Midurethral Sling Surgery Research Articles

Health-related quality of life. The effect of pelvic floor muscle training and midurethral sling surgery: a systematic review

Stress urinary incontinence (SUI) is a bothersome condition affecting health-related quality of life (HRQoL) to a great extent in women. From a patient's perspective, improving HRQoL is probably equally important as objective cure of SUI. Our objective was to assess the effect of pelvic floor muscle training (PFMT) and midurethral sling surgery on condition-specific HRQoL in women with SUI. A systematic literature search was conducted in the PubMed, Embase, and Cochrane databases. Studies reporting on HRQoL after intervention for SUI or mixed incontinence with a predominant SUI component were selected. Retrieved articles were appraised by all authors regarding participant entry criteria, study design, intervention, questionnaire, objective cure, and HRQoL presentation. There were three articles reporting HRQoL after PFMT and 11 after midurethral sling surgery. Improvement in HRQoL seemed higher after midurethral sling surgery compared with PFMT. However, methods of HRQoL assessment varied widely, limiting the possibility of comparison and interpretation between studies.

Obturator Foramen Dissection for Excision of Symptomatic Transobturator Mesh

Groin pain after transobturator synthetic mesh placement can be recalcitrant to conservative therapy and ultimately requires surgical excision. We describe our experiences with and technique of obturator foramen dissection for mesh excision. The records of 8 patients treated from 2005 to 2010, were reviewed. Obturator dissection was performed via a lateral groin incision over the inferior pubic ramus at the level of the obturator foramen, typically in conjunction with orthopedic surgery. Five patients had transobturator mid urethral sling surgery for stress urinary incontinence, 2 had mid urethral sling and trocar based anterior vaginal wall mesh kits with transobturator passage of mesh arms for stress urinary incontinence and pelvic organ prolapse, and 1 had an anterior vaginal wall mesh kit for pelvic organ prolapse. Patients had 0 to 2 prior transvaginal mesh excisions before obturator surgery. All patients presented with intractable pain in the area of the obturator foramen and/or medial groin for which conservative treatment measures had failed. Six patients underwent concurrent vaginal and obturator dissection and 2 underwent obturator dissection alone. In all cases residual mesh (3 to 11 cm) was identified and excised from the obturator foramen. Mesh was closely associated to or traversing the adductor longus muscle and tendon with significant fibrous reaction in all cases. Postoperatively 5 patients were cured of pain and/or infection, and 3 reported no or some improvement at a mean followup of 6 months (range 1 to 12). Our experience suggests that surgical excision of residual mesh can alleviate many of the symptoms in many patients. In all cases mesh remnants were identified and removed, and typically involved neuromuscular structures adjacent to the obturator foramen.

Patient-reported Goal and Goal Achievement: The Most Individualized Method of Outcome Assessment in Patients with Lower Urinary Tract Symptoms.

Patients with lower urinary tract diseases often have a constellation of symptoms, and the degree of distress due to individual symptoms varies. In particular, some symptoms are more bothersome to patients and lead to treatment. However, traditional outcomes, such as urodynamic data, voiding diaries, and standardized patient-reported outcomes, may fail to address the individual factors. In contrast, patient-centered outcomes rely on patients to assess treatment outcomes in terms of their concerns or goals. Goal achievement is a patient-centered outcome that was pioneered in prolapse surgery. Recently, this most individualized outcome measure has been evaluated in the context of lower urinary tract symptoms (LUTS). According to the studies, most patients with LUTS have symptom-related goals. After treatment, goal achievement in patients with overactive bladder or benign prostatic obstruction was low even when there were significant improvements in symptom severity in terms of traditional outcome measures. On the other hand, most women with stress incontinence achieved their treatment goals after midurethral sling surgeries. There are ongoing efforts to develop valid and reliable methods for assessing goal achievement that can facilitate the complex rating process and have responsiveness. Goal achievement shows a limited correlation with standardized patient-reported outcomes and no significant correlation with objective outcomes. Thus, at the moment, it can be used as a complimentary outcome measure along with other traditional methods. Further research is needed to reveal the correlation between goal achievement and overall patient satisfaction and, ultimately, to determine if assessing goal achievement can enhance patient satisfaction.

