Midurethral Sling Procedures Research Articles

Intraoperative Vaginal Perforation During Various Mid-Urethral Sling Procedures Treating Female Stress Urinary Incontinence

Background: Incidence of intraoperative vaginal perforation is generally considered to be low but varies among different procedures. Vaginal perforation could not only prolong the surgeries and aggravate surgical trauma but also result in postoperative discomfort or even a second surgery.Method: Vaginal perforation, vaginal epithelial perforation, vaginal wall perforation, vaginal penetration, urinary incontinence were searched in PubMed, Cochrane, Embase database to identify the qualified clinical trial and relevant literature sources were also searched.Results: A total of 9223 cases of from 33 trials from literatures and 387 cases from our own trail were analyzed, which provided detailed data on intraoperative vaginal perforation. Incidence of intraoperative vaginal perforation during mid-urethral sling surgery treating stress urinary incontinence was generally low, which was 1.56%. Incidence of intraoperative vaginal perforation during transobturator (TOR) procedure was higher than that during retropubic (RPR) procedure, which were 2.11% and 0.89% respectively. Incidence of intraoperative vaginal perforation during outside-to-inside TOR procedure like TOT and MONARC was higher than that during inside-to-outside TOR procedure like TVT-O, which were 2.74% and 1.52%, respectively. Incidence of intraoperative vaginal perforation during single-incision surgery like H-type TVT-SECUR reached 1.97%, while no report on U-type TVT-SECUR surgeries.Conclusion: The incidence of intraoperative vaginal during mid-urethral sling procedures for female stress urinary incontinence is fairly high. Vaginal perforation was more common in trans-obturator route (TOR) than retropubic route (RPR). In TOR route, it was less frequent in inside-to-outside procedure than outside-to-inside procedure. Surgery proficiency could also have an impact on this complication.

The Efficacy of Mid-Urethral Sling Procedures, Transobturator Tape and Tension-Free Vaginal Tape in the Treatment of Female Stress Urinary Incontinence: A Comparative Study of Twelve Months Follow-Up After Surgery

The Efficacy of Mid-Urethral Sling Procedures, Transobturator Tape and Tension-Free Vaginal Tape in the Treatment of Female Stress Urinary Incontinence: A Comparative Study of Twelve Months Follow-Up After Surgery

Resident simulation training improves operative time of the retropubic midurethral sling procedure for stress incontinence.

Our aim was to assess whether immediate preoperative resident simulation training decreases operative time and improves resident proficiency when performing a retropubic midurethral sling (MUS) procedure. This prospective cohort study took place over 8months at the Icahn School of Medicine, New York, USA. During the first 4months, all retropubic MUS procedures were performed by residents who underwent immediate preoperative simulation training. The cases completed during the following 4months were performed by residents who had not received preoperative simulation training. During the 8-month period, residents completed self-assessment questionnaires upon completion of the surgery and attendings evaluated the residents using the Objective Structured Assessment of Technical Skills (OSATS) global rating scale. Operative time between the two periods were compared using two-sample Student's t test. Comparative analysis between groups was performed based on the OSATS scores using the Wilcoxon rank-sum nonparametric test. There were 22 cases in the simulation group (SG) and 20 in the no simulation group (NSG). SG mean operative time was 12.6min and NSG mean operative time was 14.6min (p = 0.12). The SG mean OSATS score was 30.4 versus NSG of 27.8 (p < 0.001). This study demonstrates that preoperative simulation significantly improves operative performance of the retropubic MUS procedure among residents and also improves their confidence in the operating room. There was a decrease in mean operative time of 2min in the SG, but the difference was not statistically significant. This data is consistent in demonstrating improved surgical performance and resident confidence with simulation training.

Influence of age, BMI and parity on the success rate of midurethral slings for stress urinary incontinence.

