Midurethral Sling Research Articles

Surgical Treatments for Women with Stress Urinary Incontinence: A Systematic Review.

Stress urinary incontinence affects a large proportion of women in their lifetime. The objective of this review was to describe and compare the latest surgical trends in urinary incontinence and focus on the literature advantages, disadvantages, complications and efficacy of surgical procedures regarding this pathology. Using network meta-analysis, we have identified the most frequently used procedures (Burch surgery, midurethral sling and pubovaginal sling), and we have described and characterized them in terms of effectiveness and safety. Midurethral procedures remain the gold standard for surgical treatment of stress urinary incontinence, although the potential of serious complications following this procedure should be taken into consideration always. There is a clear need for a much more unified evaluation of possible complications and postoperative evolution. This process will help practitioners to adapt and individualize their strategy for each patient.

(018) Is Female Sexual Dysfunction an Important Factor in Physician Process of Care and Decision-Making for Common Gynecologic Procedures: An Interview Study

Abstract Introduction The mid-urethral sling (MUS) and cervical conization are two common gynecologic procedures performed to correct symptoms of stress urinary incontinence, and to treat cervical dysplasia respectively. There is limited literature surrounding the decision-making process, and process of care physicians follow when performing these procedures. Additionally, current evidence suggests that sexual dysfunction (SD) can result in some women following the MUS procedure and cervical conization, specifically the loop electrosurgical excision procedure (LEEP). Despite this, it is unclear in the literature how physicians performing these procedures perceive this evidence, and if it has an influence on their process of care and decision-making. Objectives The objective of this study was to understand the factors that impact physician decision-making surrounding MUS and cervical conization procedures. A specific interest of this research was determining if and how the recent evidence regarding the potential for post-operative complications of SD is incorporated into the decision-making process and process of care of physicians performing MUS/LEEP. Methods A qualitative semi-structured interview protocol was developed that explored three general areas: pre- and post-operative patient counseling, physicians’ decision making intra-operatively, and physicians’ approach to and perceptions of SD and sexual health counseling. Six Canadian staff physicians with specializations in relevant fields were recruited and interviewed as a pilot study. Thematic content analysis of the recorded and transcribed interviews was completed using NVivo 12. Results All participants indicated a preferred surgical approach (transobturator; LEEP). Factors that influenced this choice included reported risk data, procedure efficacy, and training. A commonly identified theme was the importance of minimizing damage to surrounding tissues (MUS) and minimizing the amount of tissue excised (conization) to mitigate post-operative complications. Most participants acknowledged that these procedures could have a negative impact on female sexual functioning (FSF). However, individual definitions of SD and the perceived type, degree, and potential of impact on these procedures on FSF were highly variable. Most of the participants indicated that they assessed some aspect of their patient’s sexual functioning post-operatively, however none specified a compete assessment of FSF or the use of a validated instrument or questionnaire. None of the MUS physicians reported discussing the evidence-based risk of the possible negative impact of the MUS procedure on orgasm function with their patients. Conclusions The results from this pilot study provide emerging evidence that physicians’ definitions of SD, and the perceived impact of LEEP and MUS on FSF are highly variable and do not fully reflect current evidence. The degree to which the physicians incorporated the reported post-operative risk of SD as a part of their process of care within the context of these procedures was also inconsistent. These results suggest the need for a standardized process of care with regard to counseling patients of the risk of post-operative SD, in addition to the assessment of female sexual health within the context of these two procedures. Further validation of these results is needed in a larger cohort, with an extension of this study that includes American physicians currently underway. Disclosure No.

Google searches for stress urinary incontinence treatment options: a worldwide trend analysis in the synthetic mesh controversy era.