Association of Baseline urodynamic measures of urethral function with clinical, demographic, and other urodynamic variables in women prior to undergoing midurethral sling surgery

To explore how baseline demographic, clinical, and urodynamic (UDS) variables correlate with measures of urethral function in women planning midurethral sling surgery. Women with predominant stress urinary incontinence (SUI) as part of the trial of mid-urethral slings (TOMUS) were characterized preoperatively including: demographics, body mass index (BMI), responses to the Medical and Epidemiologic Social Aspects of Aging (MESA) and Urogenital Distress Inventory (UDI) questionnaires, pad weight (PW), incontinence duration, prior SUI surgery, prolapse, strength of pelvic contraction, Q-tip test, uroflow, cystometrogram, and detrusor pressures at maximum flow (Pdet at Qmax). Multivariate regression analysis and modeling confirmed variables with significant correlations with maximal urethral closure pressure (MUCP), functional urethral length (FUL), and Valsalva leak point pressure (VLPP). Five-hundred thirty-nine women were included in the analysis. In multivariable analyses, PW (P = 0.045) and age (P < 0.0001) were negatively correlated with MUCP (as PW and age increased, MUCP decreased); BMI (P = 0.02) and Pdet at Qmax (P < 0.0001) were positively correlated with MUCP (as BMI and Pdet at Qmax increased, MUCP increased). Age (P = 0.002) was negatively correlated with FUL; Qtip delta (P = 0.006), pelvic organ prolapse quantification examination (POPQ) stage (P = 0.002) and strength of pelvic contraction (P = 0.03) were positively correlated with FUL. Duration of incontinence (P = 0.01) was negatively correlated with VLPP; Qtip delta (P = 0.02), BMI (P = 0.0005) and Pdet at Qmax (P = 0.0005) were positively correlated with VLPP. Age, BMI, Qtip delta, and Pdet at Qmax were variables that correlated with two or more measures of urethral function. These correlations may help direct future research in female urethral function.

Resolution of urge urinary incontinence with midurethral sling surgery in patients with mixed incontinence and low-pressure urethra

The aim of the study was to determine the rate of persistence of urgency or urge urinary incontinence following midurethral sling surgery compared to standard medication treatment in patients with mixed incontinence and ISD urethra. A prospective study was conducted at a tertiary referral Urogynecology Center. One hundred five women with stress urinary incontinence (SUI) and urgency were identified. Fifty-four consecutive women with SUI and urgency who underwent midurethral sling were compared to 51 women with SUI and urgency but treated with medications first. Women with persistent urgency or urge urinary incontinence (UUI) at 6-month follow-up following a TVT sling procedure were compared with those whose symptoms had resolved, to determine the risk factors for persistent symptoms. Forty out of 54 patients in the operation group also underwent a prolapse repair, either a colpopexy or a colpocleisis. All patients had demonstrated a mean urethral closure pressure of 20 mmHg or lower, indicating an intrinsic sphincteric deficiency. Persistent urgency (6 of 54, 11%) and UUI (3 of 54, 5.5%) were found in patients with mixed incontinence who underwent a sling operation. All 51 patients (100%) persisted with some urgency and urge incontinence despite anticholinergic medication treatment, only (7 of 51, 13.7%) reporting improvement of symptoms. Concomitant prolapse surgery, especially apical correction (OR 0.55, 95% CI 0.37–0.65), decreased the risk of urgency persistence, while age (OR 1.04, 95% CI 1.02–1.05), detrusor overactivity (OR 1.66, 95% CI 1.28–2.53), baseline symptom severity (OR 1.77, 95% CI 1.48–2.36), and previous incontinence surgery (OR 2.08, 95% CI 1.38–3.60) increased the risk of persistent urgency in the operated cohort. Women were happier in the operated cohort (45 of 54, 83.3% cure rate). A sling itself decreased the risk of persistent urge or UUI (OR 0.33, 95% CI 0.15–0.70). The most significant improvement was UUI at night. Urodynamic parameters, baseline urgency symptom severity, age, and concomitant prolapse operation are important predictors of persistent urgency or UUI following midurethral sling for mixed incontinence patients.

The argument for surgical therapy for stress urinary incontinence in females.