AimsOur aim was to evaluate, in a second data analysis of the prospective randomized controlled trial conducted by Austrian Urogynaecology Working Group, the effect of age, BMI and parity at the time of surgery on short- and long-term outcomes of women primarily treated for SUI (stress urinary incontinence) with midurethral slings.MethodsIn the original study 554 patients received randomly a retropubic (TVT) or a transobturator midurethral (TVT-O) sling procedure. 480 (87%) and 277 (50%) patients were available for a follow-up efficacy evaluation at 3 months and 5 years respectively.ResultsHigher age and BMI at surgery appear to lead to a larger probability to have a positive stress test 5 years after surgery, but not after 3 months. Older patients seem to have a worse perception of improvement 5 years after surgery as compared to younger ones, as described by the PGI-I score. Age and BMI do not affect significantly the quality of life of women surgically treated for SUI, as reflected by the results of King´s Health Questionnaire. Parity does not seem to have any effect on objective and subjective surgical outcomes.ConclusionsHigher age and BMI at surgery have a detrimental influence on the objective cure rate at 5 years after midurethral sling surgery; higher age also has a negative influence on subjective long-term outcomes. However, these demographic parameters do not influence significantly the quality of life of patients after anti-incontinence surgery. Parity does not show any significant influence on success rate of midurethral sling.

A Danish national population-based cohort study of synthetic midurethral slings, 2007-2011.

Synthetic midurethral slings (MUSs) have shown similar cure rates in several short- and medium-term follow-up studies. Recently, long-term follow-up studies have indicated that the cure rate is higher following the retropubic midurethral sling (RPMUS) compared with the transobturator midurethral sling (TOMUS) procedure. The aim was to evaluate the efficacy of synthetic MUSs and to examine the influence of department and surgeon volume and patient-related factors on the cure rate of synthetic MUSs. A retrospective cohort study based on a national population over a 5-year period (2007-2011) using data from the Danish Urogynaecological Database (DugaBase). A total of 4519 women with first-time MUS were registered in the DugaBase. Cure was achieved in 1242/1639 (75.78%) at a 3-month follow-up. RPMUSs were more frequently in use in high-volume departments compared with the other departments and more often implanted by high- than low-volume surgeons. Women treated by a medium- (adjusted OR 1.82; 95% CI 1.01-3.28, "frequency") or high-volume surgeon (1.98; 1.18-3.32, "frequency") had an increased probability of cure compared with women treated by a low-volume surgeon. The difference was only significant for women who received a TOMUS. This national population-based cohort study confirmed a high cure rate of synthetic MUSs at short-term follow-up. It is the largest study to indicate a learning curve for TOMUS. Patients were not actively involved in which synthetic MUS was to be performed as the choice of surgical option was made at the departmental level.

Preoperative and Surgical Risk Factors for Complications Requiring Sling Revision or Removal after Midurethral Sling Procedures: a Case-Control Study

Objectives: Midurethral sling (MUS) surgery is the most commonly performed procedure for treatment of stress urinary incontinence worldwide. Approximately 3% of patients undergoing incontinence surgery with mesh require re-operation for mesh complications within 10 years. We sought to identify patient characteristics and surgical factors predictive of complications requiring MUS revision/removal.

Cancer Risk After Midurethral Sling Surgery Using Polypropylene Mesh

(Abstracted from Obstet Gynecol 2018;131:469–474) The criterion standard surgery for stress urinary incontinence (SUI) is the midurethral sling procedure. Since its introduction in 1997, this procedure has been widely used for pelvic reconstructive surgery.

How to Perform Tension Free Vaginal Tape Procedures- a Guide for Residents

Video Abstract Summary: The Royal College of Physicians and Surgeons of Canada (RCPSC) identifies procedures that Obstetrics and Gynecology graduates must be competent to perform independently upon completion of residency. In 2016, mid-urethral sling (MUS) procedures were added to this list (RCPSC). MUS is an effective treatment for stress urinary incontinence in 80% of women. The retropubic approach has greater risk of bladder injury, but lower risk of repeat surgery than the transobturator approach (Ford et al. 2017. MUS operations for stress urinary incontinence in women. Cochrane Review). It is believed that the “blind” nature of these procedures make them challenging to teach; a higher rate of complications has been reported among surgeons learning to perform these procedures (Hilton et al. 2015. The learning curve for retropubic MUS procedures). This video describes the steps for retropubic MUS placement and was designed to facilitate resident education. Possible complications and their management are also discussed.

Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder

IntroductionThe mid-urethral sling (MUS) procedure is the gold-standard for the surgical treatment of stress urinary incontinence (SUI). Urethro-vesical sling exposure is one of the most serious complications of this procedure. We describe the treatment and follow-up of 18 patients with bladder or urethral sling exposure. Patients and methodsThis single-center, retrospective study assessed the diagnosis and management of MUS penetrating the lower urinary tract in 18 women. The lesions included were classed as 4B, T3-4, S3 according to the international classification of complications related to the insertion of prostheses. Diagnosis was confirmed by flexible urethro-cystoscopy. The patients were treated surgically. In all cases, the aim was to remove all synthetic materials eroding the bladder or urethra. The patients were reassessed 6 weeks after the procedure, and functional urologic sequelae were treated. Urologic symptoms were evaluated using the USP questionnaire and urologic comfort was assessed using the Contilife questionnaire. ResultsSeven MUSs were retro-pubic and 11 were trans-obturators. The material was 11 polypropylene macroporous monofilament, four polypropylene silicone coated and three non-available. There were six cases of urethral sling exposure, nine cases of bladder sling exposure, and three cases of urethral and bladder sling exposure, including five complicated cases of lithiasis and one urethra-vaginal fistula. Thirteen patients underwent one surgical procedure, four underwent two, and one underwent five procedures. Seven patients received a Martius flap. Three surgical approaches were necessary: (i) vaginal approach; (ii) urologic (urethral and suprapubic) cystoscopy approach; and (iii) laparoscopy approach. Median follow-up time was 34.5 months. At the end of follow-up, 17/18 patients had no sling exposure from the MUS, and 12/13 patients were considered comfortable from a functional urologic viewpoint. ConclusionOur study showed that surgery could treat urethro-vesical sling exposure. Three surgical approaches may be necessary. Controlled cystoscopy is vital to confirm healing due to the recurrences of sling exposure in our study.

MP75-04 THE EFFECT OF SURGEON VOLUME ON PERIOPERATIVE OUTCOMES FOR MID-URETHRAL SLING SURGERY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy III1 Apr 2018MP75-04 THE EFFECT OF SURGEON VOLUME ON PERIOPERATIVE OUTCOMES FOR MID-URETHRAL SLING SURGERY Jacqueline Speed, Ye Wang, Steven Chang, and Elodi Dielubanza Jacqueline SpeedJacqueline Speed More articles by this author , Ye WangYe Wang More articles by this author , Steven ChangSteven Chang More articles by this author , and Elodi DielubanzaElodi Dielubanza More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2096AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Higher surgical volume is associated with decreased costs, complication rates, and length of stay in many urologic procedures. We sought to examine if surgeon volume is a predictor of perioperative outcomes in mid-urethral sling (MUS) placement. METHODS We utilized the Premier Healthcare Database, a national hospital discharge database representing 700 non-federal US hospitals, to identify patients who underwent MUS placement from 2003-2015. Those undergoing concomitant procedures or who received mini-slings were excluded. Patients were stratified by their surgeon's volume. Low, intermediate, and high volume were defined as <4, 4-9, and >9 MUS procedures per year, respectively. We examined patient demographics, Charlson comorbidity index (CCI), length of stay (LOS), readmission rates, and direct hospital costs, as well as hospital and surgeon characteristics. Univariate logistic regression analysis and a median regression of costs were performed. Multivariable regression was performed to identify for potential confounders. RESULTS We identified 30,433 patients, of which 49.2%, 28.0%, and 22.8% had surgery performed by a high, intermediate, and low-volume surgeon, respectively. Compared to low volume surgeons, high volume surgeons were more likely to see older patients in community-based hospital settings (42.6% vs 31.1%) and use a transobturator vs. retropubic approach (60.9% vs 58.5%). On univariate analysis, high and intermediate-volume surgeons had lower median hospital costs ($4505 and $4598 vs $4964, p<0.001) and lower incidence of prolonged LOS (14.7% and 14.6% vs 19.7%, p<0.001) compared to the low-volume group. There was no difference in readmission. On multivariate analysis, controlling for age, race, and CCI, there remained a lower median cost for intermediate and high-volume surgeons (-$352 (IQR -$422 to -$282) and -$455 (IQR -$517 to -$392), respectively, p<0.001) as well as a lower risk of prolonged LOS (OR 0.70 (95% CI 0.64-0.76) and OR 0.69 (95% CI 0.64-0.75), respectively, p<0.001) compared to low-volume surgeons. Notably, while the readmission rate was low overall, patients of high volume surgeons were more likely to be readmitted than those of low volume surgeons (OR 1.20 (95% CI 1.02-1.41), p=0.026). CONCLUSIONS Higher surgical volume is associated with lower costs and lower incidence of prolonged length of stay but a slightly higher rate of readmission. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1009 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jacqueline Speed More articles by this author Ye Wang More articles by this author Steven Chang More articles by this author Elodi Dielubanza More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pelvic floor ultrasound in the diagnosis of sling complications.

