 0.79–1.01; P = 0.07). A sensitivity analysis including only autoimmune diseases as an outcome returned a similar result. Conclusions These findings do not support claims that synthetic mesh slings cause systemic disease. Tweetable abstract No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling. No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling.
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Affiliation(s)
- P Muller
- London School of Hygiene & Tropical Medicine, London, UK.,Royal College of Obstetricians and Gynaecologists, London, UK
| | - I Gurol-Urganci
- London School of Hygiene & Tropical Medicine, London, UK.,Royal College of Obstetricians and Gynaecologists, London, UK
| | - R Thakar
- Royal College of Obstetricians and Gynaecologists, London, UK.,Croydon University Hospital, Croydon, UK
| | | | - J Van Der Meulen
- London School of Hygiene & Tropical Medicine, London, UK.,Royal College of Obstetricians and Gynaecologists, London, UK
| | - S Jha
- British Society of Urogynaecology, London, UK.,Sheffield Teaching Hospitals, Sheffield, UK
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Joukhadar R, Radosa J, Paulus V, Hamza A, Solomayer EF, Herr D, Wöckel A, Baum S. Influence of Patient's Age on the Outcome of Vaginal and Laparoscopic Procedures in Urogynaecology. Geburtshilfe Frauenheilkd 2019; 79:949-958. [PMID: 31523095 PMCID: PMC6739203 DOI: 10.1055/a-0854-5916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 11/14/2022] Open
Abstract
Introduction
In the treatment of prolapse and incontinence, the choice of surgical procedure often depends not only on the clinical findings but also on the age of the patient. Uncertainty exists at present regarding the effect of patient age on treatment outcomes for both vaginal and laparoscopic procedures. The aim of this study is therefore to compare both the anatomical outcome after prolapse surgery and the functional outcome after incontinence surgery in the context of the treatment of stress urinary incontinence in older and younger patients.
Patients/Methods
This is a retrospective single-centre study conducted at a university site. Over the study period, a total of 407 women underwent surgery, 278 of whom were < 70 and 129 ≥ 70 years of age. They were assigned to one of three treatment groups (prolapse surgery, incontinence surgery or a combination of both types of surgery) and were then subjected to statistical analysis after assessment of the anatomical and functional outcome after 3 – 6 months.
Results
The most common form of prolapse among the 407 evaluated patients was in the anterior and middle compartment, with a higher degree of severity being diagnosed in the older patients. Grade 4 prolapse according to the Baden–Walker system was thus present in the anterior compartment in 15.6 vs. 28.8% (p = 0.033) and in the middle compartment in 5.7 vs. 23.7% (p < 0.001) of cases. Younger women underwent vaginal mesh implantation less frequently and laparoscopic sacropexy more frequently for this overall. The proportion of cases of combined prolapse and incontinence surgery was the same in both groups. Overall, high success rates were observed in both younger and older patients following prolapse and incontinence surgery. These rates were 93.5 vs. 84.8% (p = 0.204) after prolapse surgery and 92.8 vs. 84.2% (p = 0.261) after incontinence surgery. A significant disadvantage for the older patients was the persistence of stress urinary incontinence after prolapse surgery alone (19.6 vs. 50%, p = 0.030) and the rate of occult (de novo) stress urinary incontinence (7.4 vs. 20%, p = 0.030).
Conclusion
Our data show that both pelvic organ prolapse and stress urinary incontinence can be treated with surgery with good results in women aged ≥ 70 years. It was thus possible to show for the first time in a large patient population that older women should not be denied appropriate surgery but can be offered the same range of surgical options as younger patients.