Stress urinary incontinence (SUI) affects 4% to 35% of women.1 Many patients find it difficult to bring up the topic of incontinence, so it is imperative that when the complaint is brought forward, we deal with it swiftly and in the most effective manner possible. In 2007, Harris and colleagues published that only 45% of women and 22% of men with incontinence disclosed it to a health care provider; of those, only 60% received treatment. Furthermore, half of those 60% felt that they continued to have daily leakage and remained frustrated.2 Surgery for SUI is fast and effective. Once the SUI diagnosis has been made and other significant dysfunction has been ruled out, the patient and provider must agree on an initial therapeutic approach. Surgery should not be offered immediately to: (1) women of childbearing age who have not completed their family planning; (2) women with significant comorbidities and high surgical risk; and (3) women with overactive bladder (OAB) and mixed urinary incontinence, where the OAB has not been first addressed. Notwithstanding these contraindications, surgery for SUI is often straightforward and the best option. All incontinence surgeons love the words, “Can’t I just have surgery?” Before we pour on the accolades for mid-urethral sling (MUS) surgery and declare it a winner (can you beat success rates of 77% cure rate at 11 years from Finland3 or the 85% cure rate at 7 years from Greece4), we are obliged to look at the alternatives. We all attempt to modify our patient’s behaviours, such as reduce their coffee intake, increase weight loss and suggest pelvic floor physiotherapy. Yet each surgeon wonders: “When will this fail and when can I book her surgery?” Behaviour modification is not successful because patients need to understand, learn about their condition, perform regular and intentional physical exercises and consciously make challenging lifestyle adjustments. Most people are incapable of taking on this responsibility or are unwilling to pay for uninsured services.

Is there still a role for pubovaginal slings in the treatment of SUI in the era of mid-urethral slings?

The treatment of female stress urinary incontinence (SUI) has evolved over the last decade.1 Traditional surgeries for SUI, such as the Burch colposuspension and pubovaginal slings, have slowly been supplanted by mid-urethral slings (MUS). In some centres, retropubic surgeries have become almost obsolete. This has not had a negative impact on the surgical treatment of female SUI. In fact, various databases have demonstrated almost a threefold increase in the overall number of incontinence procedures performed.2,3 The rationale for this shift in surgical procedure and for the increase in surgical volume appears to be related to decreased complication rates, shorter operative time and the simplicity of MUS surgery without compromising objective and subjective cure rates.4,5 Are surgical procedures, such as autologous rectus fascia pubovaginal sling (AF-PVS), history or do they still have a role in female SUI. Welk and Herschorn support that AF-PVS can be a vital tool in the treatment of complex SUI.1 They describe an extremely complex patient population with recurrent SUI that underwent AF-PVS at their centre. Over half of the patient population had mesh erosions, urethral diverticuli or trauma. The remaining patients underwent on average 2 prior surgical procedures to treat their SUI before undergoing an AF-PVS. Their surgical outcomes and patient satisfaction were quite commendable considering the complexity of the patient population. Average pad use decreased from 5 pads per day (PPD) preoperatively to 1 PPD postoperatively. Moreover, the patients’ rating of their overall quality of life was reasonable (62% scored from 4 [mixed] to 7 [delighted]). There is, however, an underlying concern from an education perspective that permeates throughout the paper concerning the shift to MUS.1 Although AF-PVS, Burch colposuspension and other retropubic surgeries may be indicated in various surgical settings for female SUI, graduating urology residents may not have the surgical acumen and experience to perform them. Wu and colleagues found that the number of retropubic suspension surgeries in the United States fell from 52.8% of SUI procedures in 1998 to 13.8% in 2007.2 As the number of pubovaginal slings performed in academic centres continues to fall, graduating urology residents may not be adequately exposed to these procedures to perform them competently and safely. As a result, these operations have the potential to become largely historical procedures or isolated in tertiary referral centres. Alarms have already been sounded concerning graduating Canadian urology residents’ surgical exposure to open radical nephrectomy and open radical retropubic prostatectomy.6 Perhaps these “complex surgical incontinence surgeries,” need to be added to that list.