To analyze trends in worldwide public interest in the treatment options for stress urinary incontinence around the latest FDA 2019 ban on vaginal mesh for prolapse. We used the web-based tool Google Trends to analyse online searches related to the following terms: 'pelvic floor muscle exercises', 'continence pessary', 'pubovaginal slings', 'Burch colposuspension', 'midurethral slings', 'injectable bulking agents'. Data were expressed as relative search volume on a scale of 0-100. Comparisons of annual relative search volume and average annual percentage change, were analyzed to assess loss or gain of interest. Finally, we assessed the impact of the last FDA alert. The mean annual relative search volume for midurethral slings was 20% in 2006 and significantly decreased until 8% in 2022 (p < 0.01). A regular decrease interest was recorded for autologous surgeries but a regain of interest for pubovaginal slings was registered since 2020 (+ 2.8%; p < 0.01). Conversely, a steep interest was noted for injectable bulking agents (average annual percentage change: + 4.4%; p < 0.01) and conservative therapies (p < 0.01). When trends were compared before and after the FDA 2019 alert, a lower research volume was found for midurethral slings, while a higher research volume was observed all others treatments (all p < 0.05). The online public researches about midurethral slings have considerably decreased following warnings on the use of transvaginal mesh. There seems to be a growing interest in conservative measures, bulking agents, and recently pubovaginal slings.

Среднеуретральный синтетический слинг с возможностью ранней мобилизации в лечении недержания мочи при напряжении у женщин.

Introduction. The use of midurethral synthetic slings is currently considered to be the most widespread treatment option for stress urinary incontinence (SUI). The most difficult in the existing approaches is to achieve the optimal tension of the sling, on which the result of treatment directly depends. To solve this problem, sling systems with the possibility of tension adjustment in the early postoperative period were created. A comparative study of the effectiveness and safety of such a system and a sling without the possibility of adjustment seems to be a relevant task. Materials and Methods. The study involved 320 female patients with a mean age of 55.2±11.2 years and a confirmed diagnosis of SUI. The patients were allocated into two groups: the first group underwent a synthetic suburethral sling by the standard technique (TOT); the second group received a suburethral sling with early mobilization (TTT). All patients underwent stress test, uroflowmetry and ultrasound investigation to determine the volume of residual urine. UDI-6, ICIQ-SF, PISQ-12 questionnaires were filled out to assess subjective efficiency. Results. In the second group, 28% of the patients needed to increase the tension of the prosthesis. Due to the possibility of tightening the sling in the early postoperative period, the operation was ineffective at the delayed follow-up stage at 36 months only in 11% of the women in the TTT group and in 32% of the patients in the LTT group, p&lt;0.001. Loosening the sling tension was required in every fourth patient in the TTT group. Signs of obstructive urination at the stage of 36 months persisted in 13 patients in the TOT group and were completely absent in the TTT group. Subjective satisfaction with treatment was higher in the TTT group and amounted to 82%. Conclusion. A synthetic mid-urethral tuneable tension tape is superior to a classic sling without adjustment capability in long-term efficacy and safety.

Risk Factors for De Novo Overactive Bladder After Midurethral Sling.

The low incidence of de novo overactive bladder (OAB) symptoms after a midurethral sling (MUS) procedure better informs preoperative counseling. The study aimed to measure the incidence and risk factors for de novo OAB after MUS. This was a retrospective cohort study of de novo OAB symptoms in patients who underwent MUS surgery in a health maintenance organization between January 1, 2008, and September 30, 2016. Patients were identified using Current Procedural Terminology codes for MUS and International Classification of Diseases, Tenth Revision codes for urinary urgency, frequency, nocturia, OAB, and urgency urinary incontinence (UUI). The cohort of patients was identified by the absence of these International Classification of Diseases, Tenth Revision codes 12 months preoperatively and the presence of these codes within 6 months after surgery. This cohort was used to calculate the rate of de novo OAB after MUS surgery. Clinical and demographic factors were abstracted. Statistical analysis was performed using descriptive, χ2 , simple logistic, and multiple logistic regression. During the study period, 13,893 patients underwent MUS surgery and 6,634 met the inclusion criteria. The mean age was 56.9 years, mean parity was 2.76, and mean body mass index was 28.9 (calculated as weight in kilograms divided by height in meters squared). Of these, 410 (6.1%) developed de novo OAB within 12 months. The most common symptoms were urgency (65.4%), UUI (42.2%), and frequency (19.8%). On multivariable regression modeling, de novo urgency and UUI were not associated with concurrent surgery ( P < 0.05). Increasing age and body mass index were associated with an increased risk of nocturia ( P < 0.05). The incidence of de novo OAB after MUS surgery was 6.1%. This aligns with current literature and critically informs preoperative counseling for MUS surgery.