The mid-urethral synthetic sling (MUS) procedure has become the standard of care for treatment of female stress urinary incontinence. However, a small number of patients will have complications following MUS including failure, obstructive voiding, sling erosion, or chronic pain. This paper discusses the role of 2D and 3D ultrasound imaging in the evaluation of the female patient with complications following placement of a synthetic mid-urethral sling. The MUS is easily visualized as an echogenic structure on ultrasound and can be imaged by transperineal, transvaginal and introital approaches. Ultrasound allows dynamic assessment of the sling and can assist in the diagnosis of sling failure, obstruction, erosion and mesh related pain. Pelvic floor ultrasound has an emerging role in the assessment of complications following MUS surgery. 3D ultrasound can assist the clinician in assessment of the complex patient with multiple slings or meshes in situ.

Cancer Risk After Midurethral Sling Surgery Using Polypropylene Mesh.

To assess whether there is any association between the implantation of synthetic polypropylene mesh slings for the treatment of stress urinary incontinence (SUI) and risk of cancer. We performed a nationwide cohort study based on the general female population in Sweden. All women entered the observational period as unexposed on January 1, 1997, and contributed person-time as unexposed unless they underwent a midurethral sling procedure for SUI, after which they contributed person-time as exposed until first occurrence of any cancer, death, emigration, or end of the observational period (December 31, 2009). Occurrence of primary cancer was ascertained from the Cancer Register. Hazard ratios (HRs) with 95% CIs were calculated by Cox proportional hazards regression. The final study population included 5,385,186 women, including 20,905 exposed, encompassing a total of 44,012,936 person-years at risk. Other than an inverse association with rectal cancer (HR 0.5, 95% CI 0.3-0.8), there were no significant differences in risk between exposed and unexposed women for pelvic organ cancers including ovarian (HR 0.8, 95% CI 0.5-1.2), endometrial (HR 1.1, 95% CI 0.8-1.4), cervical (HR 0.4, 95% CI 0.2-1.0), bladder, and urethra (HR 0.7, 95% CI 0.4-1.2). No significant association was observed between exposed women and primary cancer in any organ system when compared with unexposed women. The relative risk for cancer after exposure showed little variation over time except for an inverse overall correlation within the first 4 years of surgery (HR 0.7, 95% CI 0.7-0.8). The incidence rates per 100,000 person-years (95% CIs) for exposed vs unexposed women were 20.5 (14.3-29.5) vs 21.0 (20.6-21.5) for rectal cancer, 25.5 (18.4-35.3) vs 19.8 (19.4-20.2) for ovarian cancer, 65.0 (53.0-79.8) vs 33.1 (32.6-33.7) for endometrial cancer, 5.7 (2.8-11.3) vs 11.9 (11.6-12.2) for cervical cancer, and 19.1 (13.1-27.8) vs 13.3 (13.0-13.7) for bladder and urethra cancer. Our results suggest that midurethral polypropylene sling surgery for SUI is not associated with an increased cancer risk later in life.

Influence of body mass index on short-term subjective improvement and risk of reoperation after mid-urethral sling surgery.

