Counseling for stress urinary incontinence in the era of adverse publicity around mesh usage: Results from a large-sample global survey

OBJECTIVE

To investigate doctors' opinions of the use of synthetic mesh for the treatment of stress urinary incontinence (SUI) and the effect on patient's attitude following recent adverse publicity and legal findings.

METHODS

Electronic survey approved by International Urogynecological Association (IUGA) and American Urogynecologic Society (AUGS), distributed to their members.

RESULTS

A total of 593 respondents completed the survey. The preferred initial surgical treatment for SUI was retropubic midurethral sling (MUS) (62%), followed by trans-obturator MUS (19%), mini-slings (10%), and then bulking agents (5%). Despite prolongation of consultation, most respondents (87%) believed that clinicians should provide a patient information leaflet (PIL) for their patients. However, only 70% of respondents were doing this. Most participants would use either the IUGA PIL or their institution PIL (61%). Only 8% felt that patients have a positive preconception of synthetic mesh for SUI. Eighty-three per cent of respondents had not changed their recommendations for treatment and the consent process. A logistic regression model identified preferences of certain geographic areas as predictors of consenting practices.

CONCLUSION

Despite the negative publicity and the current medicolegal litigation involving MUS for SUI treatment, the majority of respondents still prefer this as the initial surgical treatment. Most clinicians value PIL in the surgical consent process.

Comparing risk of repeat surgery for stress urinary incontinence after mid-urethral slings and polyacrylamide hydrogel

INTRODUCTION

Over the last two decades synthetic mid-urethral slings (MUS) have become established as the main surgical method for correcting stress urinary incontinence (SUI). However, transurethral injections with polyacrylamide hydrogel are gaining popularity. We used surgical codes from a national registry to explore potential differences in risk of later surgery for SUI comparing retropubic slings, obturator slings, and polyacrylamide hydrogel injections.

MATERIAL AND METHODS

This cohort study used surgical codes from The Norwegian Patient Registry. All women recorded as having had surgery for SUI coded as retropubic sling, obturator sling, or polyacrylamide hydrogel injection from 2008 until end-of-study censoring in 2017, were included. Main outcome was time to any recorded new SUI procedure later in the study period. Unadjusted comparison between groups was done using Kaplan-Meier. A Cox regression analysis was then performed to adjust for hospital unit size and patient age at surgery.

RESULTS

The unadjusted analyses showed significant differences between the chosen index method and the risk of later SUI surgery favoring retropubic slings (p < 0.01). The proportions of patients without any recorded new SUI procedure at 1 and 5 years were 99.3% and 97.7% for retropubic MUS, 98.7% and 96.1% for obturator MUS, and 82.7% and 72.4% for polyacrylamide hydrogel injections. The majority of women having a repeat procedure for SUI after a polyacrylamide hydrogel injection underwent repeat treatment within 1 year (63%). After adjusting for age at time of surgery and hospital size, obturator slings (hazard ratio 1.8, 95% CI 1.4-2.4) and polyacrylamide hydrogel (hazard ratio 23.1, 95% CI 17.6-30.3) remained associated with a higher risk of later incontinence surgery.

CONCLUSIONS

Both retropubic and obturator slings have low long-term risks of repeat incontinence surgery compared with polyacrylamide hydrogel injections. Retropubic slings were found to have superior longevity of the surgical result.

Has the use of preoperative urodynamics for stress urinary incontinence surgery changed following the VALUE study?

AIMS

To assess whether routine urodynamic testing (UDT) in women undergoing slings for uncomplicated stress urinary incontinence (SUI) has decreased following publication of the landmark VALUE study, which recommended against routine UDT in uncomplicated SUI.

METHODS

We identified women in the Virginia All Payers Claims Database diagnosed with SUI between 2011 and 2016 using International Classification of Disease (ICD) codes (N39.3, 625.6). Appropriate ICD/CPT (current procedural terminology) codes were used to exclude non-index patients (prior anti-incontinence/prolapse surgery, urge incontinence, neurogenic bladder). Beta regression was used to assess for changes in the monthly proportion of urethral slings with preoperative UDT. Interventional ARIMA modeling was used to assess for a relationship between the date of VALUE (The Value of Urodynamic Evaluation) publication and the incidence of slings with preoperative UDT.