The transvaginal mesh class action: a tertiary teaching hospital experience of all mid-urethral sling procedures performed between 1999 and 2017.

Class action against Ethicon (J&J), manufacturer of transvaginal mesh devices, including mid-urethral slings (MUS), was brought to the Federal Court of Australia in 2016 by Shine Lawyers. As a result, subpoenas to all hospitals and networks were received, which overrode patient privacy concerns. This medical record search allowed a complete audit and communication with patients to offer clinical review. This enabled a review of complications, readmission and re-operation for women who underwent a MUS for stress urinary incontinence. A cohort study of women who underwent MUS treatment for stress urinary incontinence (SUI) at a single tertiary teaching hospital between 1999 and 2017 was carried out. The main outcome measures were the rate of readmission and re-operation following MUS procedures. These include voiding dysfunction managed by sling loosening or sling division, mesh pain or exposure managed by mesh removal and reoperation for recurrent stress urinary incontinence. Between 1999 and 2017, a total of 1,462 women were identified as having a MUS; of these, 1,195 (81.7%) had full patient records available. Voiding dysfunction requiring surgical intervention with sling loosening or division was 3%, excision for mesh exposure was 2%, and partial or complete excision for pain was 1% at a median of 10 years from index surgery. The reoperation rate for recurrent stress urinary incontinence was 3%. This audit of all MUS procedures performed at a tertiary centre confirms an overall low rate of readmission for complications and recurrent SUI surgery; this justifies its continued availability with appropriate informed consent.

Tape-Releasing Suture with "Long Loop" on Mid-Urethral Sling: A Novel Procedure for Management of Iatrogenic Urethral Obstruction.

To report our experiences of a tape-releasing suture with "long-loop" in women with iatrogenic urethral obstruction following the mid-urethral sling procedure. A total of 149 women underwent a tape-releasing suture with "Long Loop" during the operation. Post-void residual volume was evaluated after Foley removal. Lower urinary tract symptoms and urodynamic studies were assessed before and six months postoperatively. Nine women out of 149 who underwent mid-urethral sling surgery were found to have iatrogenic urethral obstruction post-operatively based on their urinary symptoms and ultrasound findings. There was no apparent difference between tested groups in mid-urethral sling products and concomitant procedures. 77.8% had successful releases after the first Long-loop manipulation procedure, and 22.2% required two or more releases. However, the SUI cure rate is similar in groups receiving the Long-loop manipulation or not (88.9% and 87.1%, respectively). We are convinced of the practicability and efficacy of the tape-releasing suture "Long-loop." We adopted subjective and objective means to evaluate both groups before and after a six-month follow-up. The Long-loop manipulation procedure can successfully resolve the iatrogenic urethral obstruction without compromising the effectiveness of mid-urethral sling for the treatment of SUI.

Persistence of lower urinary tract symptoms in post- menopausal women after mid-urethral sling: the role of urodynamics in patient counselling

Persistence of lower urinary tract symptoms in post- menopausal women after mid-urethral sling: the role of urodynamics in patient counselling

Effects of Same-Day Discharge on 30-Day Readmission Rates in Women Aged 65 Years and Older Undergoing Minimally Invasive Pelvic Organ Prolapse Surgery.