The objective was to evaluate the impact of body mass index (BMI) on the subjective improvement and risk of reoperation after first-time mid-urethral sling surgery. Data were retrieved from the national Danish Urogynaecological Database, including women with first-time surgery with mid-urethral polypropylene slings from 2011 to 2016. The subjective improvement was assessed by the difference in symptoms based on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) completed pre- and 3months postoperatively. A reoperation was defined as any new surgical procedure for stress urinary incontinence performed within the study period. During the study period, 6,414 mid-urethral sling procedures were performed; 80.0% of these women filled out both pre- and post-surgical International Consultation on Incontinence Questionnaire (ICI-Q) forms. 42.4% had a BMI < 25, 34.6% had BMI 25-30, 16.9% had BMI 30-35, and 6.0% BMI >35. The subjective improvement after surgery was high in all BMI categories and there were no differences between the categories. The overall cumulative hazard proportion at 2years of follow-up was 1.9% (CI 95%: 1.6-2.3) and after 5years 2.4% (CI 95%: 2.0-2.9). Adjusted for age, smoking, and use of alcohol, the cumulative hazard proportion after 2years of follow-up was 3.2% (CI 95%: 1.6-6.2) for women with BMI >35 and after 5years 4.0% (CI 95%: 2.0-7.7), which was the highest proportion of reoperation in the study. The crude hazard ratio was 1.84 (CI 95%: 0.89-3.83) women with BMI >35 and the adjusted hazard ratio was 1.94 (CI 95%: 0.92-4.09). We found high subjective improvement after the first-time surgery unrelated to BMI. Women with a BMI over 35 had the highest proportion of reoperations, although this was not statistically significant.

Associations Between Childbirth and Urinary Incontinence After Midurethral Sling Surgery.

To assess whether subsequent childbirths affect the outcomes of midurethral sling surgery with regard to stress urinary incontinence (SUI). In this population-based cohort study, we used the validated Swedish nationwide health care registers (the Patient Register and the Medical Birth Register) to identify women with a delivery after midurethral sling surgery (n=207, study group). From the same registers we then randomly identified a control group who had no deliveries after their midurethral sling procedure (n=521, control group). The women in the control group were matched to the women in the study group by age and year of surgery. The Urogenital Distress Inventory and the Incontinence Impact Questionnaire were sent out to the study population. Symptomatic SUI was defined as the primary outcome. Secondary outcomes included the total Urogenital Distress Inventory score, Urogenital Distress Inventory subscale scores, and Incontinence Impact Questionnaire scores. A total of 728 women were eligible for the study. The response rate was 74%; 163 in the study group (64 with vaginal delivery and 95 with cesarean delivery) and 374 women in the control group were included in the analysis. The rate of SUI (primary outcome) was 36 of 163 (22%) in the study group and 63 of 374 (17%) in the control group. In a multivariate regression analysis of the primary outcome, we found no significant difference between the groups (odds ratio [OR] 1.2, 95% CI 0.7-2.0). Vaginal childbirth after midurethral sling surgery did not increase the risk of SUI compared with cesarean delivery (22% vs 22%, OR 0.6, 95% CI 0.2-1.4). There were no significant differences in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores between any of the groups. Childbirth after a midurethral sling procedure is not associated with an increased risk of patient-reported SUI, and continence status is not affected by the mode of a subsequent delivery.

70: Long-term improvements in physical activity levels and physical functioning after midurethral sling for female stress urinary incontinence