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Affiliation(s)
- Ralf Joukhadar
- Department of Obstetrics and Gynaecology, Würzburg University Medical Centre, Würzburg, Germany.,Department of Obstetrics and Gynaecology, University of Saarland, Homburg, Saar, Germany
| | - Julia Radosa
- Department of Obstetrics and Gynaecology, University of Saarland, Homburg, Saar, Germany
| | - Viola Paulus
- Department of Obstetrics and Gynaecology, University of Saarland, Homburg, Saar, Germany
| | - Amr Hamza
- Department of Obstetrics and Gynaecology, University of Saarland, Homburg, Saar, Germany
| | - Erich Franz Solomayer
- Department of Obstetrics and Gynaecology, University of Saarland, Homburg, Saar, Germany
| | - Daniel Herr
- Department of Obstetrics and Gynaecology, Würzburg University Medical Centre, Würzburg, Germany
| | - Achim Wöckel
- Department of Obstetrics and Gynaecology, Würzburg University Medical Centre, Würzburg, Germany
| | - Sascha Baum
- Department of Obstetrics and Gynaecology, Lübeck University Medical Centre, Lübeck, Germany.,Department of Obstetrics and Gynaecology, University of Saarland, Homburg, Saar, Germany
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Onuk Ö. A minimally invasive modified technique for female stress urinary incontinence: transobturator tape without paraurethral dissection. Wideochir Inne Tech Maloinwazyjne 2019; 14:278-83. [PMID: 31118995 DOI: 10.5114/wiitm.2018.77715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/13/2018] [Indexed: 11/21/2022] Open
Abstract
Introduction Mid-urethral slings, including transobturator tape (TOT), tension-free vaginal tape (TVT), tension-free vaginal tape-obturator (TVT-O), and a single incision sling, are the most popular procedures for the treatment of stress urinary incontinence (SUI). Although the classical TOT procedure is a minimally invasive technique, we believe that this technique can be further improved. Aim To determine whether there was a difference in success and complication rates between the classical TOT technique and a novel technique called “modified transobturator tape” (mTOT), which avoids periurethral dissection. Material and methods In total, 98 patients who underwent incontinence surgery between July 2011 and January 2017 were recruited for this prospectively planned study. Of the 98 patients, 47 patients underwent classical TOT, and 51 patients underwent the new mTOT procedure. Incontinence Impact Questionnaire-7 (IIQ-7) and visual analogue scale (VAS) scores were obtained preoperatively and postoperatively. Average or serious symptomatic scores in IIQ-7 were considered as subjective failure. Results Nerve damage, vascular damage, retropubic hematomas, and bladder-urethra erosion were not observed in either group. There were no significant between-group differences in IIQ-7 scores. There were also no between-group differences in postoperative 1-month, 6-month, and 1-year VAS scores, but postoperative first day scores of the mTOT group were significantly lower than those of the classical TOT group (p < 0.05). Conclusions The proposed modified technique provides the same efficiency and reliability as the classic technique but is more advantageous in terms of reduced pain and resumption of earlier sexual activity.
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Rautenberg O, Zivanovic I, Kociszewski J, Kuszka A, Münst J, Eisele L, Viereck N, Walser C, Gamper M, Viereck V. Current Treatment Concepts for Stress Urinary Incontinence. Praxis (Bern 1994) 2017; 106:829e-836e. [PMID: 29143573 DOI: 10.1024/1661-8157/a002843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Initially, stress urinary incontinence should be treated by conservative measures, such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise and/or the use of pessaries. Incontinence surgeries are only recommended in case of unsuccessful conservative therapy. Today, tension-free suburethral sling insertions represent the gold standard of incontinence surgery yielding very good outcomes (cure rates of 80–90 %). Pelvic-floor sonography provides important information on decision of surgical methods and the management of complications. Furthermore, intra- or paraurethral injection of bulking agents is a promising, minimally invasive surgical alternative. This article discusses treatment concepts, pre-, intra- and post-operative examinations, decision on surgical methods, operational details for surgical success, and the prevention and management of complications.
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Affiliation(s)
- Oliver Rautenberg
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
| | - Irena Zivanovic
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
| | - Jacek Kociszewski
- 2 Department of Gynecology and Obstetrics, Lutheran Hospital Hagen-Haspe, 58135 Hagen, Germany
| | - Andrzej Kuszka
- 2 Department of Gynecology and Obstetrics, Lutheran Hospital Hagen-Haspe, 58135 Hagen, Germany
| | - Julia Münst
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
| | - Lilly Eisele
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
| | - Nicole Viereck
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
| | - Claudia Walser
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
| | - Marianne Gamper
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
| | - Volker Viereck
- 1 Department of Gynecology and Obstetrics, Cantonal Hospital Frauenfeld, 8501 Frauenfeld, Switzerland
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Rautenberg O, Zivanovic I, Kociszewski J, Kuszka A, Münst J, Eisele L, Viereck N, Walser C, Gamper M, Viereck V. [Not Available]. Praxis (Bern 1994) 2017; 106:829-836. [PMID: 28745112 DOI: 10.1024/1661-8157/a002743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Zusammenfassung: Eine Belastungsinkontinenz sollte immer zuerst konservativ behandelt werden. Schon eine Gewichtsreduktion, Hormonpräparate, Physiotherapie, Beckenbodentraining und/oder die Anwendung von Pessaren können zum Erfolg führen. Nach Ausschöpfen dieser Therapien werden heute Inkontinenzoperationen mit meist sehr guten Heilungschancen (ca. 80–90 %) angeboten. Der operative Goldstandard ist die suburethrale Schlingeneinlage. Die Pelvic-Floor-Sonografie liefert dazu sehr wichtige Hinweise zur Wahl der Operationstechnik und zur Behebung von Komplikationen. Ferner bildet die intra- oder paraurethrale Injektion von Bulking Agents eine vielversprechende, wenig invasive operative Alternative. In diesem Artikel werden Behandlungskonzepte, prä-, intra- und postoperative Untersuchungen, Wahl der Operationsmethode, operationstechnische Details für den Operationserfolg sowie Vorbeugung und Behandlung von Komplikationen diskutiert.