To compare the effects of same-day discharge on 30-day readmission after minimally invasive pelvic organ prolapse (POP) surgery in older patients. This retrospective cohort study examined all minimally invasive POP surgeries performed and included in the national Centers for Medicare & Medicaid Services 5% Limited Data Set (2011-2018). Our primary outcome was 30-day hospital readmission, and our secondary outcome was 30-day emergency department (ED) visits. Of the 7,278 patients undergoing surgery, patients who had same-day discharge were older (73.5 years vs 73.1 years, P =.04) and less likely to undergo concomitant hysterectomy (9.5% vs 34.9%, P <.01) or midurethral sling (36.8% vs 40.1%, P =.02). Same-day discharge increased over the study period from 15.7% in 2011 to 25.5% in 2018 ( P <.01). On propensity score-matching multiple logistic regression, the adjusted difference was statistically significant, with same-day discharge increasing the odds of 30-day readmission compared with next-day discharge (adjusted odds ratio [OR] 1.57, 95% CI 1.19-2.08). There was no difference (OR 0.81, 95% CI 0.63-1.05) for 30-day ED visits on propensity score-matching multiple logistic regression. After minimally invasive POP surgery, older women have low rates of readmission and ED visits within 30 days. After propensity score matching and adjustment for perioperative factors, there may be increased odds in readmission and no difference in ED visits risk in those who had same-day discharge. When considering patient factors, same-day discharge after minimally invasive POP surgery may be effective for older patients.

Combined treatment with vaginal native tissue repair plus mid-urethral sling or pelvic floor muscle training in patients with anterior defect and occult stress urinary incontinence: quality of life and sexual function analysis.

The aim of this study was to compare the efficacy of vaginal native tissue repair (VNTR) combined with tension-free transobturator tape (TVT-O) or pelvic floor muscle training (PFMT) in terms of quality of life (QoL) and sexual function (SF) in women affected by anterior defect and occult stress urinary incontinence (OSUI). One hundred forty-seven patients with symptomatic anterior defect with OSUI underwent VNTR. In 71 patients TVT-O was inserted and 76 underwent PFMT after surgery. Clinical exam, 3-day voiding diary and urodynamic testing were evaluated in preoperative and postoperative times. Specific questionnaires were also administered, in order to indagate disease perception and the impact on QoL and SF. Nine patients had postoperative pain in the TVT-O group vs. 0 patients in the PMFT group (P=0.001) and 7 patients reported de novo urgency vs. 3 in the two groups, respectively. At 12 weeks follow-up (FU), the first voiding desire was at 88.12+19.70 mL in VNTR+TOT vs. 102.29+19.13 (P=0.03); the mean number of voids (24 hours) was 9.95±2.66 vs. 6.14±1.77 (P=0.04), respectively. No significant differences in terms of QoL and SF were shown. This retrospective study suggests that VNTR+TVT-O and VNTR+PMFT have the same efficacy in terms of QoL and SF, with several post-operative complications, even if minor, in patients treated with combined surgery.

Late-onset Isolated Myositis Following Transobturator Mid-Urethral Sling: A Case Report

Late onset of isolated myositis following a Transobturator (TOT) mid-urethral sling (MUS) is a rare post-operative complication.

The Journal of Urology® Home Study Course 2023 Volume 209/210.

The Journal of Urology® Home Study Course 2023 Volume 209/210.

Outcomes and postoperative management of autologous fascial pubovaginal slings in females who have failed a midurethral sling

Outcomes and postoperative management of autologous fascial pubovaginal slings in females who have failed a midurethral sling

Efficacy of Pelvic Floor Ultrasound for Assessing Transobturator Tape Sling Procedure.