RESULTS

Analysis identified 6740 women with SUI undergoing sling placement, with 343 non-index patients excluded. Of 6397 remaining women, 4026 (62.9%) underwent preoperative UDT. The annual number of slings with preoperative UDT declined from 748 to 402 between 2011 and 2016. Beta regression analysis demonstrated a decrease in the proportion of slings with preoperative UDT over the study (68%, 2011; 58%, 2016), with a statistically significant decrease in the proportion of slings with UDT after May 2012 (β coefficient, -.0093; P < .001). Interventional ARIMA models showed a trend toward decreasing slings with preoperative UDT after the VALUE trial (P = .057).

CONCLUSIONS

Our analysis demonstrated a decrease in the proportion of women undergoing preoperative UDT in uncomplicated SUI patients following the VALUE study. Further research is needed to examine factors underlying UDT utilization trends and promote value-driven care.

[Long-term follow-up of the efficacy of tension-free vaginal tape and trans-obturator tape for different types of stress urinary incontinence]

OBJECTIVE

To evaluate the long-term efficacy of tension-free vaginal tape (TVT)and trans-obturator tape (TOT)for different types of female stress urinary incontinence (FSUI).

METHODS

The clinical data of all female patients with stress urinary incontinence (SUI) who underwent mid-urethral slings (MUS) in Peking University People's Hospital from January 2008 to June 2016 were retrospectively analyzed, and all the patients were followed up. Based on the level of abdominal leak point pressure (ALPP), the patients with ALPP lower than or equal to 60 cmH₂O (1 cmH₂O=0.74 mmHg) were regarded as intrinsic sphincter deficiency (ISD) type, and the patients with ALPP higher than 60 cmH₂O were regarded as non-ISD type. According to the degree of remission of leakage of urine by using the International Consultation on Incontinence Questionnaire Short Form (ICI-Q-SF), the surgical outcomes were divided into three categories: cured, improved or failed. The efficacy of TVT and TOT for different types of FSUI was evaluated by comparing the cure rate of TVT with the cure rate of TOT in ISD type and non-ISD type separately.

RESULTS

A total of 170 patients were included in this study. The patients were among 30-78 years, and the follow-up period were among 12-110 months. In the study, 117 patients belonged to non-ISD type. Of whom 30 underwent TVT with a cure rate of 86.7% (26/30), and the other 87 underwent TOT with a cure rate of 69.0% (60/87). The cure rate of TVT was higher than that of TOT in non-ISD type, however, Chi-square test showed that there was no significant difference (χ²=3.589, P>0.05). In addition, 53 patients belonged to ISD type, of whom 16 underwent TVT with a cure rate of 87.5% (14/16), and the other 37 underwent TOT with a cure rate of 51.4% (19/37). The cure rate of TVT was higher than that of TOT in ISD type, and Chi-square test showed that the difference was statistically significant (χ²=6.212, P<0.05).

CONCLUSION

For the treatment of FSUI, MUS can achieve satisfactory long-term efficacy. For non-ISD type, the cure rates of TVT and TOT are similar, while for ISD type, the cure rate of TVT is higher than that of TOT.

Usefulness of Ospemifene in the treatment of urgency in menopausal patients affected by mixed urinary incontinence underwent mid-urethral slings surgery