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Affiliation(s)
- Oliver Rautenberg
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
| | - Irena Zivanovic
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
| | - Jacek Kociszewski
- 2 Abteilung für Gynäkologie und Geburtshilfe, Evangelisches Krankenhaus Hagen-Haspe, Hagen, Deutschland
| | - Andrzej Kuszka
- 2 Abteilung für Gynäkologie und Geburtshilfe, Evangelisches Krankenhaus Hagen-Haspe, Hagen, Deutschland
| | - Julia Münst
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
| | - Lilly Eisele
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
| | - Nicole Viereck
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
| | - Claudia Walser
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
| | - Marianne Gamper
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
| | - Volker Viereck
- 1 Blasen- und Beckenbodenzentrum, Frauenklinik, Kantonsspital Frauenfeld
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10
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Abstract
The Danish Urogynaecological Database is established in order to ensure high quality of treatment for patients undergoing urogynecological surgery. The database contains details of all women in Denmark undergoing incontinence surgery or pelvic organ prolapse surgery amounting to ~5,200 procedures per year. The variables are collected along the course of treatment of the patient from the referral to a postoperative control. Main variables are prior obstetrical and gynecological history, symptoms, symptom-related quality of life, objective urogynecological findings, type of operation, complications if relevant, implants used if relevant, 3–6-month postoperative recording of symptoms, if any. A set of clinical quality indicators is being maintained by the steering committee for the database and is published in an annual report which also contains extensive descriptive statistics. The database has a completeness of over 90% of all urogynecological surgeries performed in Denmark. Some of the main variables have been validated using medical records as gold standard. The positive predictive value was above 90%. The data are used as a quality monitoring tool by the hospitals and in a number of scientific studies of specific urogynecological topics, broader epidemiological topics, and the use of patient reported outcome measures.
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Affiliation(s)
| | - Kim Oren Gradel
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Michael Due Larsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
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11
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Brown J, King J. Age-stratified trends in 20 years of stress incontinence surgery in Australia. Aust N Z J Obstet Gynaecol 2016; 56:192-8. [PMID: 26869461 DOI: 10.1111/ajo.12445] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/09/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Stress urinary incontinence (SUI) is a common, debilitating condition in Australian women. Since its introduction in 1998-1999, the less invasive mid-urethral sling (MUS) procedure has become the new standard for surgical correction of SUI and overall numbers of continence procedures increased. Trends since 2009 have not been analysed. AIMS To identify patterns in the surgical treatment of women with SUI in Australia from January 1994 to December 2014 stratified by age. MATERIALS AND METHODS Gender- and age-specific data from Medicare Australia between January 1994 and December 2014 were extracted and the patterns of SUI surgery analysed for the 20-year period. Data on gynaecologists and urologists performing MUS and colposuspension were collected from Department of Human Services. RESULTS Following the introduction of MUS, total SUI operations increased with the peak in 2002, a plateau between 2006 and 2011, and a new decline from 2012 onwards. There has been a sustained 51.7% increase in total SUI operations in 75- to 84-year-old women, and a 105.2% increase in women aged over 84. However, SUI operations in 45- to 64-year-olds decreased below pre-MUS baseline in 2014. CONCLUSIONS Mid-urethral sling has become the standard SUI procedure being performed in Australia since its introduction in 1999. SUI operations have increased each year for patients aged over 65, with the greatest increase seen in patients aged over 84 - indicating expanded eligibility for SUI surgery in older women. However, since 2010, there has been a fall in SUI operations to below the pre-MUS baseline.