Complications after midurethral sling, which require a high degree of clinical suspicion for timely diagnosis, accurate evaluation, and proper intervention, are closely associated with surgical success or failure. This study aimed to evaluate the efficacy and complications of tension-free midurethral sling for stress urinary incontinence (SUI) using pelvic floor ultrasound. This retrospective study included 152 female patients with SUI admitted to the Jinhua Central Hospital between January 2020 and December 2021 who were selected. All patients underwent midurethral transobturator tape sling procedures and were divided into success, voiding dysfunction, overactive bladder, and failure groups according to postoperative efficacy and complications. The pelvic floor ultrasound examination was performed before and after the surgery. The posterior vesicourethral angle difference ( P < 0.01) was significantly lower after the surgery than before the surgery. The rate of bladder neck funneling ( P < 0.01) and the area of bladder neck funneling ( P < 0.01) were smaller after the surgery than before the surgery. The tape-longitudinal smooth muscle distance, the tape-symphysis pubis distance, the sling angle, and the tape-bladder neck/urethra increased successively in the voiding dysfunction, overactive bladder, success, and failure groups. Pelvic floor ultrasound can accurately evaluate the postoperative efficacy and complications of transobturator tape sling procedures for SUI and can reasonably guide the management of complications. Therefore, it is an effective imaging method for postoperative follow-up after tension-free midurethral tape suspension.

(025) Disclosure of Mid-Urethral Sling and Radical Prostatectomy Risks: A Comparative Analysis of Hospital-Affiliated Online Resources

Abstract Introduction Radical prostatectomy (RP) involves the removal of the prostate gland to treat cancer. The mid-urethral sling (MUS) procedure, used to correct symptoms of stress urinary incontinence in women, affects anterior vaginal wall female periurethral tissue (AVW-FPT). Glandular structures in AVW-FPT have similar immunohistochemistry to prostatic tissue. Erectile dysfunction and female orgasmic disorder have been reported following RP and MUS, respectively. The disclosure of these, and other associated risks, in patient education materials has yet to be assessed. Further investigation is required to determine if and how risk information reported in the literature is presented to patients, as it may impact the ability of patients to make informed health-related decisions. Objective To assess the level of knowledge translation to patients of reported risks associated with MUS and RP procedures in hospital affiliated online resources (HAORs) from Canada, Australia, and the United Kingdom, and to evaluate the accessibility of this information using validated measures of health literacy. Methods A list of healthcare institutions in Canada, Australia, and the UK was generated. RP and MUS-specific HAORs were collected from all institutions. Qualitative analysis of 35 HAORs (RP n=20 and MUS n=15) was conducted using NVivo12. The Patient Education Materials Assessment Tool- Print version (PEMAT-P), was used to determine understandability and actionability, and the Flesch-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), and Simple Measure of Gobbledygook (SMOG) were used to assess the readability. Results Most RP and MUS HAORs were written higher than the recommended grade 5/6 reading level and were below the threshold values for understandability and actionability. The majority of Canadian MUS HAORs met the adequate threshold values for understandability and actionability, unlike the MUS HAORs from Australia and the UK and the RP resources from all three regions. There was inconsistency between the risks reported in the RP and MUS HAORs from Canada and Australia compared to the risks commonly reported in literature. The organization of information including the use of diagrams and medical jargon in the HAORs differed between RP and MUS documents and across the three regions. RP HAORs used diagrams more consistently than MUS HAORs and scored higher on measures of understandability and actionability. The RP and MUS HAORs from the three regions that used medical jargon scored lower on measures of readability. There was inconsistency in the reporting of sexual health risks between the RP and MUS HAORs in all three regions. MUS HAORs less consistently reported sexual health risks following surgery compared to RP HAORs. Conclusions HAORs are important means by which health-related information is translated to patients. There were inconsistencies in the risk information reported for RP versus MUS in Canada, Australia, and the UK. This discordance may impact patient decision-making and health outcomes. The development of guidelines for HAORs curation for healthcare institutions operating under similar healthcare frameworks may be beneficial in ensuring equal access to health information for all patients. Disclosure No

(027) Considerations of Mid-Urethral Sling Procedures: Patient and Provider Perspectives on Outcomes and Experiences