To estimate the long-term effect of the midurethral sling on leisure physical activity (PA) levels and physical functioning (PF) in women 5 or more years after surgery for stress urinary incontinence (SUI). We conducted a long-term follow-up study of a previously published prospective, observational study of women undergoing outpatient midurethral sling for SUI from 2009 to 2011. For the primary study, and this follow-up study, women completed validated questionnaires for incontinence, leisure PA, and PF at baseline and postoperatively. The questionnaires included the UDI-6, International Physical Activity Questionnaire (IPAQ), Pelvic Floor Distress Inventory-20 (PFDI-20), Body Image Scale (BIS), and the NIH Patient-Reported Outcomes Measurement Information System measure for physical functioning (PROMIS-PF). Women were categorized as having sedentary, insufficient, or sufficient leisure PA levels by metabolic equivalents (MET-min/week on the IPAQ). They were also categorized as having low, moderate, or high overall PA levels using IPAQ scoring rules. For this follow-up study, all patients who consented to participating in future studies at the time of enrollment in the initial study were contacted via telephone to complete questionnaires through mail or e-mail. PA and PF levels were compared pre-operatively and at 5 or more years follow-up. Paired T-tests, signed-rank tests, and linear regression were used to estimate the effect of improvements in urinary symptoms on PA levels and PF scores at long-term follow-up. Of the 85 women enrolled in the primary study, 48 consented to being contacted for future studies. Of these, 28 completed surveys through mail or e-mail (58% response rate) and the long-term follow-up range was 5 to 7.5 years. The baseline mean age of the 28 participants was 51 years (SD 8), 64.3% had comorbidities, mean baseline UDI score was 50.3 points (SD 22.4). At baseline, no patients were categorized as having low overall PA, 26.9% were categorized as moderate, and 73.1% were categorized as high. 26.9% were categorized as having sedentary baseline leisure PA levels, 15.3% as insufficient, and 57.7% as sufficient. At long-term follow-up, 57.1% of women with low baseline leisure PA levels improved to moderate or high levels and 50.0% of women with moderate leisure PA improved to high leisure PA levels (P = 0.6). For overall PA levels, 7.7% improved their overall level of PA, while 53.8% maintained the same level of overall PA (P > 0.05). PROMIS-PF scores improved significantly between baseline and long-term follow up (mean 44.8 vs 52.9, P < 0.0001). When comparing 6 month post-operative results to long-term follow-up, BMI remained stable (29.78 vs 29.23), as did PFDI (11.98 vs 14.06), and BIS (4 vs 3) scores (all P > 0.05). On multiple linear regression, each 11- point improvement in UDI was associated with a mean improvement of 1.32 points in PF scores (P = 0.04), adjusting for age, comorbidity and baseline PA level at long-term follow up. Midurethral sling procedures for SUI are associated with long-term improvements in PA levels and PF.

No incision and tension-free vaginal sling for stress urinary incontinence: The role of knotless barbed suture

Midurethral mesh sling is the most performed incontinence procedure. This hypotheses propose knotless barbed suture could be positioned as a tension-free trans-vaginal sling under the mid-urethra without vaginal incision. Knotless suture sling support and stabilize mid-urethra when intraabdominal pressure increase. This procedure is designed to replace midurethral mesh sling operation, aiming at reducing complications. It is completed in a similar way with retropubic mesh sling procedure, and less invasive. This involve the passage of fine needle from suprapubic skin to midurethral vaginal wall, and knotless suture passing through in fine needle as a U shape. The foundational promises for this hypothesis pertain to two clinical facts: midurethral sling procedure is a gold standard treatment, and the knotless suture offer superior tissue holding or fixation strength originated from the unique barbed design.

Mixed urinary incontinence: A prospective study on the effect of trans-obturator mid-urethral sling

ObjectivesIt is hypothesized that urethral dysfunction is central in mixed urinary incontinence (MUI) in women, since urine entering the proximal urethra under increased intra-abdominal pressure provokes a urethro-detrusorial reflex and involuntary detrusor contraction. Mid-urethral slings have been proposed as a solution. Our primary objective was to evaluate the long-term subjective and objective outcomes on continence and other urinary symptoms of a trans-obturator mid-urethral sling (TOT) procedure. Our secondary objectives were to determine its impact on quality of life (QoL), and to investigate which factors influence outcomes. Study designThis is a single-centre prospective study on a consecutive series of 86 women who underwent TOT for MUI as defined by ICS/IUGA. Since the definition of MUI that we used is symptom-based, we included patients both with and without associated detrusor overactivity. All patients underwent placement of Monarc® Subfascial Hammocks. Statistical analysisWe used the McNemar chi-square test, the paired t-test and Fisher’s exact test. A logistic regression model and odds ratios were used to assess age, parity, body mass index, menopausal status, preoperative detrusor over-activity, and detrusor pressure at maximum flow as possible factors for treatment failure. Only those that were statistically significant in the univariate analysis were included in the multivariate analysis. ResultsWith a mean follow-up of 59 months, SUI was cured objectively in 83.7% of patients and subjectively in 87.2%. Three patients underwent further anti-incontinence surgery. The continence rates were 74.4% for urgency urinary incontinence (UUI) and 66.3% for SUI-UUI. The patient-reported success rate was 87.2% (‘much better’ or ‘very much better’ on Patient Global Impression of Improvement scale). There were statistically significant improvements in all domains except general health. The univariate analysis found no significant risk factor for persistence of SUI. Median age >60 years and menopause were predictive for persistence of UUI. Median and mean age >60 years were predictive of persistence of overall incontinence. In the multivariate model, all variables lost their statistical significance. ConclusionOur study demonstrates TOT surgery can be performed for patients with MUI following unsuccessful conservative therapy. We also demonstrate that menopause and age >60 are risk factors for failure. This should be considered when counselling preoperatively.

Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion.

Voiding dysfunction following midurethral sling procedures is not a rare event. There is no current consensus regarding management of this complication. Although it is often transient and self-limiting, chronic post-midurethral sling voiding dysfunction may lead to irreversible changes affecting detrusor function. Initial management includes intermittent catheterization, and addressing circumstantial factors interfering with normal voiding, such as pain. Early sling mobilization often resolves the dysfunction, and is associated with minimal morbidity. Sling incision or excision at a later stage, although fairly effective, could be associated with recurrence of stress urinary incontinence. There is insufficient evidence to justify urethral dilatation in this context.

Surgical Treatment of Female Stress Urinary Incontinence: Pubovaginal Slings

Autologous tissue has been used for pubovaginal sling construction for over a century. Compared with synthetic materials, fascial harvest carries additional and expected morbidity. However, by the nature of its definition, the use of autologous tissues is not associated with a significant immunogenic or any foreign body response. Randomized controlled trials have demonstrated and confirmed the durability of these procedures when compared with both colposuspensions and synthetic midurethral sling procedures. In light of the recent FDA warning regarding the use of synthetic materials for stress incontinence and pelvic organ prolapse surgery, the role of the autologous sling may be more prominent going forward. As such, the autologous pubovaginal sling remains a standard of care for the management of female stress urinary incontinence. This review contains 6 figures and 30 references Key words: autologous rectus fascia, complications, outcomes, pubovaginal sling, randomized controlled trials, stress urinary incontinence

Cost Analysis of Vaginal Mid Urethral Sling Suburethral Removal

IntroductionFor cost analysis of mid urethral sling surgery there is a lack of data on costs associated with long-term complications. Therefore, we studied the costs related to a vaginal suburethral synthetic sling removal procedure over 2 consecutive years. MethodsFrom a prospectively maintained database of consecutive women who underwent 1 vaginal suburethral synthetic sling removal only, we analyzed the cost of suburethral synthetic sling removal for 2013 and 2014. Costing data were obtained for operating room expenses, medical and surgical supplies, pharmacy, anesthesia supplies, and room and bed. Professional fees for the suburethral synthetic sling removal procedure were obtained from the Medicare fee-for-service schedule. Costs for 2013 were adjusted by 3% to match 2014 costs. ResultsFrom 2013 to 2014 a total of 46 women underwent suburethral synthetic sling removal. Mean ± SD length of surgery was 62 ± 22 minutes and median length of stay was 1 day (range 0 to 2). Costs for medical and surgical supplies decreased significantly from 2013 to 2014 while operating room and total cost increased during that time. No significant differences were found among payer types. With the 3% inflation adjustment for 2013 the mean total cost based on these factors was $3,714 ± $941, with a median cost of $3,556. Of the 46 women 13 were treated on an outpatient basis and the median cost was reduced at $3,030. ConclusionsAt our tertiary care center the mean total cost of suburethral synthetic sling removal was $3,714, with a slight total cost increase from 2013 to 2014 but a cost saving for those treated as outpatients. This information will be useful for inclusion in the overall cost of mid urethral sling procedures.