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Affiliation(s)
- James Brown
- Obstetrics and Gynaecology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jennifer King
- Obstetrics and Gynaecology, Westmead Hospital, Westmead, New South Wales, Australia
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12
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Khan ZA, Nambiar A, Morley R, Chapple CR, Emery SJ, Lucas MG. Long-term follow-up of a multicentre randomised controlled trial comparing tension-free vaginal tape, xenograft and autologous fascial slings for the treatment of stress urinary incontinence in women. BJU Int 2014; 115:968-77. [PMID: 24961647 DOI: 10.1111/bju.12851] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare the long-term outcomes of a tension-free vaginal tape (TVT; Gynecare™, Somerville, NJ, USA), autologous fascial sling (AFS) and xenograft sling (porcine dermis, Pelvicol™; Bard, Murray Hill, NJ, USA) in the management of female stress urinary incontinence (SUI). PATIENTS AND METHODS A multicentre randomised controlled trial carried out in four UK centres from 2001 to 2006 involving 201 women requiring primary surgery for SUI. The women were randomly assigned to receive TVT, AFS or Pelvicol. The primary outcome was surgical success defined as 'women reporting being completely 'dry' or 'improved' at the time of follow-up'. The secondary outcomes included 'completely dry' rates, changes in the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) and EuroQoL EQ-5D questionnaire scores. RESULTS In all, 162 (80.6%) women were available for follow-up with a median (range) duration of 10 (6.6-12.6) years. 'Success' rates for TVT, AFS and Pelvicol were 73%, 75.4% and 58%, respectively. Comparing the 1- and 10-year 'success' rates, there was deterioration from 93% to 73% (P < 0.05) in the TVT arm and 90% to 75.4% (P < 0.05) in the AFS arm; 'dry' rates were 31.7%, 50.8% and 15.7%, respectively. Overall, the 'dry' rates favoured AFS when compared with Pelvicol (P < 0.001) and TVT (P = 0.036). The re-operation rate for persistent SUI was 3.2% (two patients) in the TVT arm, 13.1% (five) in the Pelvicol arm, while none of the patients in the AFS arm required further intervention. CONCLUSIONS Our study indicates there is not enough evidence to suggest a difference in long-term success rates between AFS and TVT. However, there is some evidence that 'dry' rates for AFS may be more durable than TVT.
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Affiliation(s)
- Zainab A Khan
- Department of Uro-gynaecology, Singleton Hospital, Swansea, UK
| | - Arjun Nambiar
- Department of Urology, Morriston Hospital, Swansea, UK
| | - Roland Morley
- Department of Urology, Kingston Hospital, Kingston Upon Thames, Surrey, UK
| | - Christopher R Chapple
- Department of Urology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Simon J Emery
- Department of Uro-gynaecology, Singleton Hospital, Swansea, UK
| | - Malcolm G Lucas
- Department of Uro-gynaecology, Singleton Hospital, Swansea, UK.,Department of Urology, Morriston Hospital, Swansea, UK
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13
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Abstract
The biggest controversy in female urology in the past few years is the use of mesh in vaginal surgery. The major societies of Female Urology and Urogynecology has announced position statements in regards to the use of mesh sling for incontinence surgery. Lecture will also include transvaginal and trans-abdominal methods to repair pelvic prolapse given the complications from mesh.
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14
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Zyczynski HM, Sirls LT, Greer WJ, Rahn DD, Casiano E, Norton P, Kim HY, Brubaker L. Findings of universal cystoscopy at incontinence surgery and their sequelae. Am J Obstet Gynecol 2014; 210:480.e1-8. [PMID: 24380742 DOI: 10.1016/j.ajog.2013.12.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/24/2013] [Accepted: 12/27/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The purpose of this study was to report the frequency of abnormal cystoscopy at incontinence surgery and to identify risk factors and sequelae of injury. STUDY DESIGN Findings of cystoscopy were collected prospectively in 3 multicenter surgical trials. Clinical, demographic, and procedure characteristics and surgeon experience were analyzed for association with iatrogenic injury and noninjury abnormalities. Impact of abnormalities on continence outcomes and adverse events during 12 months after the procedure were assessed. RESULTS Abnormal findings in the bladder or urethra were identified in 95 of 1830 women (5.2%). Most injuries (75.8%) were iatrogenic. Lower urinary tract (LUT) injury was most common at retropubic urethropexy and retropubic midurethral sling (MUS) procedures (6.4% each), followed by autologous pubovaginal sling procedures (1.7%) and transobturator MUS (0.4%). Increasing age (56.9 vs 51.9 years; P = .04), vaginal deliveries (3.2 vs 2.6; P = .04), and blood loss (393 vs 218 mL; P = .01) were associated with LUT injury during retropubic urethropexy; however, only age (62.9 vs 51.4 years; P = .02) and smoking history (P = .04) were associated for pubovaginal sling procedures. No factors correlated with increased risk of injury at retropubic and transobturator MUS. Notably, previous incontinence surgery, concomitant procedures, anesthesia type, and trainee participation did not increase LUT injury frequency. Although discharge with an indwelling catheter was more common after trocar perforation compared with the noninjury group (55.6% vs 18.5%; P < .001), they did not differ in overall success, voiding dysfunction, recurrent urinary tract infections, or urge urinary incontinence. CONCLUSION Universal cystoscopy at incontinence surgery detects abnormalities in 1 in 20 women. Urinary trocar perforations that are addressed intraoperatively have no long-term adverse sequelae.
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