Abstract Introduction The mid-urethral sling procedure (MUSP) treats symptoms of stress urinary incontinence. Recent studies have identified the potential for negative outcomes following MUSP; however, there is a limited understanding of the patient and healthcare provider perspectives on procedural experiences and outcomes. Specifically, there is discordance surrounding the role of female periurethral tissue in sexual responses, and limited knowledge of post-MUSP outcomes and symptoms as perceived by patients. Further understanding of current counselling and resource practices is needed, especially regarding informed consent and risk disclosure. Objective To investigate the experiences associated with MUSP from patients who have reported bothersome symptoms following MUSP, and from providers who routinely perform the procedure. Furthermore, to characterize recent patient experiences, explore factors which may influence current provider decision-making, and outline patient-used and provider-recommended counselling and resources. Methods Patients (n=10) who underwent MUSP and reported negative outcomes, and providers (n=22) with experience performing MUSP were recruited. Patients first completed an online survey which captured demographic information, medical history, and sexual function. Both patients and providers completed semi-structured interviews relating to MUSP outcomes and experiences. Interview responses were transcribed using Trint, and qualitative analyses were completed using NVivo 12. Results Perspectives and experiences gathered from patient and provider interviews revealed discordant narrative surrounding MUSP outcomes and treatment. Analysis of patient narratives revealed a unique symptom profile including periurethral pain and numbness, altered lubrication and loss of desire. In addition, patients discussed post-MUSP infections, as well as pain, weakness, and lower limb impairment having impacts on and extending to other aspects of life, including social relationships, work obligations, and day-to-day responsibilities. Patients described a preference for informed pre-procedural care, and supportive and comprehensive post-procedural counselling. Provider narratives revealed aims of fostering open discussions and efforts to offer procedural support. However, providers referenced limitations in time, experience, and understanding of the adverse outcome symptom profile. Further, regarding post-procedural care, both providers and patients discussed limitations in currently available counselling routes and resources. Conclusions The results of this study highlight discordance between the perceptions of patients and providers regarding MUSP outcomes and experiences. There are differences in the understanding of post-MUSP negative outcome experiences as perceived by patients, compared to providers. These findings support the need for improvements in post-MUSP support and targeted counselling, and resources. Differences in the knowledge of symptoms and negative outcome experiences as related to sexual function are emphasized in this context, highlighting, and encouraging the need for improvements in clinical practice which includes sexual health conversations and accessible resources. Disclosure No

Return to work and normal activities after mid-urethral sling: secondary analysis of the Trial of Mid-Urethral Slings.

We aim to evaluate the timing of patients returning to work and to normal daily life following mid-urethral sling surgery. This is a secondary analysis of the Trial of Mid-Urethral Slings (TOMUS). Our primary outcome is the timing of return to work and normal activities. Secondary outcomes included paid days off, number of days to return to normal daily life, and objective and subjective failures. Predictors affecting the timing of return to work and normal activities were also assessed. Patients who underwent concomitant surgery were excluded. Among patients undergoing a mid-urethral sling, 183 (41.5%) returned to normal activities within 2weeks. Within 6weeks of surgery, 308 (70.0%) had returned to normal activities including work. At the 6-month follow-up, 407 (98.3%) had returned to normal activities including work. Patients took a median of 14days (interquartile range 1-115days) to return to normal activities including work and took a median of 5 (interquartile range 0-42days) paid work days off. Those who returned within 2weeks versus after 2weeks did not have significantly different characteristics, or failure and complication rates. In the multivariate regression analysis, there was no significant predictor of the timing of returning to normal activity/work. Less than half of patients returned to work and normal activities within 2weeks of a mid-urethral sling surgery and took many fewer paid days off. The timing of return to work was not associated with significant differences in treatment failure or adverse outcomes.

43 - Surgical timing in patients with retention/dysuria after mid-urethral sling: A modified Delphi consensus

43 - Surgical timing in patients with retention/dysuria after mid-urethral sling: A modified Delphi consensus

62 - De novo overactive bladder after midurethral sling surgery: Prevalence, timing and risk factors

62 - De novo overactive bladder after midurethral sling surgery: Prevalence, timing and risk factors

61 - Persistent overactive bladder after midurethral sling surgery: Prevalence, timing and risk factors

61 - Persistent overactive bladder after midurethral sling surgery: Prevalence, timing and risk factors