The aim of this study was to assess the effectiveness and safety of Ospemifene in the improvement of urgency component in women affected by mixed urinary incontinence (MUI) who underwent surgery with mid-urethral sling (MUS). Eighty-one patients with MUI underwent surgical intervention with MUS were enrolled. After surgical intervention 38 patients received Ospemifene 60 mg one tablet daily per os for 12 weeks. Physical examination, 3-day voiding diary, urodynamic testing were performed at the start and the follow-up after 12 weeks in the Trans-Obturator-Tape (TOT)-Alone group and TOT-Ospemifene. Patients completed the Overactive Bladder Symptom and Health-Related Quality of Life Short-Form (OAB-Q SF), International Consultation on Incontinence Questionnaire (ICIQ-UI-SF), and King' s Health Questionnaire (KHQ). A significant difference between the two groups was observed in peak flow (ml/s), in first voiding desire (ml), in maximum cystometric capacity (ml), and in detrusor pressure at peak flow (cmH₂O) at urodynamic evaluation. A significative difference between the two groups at voiding diary was observed in the mean number of voids, urgent micturition episodes/24 h, urge urinary incontinence, and in nocturia events. The OAB-Q symptoms and OAB-Q (HRQL) scores after 12 weeks showed a significative difference between the two groups. Ospemifene is an effective potential therapy after MUSs in women with MUI improving urgency symptoms and quality of life.

Long-term results of transurethral endoscopic excision using the holmium laser for urethral perforation of synthetic slings

OBJECTIVE

This study reports on the long-term results of transurethral endoscopic excision using the Holmium laser (TEEH) for large urethral perforation (UP; defined as involving one-quarter or more of the urethral circumference) from synthetic slings.

METHODS

Charts of women treated with TEEH for large UP were reviewed. TEEH was performed using a 365-μm laser fiber passed inside an open-ended ureteral catheter positioned in a holmium laser enucleation of the prostate (HoLEP) sheath to stabilize the laser fiber. Data extracted included patient demographics, clinical presentations, surgical details, postoperative functional outcomes and complications, and any secondary repairs.

RESULTS

From 2011 to 2016, 12 women underwent TEEH. The mean interval between sling placement and first TEEH was 47 months (range 10-161 months). The types of slings included transvaginal tape (n = 2), transobturator tape (n = 4), mini-invasive (n = 4), and Solyx (1), or were not specified (n = 1). The mean number of TEEH procedures was 1.6 (range 1-3), and the mean length of initial treatment was 40 min (range 15-79 min), with subsequent treatments <30 min. Mean follow-up time was 43 months (range 14-70). Resolution of UP by TEEH alone was achieved in 6 patients, with 2 requiring multiple TEEH. Six patients underwent secondary vaginal mesh sling excision alone or with an associated repair including 2 small distal urethrovaginal fistulas.

CONCLUSION

TEEH is a minimally invasive procedure that can avoid a more complex initial urethral reconstruction and should be considered for treating large UP. Secondary repairs for residual small UP or associated lower urinary tract symptomatology may be necessary and patients should be counseled accordingly.

Long-term outcomes for transobturator tension-free vaginal tapes in women with urodynamic mixed urinary incontinence

AIMS

To assess the long-term patient reported outcomes following transobturator tension-free vaginal tapes (TO-TVT) in women with urodynamic mixed urinary incontinence (MUI).

METHODS

A secondary analysis of the 9-year follow-up of the E-TOT study: 341 women with predominant stress urinary incontinence symptoms were randomized to undergo either inside-out or outside-in TO-TVT between April 2005 and April 2007. Forty-eight women had preoperative urodynamic MUI and were available for 9-year follow-up. Primary outcome was the patient-reported success rate defined as very/much improved on Patient's Global Impression of Improvement PGI-I. Secondary outcomes included impact on women's quality of life, sexual function, overactive bladder symptoms,and late adverse events. Statistical analysis was performed using SPSS v.23.

RESULTS

Forty-eight women completed the 9-year follow-up, with adjusted response rate of 63%. The success based on the PGI-I was 64.6% (n = 31), with a further 14.6% (n = 7) who reported "improved." There was no significant difference between groups (OR 1.11; 95%CI 0.33, 3.70; P > 0.999). Clinically significant improvement in quality of life was found in 85.3%. Cure of urgency and UUI was reported by 35% and 41%, whereas worsening was reported in 6.5% and 2.3%, respectively. One patient reported chronic groin/leg pain. The small sample size and the sizeable loss to follow-up are limitations in this study.

CONCLUSIONS

This is the first study to report the long-term outcomes of TO-TVT in women with urodynamic MUI; TO-TVT is associated with a good and sustained patient-reported success rate in women with MUI up to 9-years follow-up.

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.