Anatomic and Functional Outcomes with the Prolift Procedure in Elderly Women with Advanced Pelvic Organ Prolapse Who Desire Uterine Preservation

Study ObjectiveTo assess the clinical outcomes of total mesh repair with the Prolift technique as treatment of advanced pelvic organ prolapse in elderly patients who desire uterine preservation. DesignCase control series study (Canadian Task Force classification II-2). SettingMedical school–affiliated hospital. PatientsSixty-eight patients over the age of 70 years with advanced pelvic organ prolapse, Pelvic Organ Prolapse Quantification stage III (n = 59) or IV (n = 9), underwent a total Prolift procedure and were followed up for a minimum of 2 years. InterventionsTransvaginal pelvic floor repairs were performed with a total Prolift system. The concurrent pelvic surgery included midurethral sling operation with a TVT-O, if indicated. The assessment included intraoperative and postoperative complications, Urogenital Distress Inventory scores, and Incontinence Impact Questionnaire scores. Measurements and Main ResultsObjective and subjective data were available for 68 patients. The anatomic success rate was 97.1% after 2 years. Complications included bladder perforation in 1 patient (1.5%), de novo stress urinary incontinence in 20 patients (29.4%), dyspareunia in 4 patients (22.2%), and vaginal erosion in 1 patient (1.5%). The Pelvic Organ Prolapse Quantification stages, Urogenital Distress Inventory scores, and Incontinence Impact Questionnaire scores all improved significantly after surgery. ConclusionsThe total Prolift procedure is an alternative surgical option that uses a minimally invasive transvaginal approach to surgically treat elderly patients with advanced pelvic organ prolapse.

Predictors of Voiding Dysfunction after Mid-urethral Sling Surgery for Stress Urinary Incontinence

PurposePostoperative voiding dysfunction is a bothersome complication after mid-urethral sling surgery. The current study presents multiple repeated postoperative voiding trials against a urine load of preoperative functional bladder capacity, as estimated by a preoperative frequency volume chart, to identify the relevance of preoperative and immediate factors to the outcome.MethodsA total of 180 patients were enrolled from August 2008 to August 2011. Patients received mid-urethral sling surgery with a transobturator tape, with or without concomitant cystocele repair. Patients reported relevant medical histories and a 3-day frequency volume chart and underwent urodynamic studies. After surgery, patients were filled to their maximum bladder capacity as dictated by their frequency volume chart and performed the first voiding trial. Two subsequent voiding trials were performed after natural filling. Failure of any single voiding trial was considered failure. Patients who failed the final voiding trial received intermittent catheterization to follow-up. After screening for relevant factors with the use of univariate analyses, preoperative, surgical, and postoperative factors predicting outcome were estimated by logistic regression analysis.ResultsThe urine load at the voiding trial and the peak flow rate immediately preceding the voiding trial predicted voiding trial success in the multivariate analysis. Urine load and previous trial peak flow rate were relevant when tested against each individual voiding trial. Preoperative and surgical factors, such as age, parity, and concomitant cystocele repair, showed significance in the univariate analysis. Overall, 16.1% of patients who passed the first voiding trial failed on subsequent trials, whereas 36.8% of patients who failed the first voiding trial succeeded.ConclusionsPostoperative voiding dysfunction is transient and is associated with the immediate voiding conditions following surgery. Close observation against urine overload in the bladder is important when weaning patients back to normal voiding conditions.

Randomized Controlled Study of MONARC® vs. Tension-free Vaginal Tape Obturator (TVT-O®) in the Treatment of Female Urinary Incontinence: Comparison of 3-Year Cure Rates

PurposeTransobturator approaches to midurethral sling surgery are one of the most commonly performed operations for female stress urinary incontinence throughout the world. However, very few results of randomized clinical trials of transobturator midurethral sling surgery (MONARC vs. TVT-O) for the treatment of female urinary incontinence have been reported. In this study, we compared the 3-year follow-up cure rates of these two procedures.Materials and MethodsFrom July 2006 to June 2008, 74 patients who had undergone MONARC (35 patients) or TVT-O (39 patients) were included in the study and were analyzed prospectively. The mean follow-up duration of both groups was 39.2 months. Preoperative and postoperative evaluations included physical examination, uroflowmetry and postvoid residual measurement, involuntary urine loss with physical activity, and urinary symptoms. Cure of female urinary incontinence was defined as patient report of no loss of urine upon physical activity. The patients' satisfaction after treatment was rated as very satisfied, satisfied, equivocal, and unsatisfied. Very satisfied and satisfied were considered as the satisfied rate.ResultsThere were no significant differences in preoperative patient characteristics, postoperative complications, or success rate between the two groups. The cure rate of the MONARC and TVT-O groups was 85.7% and 84.6%, respectively. The patient satisfaction (very satisfied, satisfied) rate of the MONARC and TVT-O groups was 82.8% and 82.1%, respectively.ConclusionsThe MONARC and TVT-O procedures were equally efficient for the treatment of female urinary incontinence, with maintenance of high cure rates for 3 years. Longer follow-up is needed to confirm these results.

Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study

Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study

Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study

Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study

Intraoperative maximal urethral closing pressure measurement: a new technique of tape tension adjustment in transobturator sling surgery?

Tape tension adjustment is an essential procedure in mid-urethral sling surgery. The goal of this study was to determine if intraoperative maximal urethral closing pressure (MUCP) elevation could be used as a reference value for adequate tape tension adjustment and predict transobturator (TOT) sling surgery outcome. A prospective study was performed using MUCP measurements just before tape insertion and just after tension adjustment during surgery. Clinical data including preoperative urodynamic results were collected. The cure rate was determined by questionnaire. Patients were divided into two groups. The MUCP elevation group included patients with a MUCP elevation of more than 10 cmH(2)O before tape insertion; the others were regarded as the non-elevation group. The cure rate and pre- and postoperative clinical variables were compared between the two groups. A total of 48 patients had TOT surgery. The MUCP elevation group (n = 19) and the non-elevation group (n = 29) were similar with regard to patient characteristics and the preoperative parameters including age, mixed incontinence prevalence, Q-tip angle, peak flow rate, MUCP and the valsalva leak point pressure (VLPP). The mean follow-up period was nine months. The cure rate was significantly higher in the group with MUCP elevation than in the non-elevation group (84% vs. 52%, p = 0.02). There was no significant difference in the mean postoperative peak flow rate between the two groups and there was no retention episode. MUCP elevation of more than 10 cmH(2)O just after tape insertion was a prognostic factor.

Slings in surgery of genuine stress incontinence

To summarize the available evidence concerning efficacy and safety of standard mid-urethral sling (SMUS) operations for the treatment of stress urinary incontinence (SUI). A non-systematic literature review was carried out in order to collect the available evidence concerning efficacy and safety of SMUS operations for the treatment of SUI. According to the data of our prior meta-analysis, patients receiving SMUS had significantly higher overall and objective cure rates than those receiving Burch colposuspension, although they had a higher risk of bladder perforations. Patients undergoing SMUS and pubovaginal slings had similar cure rates, although the latter were slightly more likely to experience storage lower urinary tract symptoms and had a higher reoperation rate. Patients treated with retropubic SMUS had slightly higher objective cure rates than those treated with transobturator tape (TOT); however, subjective cure rates were similar, and patients treated with TOT had a much lower risk of some complications. Meta-analysis demonstrated similar outcomes for TOTs. With regard to the novel mini-sling, another meta-analysis from Abdel-fattah et al. demonstrated that repeat continence surgery and de novo urgency incontinence were significantly higher in the patients treated with mini-slings. Patients treated with retropubic tape (RT) experienced slightly higher continence rates than those treated with Burch colposuspension, but they faced a much higher risk of intraoperative complications. RT and pubovaginal slings were similarly effective. The use of RT was followed by objective cure rates slightly higher than TOT and by higher risk of complications. The novel mini-slings do not seem to be more effective than the SMUS.

Midurethral Sling Surgery in Patients with Mixed Incontinence and ISD Urethra

Midurethral Sling Surgery in Patients with Mixed Incontinence and ISD Urethra

Partner dyspareunia—a report of six cases

One of the rarely cited complications of the use of alloplastic materials in pelvic floor surgery is dyspareunia of the partner caused by prominence or vaginal exposure of the sling material. Even though this entity is real and an important problem, it is rarely reported in literature. We report six cases of partner dyspareunia, in which there were two incidences of partner penile injury, occurring as a complication of synthetic midurethral sling surgery. There were three tension-free vaginal tapes, two transobturator tapes and one anterior intravaginal sling in the series. Time interval between tape insertion and the presentation of complications ranged from 3 to 48 months. Vaginal exposure was seen in five of the six cases and in one patient prominence of sling material without exposure was noted. Recognizing partner dyspareunia as an important complication of the vaginal use of alloplastic prosthesis is not only important in preoperative counseling of patients but also to avoid legal implications.

Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study

To describe surgical complications in 597 women over a 24-month period after randomization to retropubic or transobturator midurethral slings. During the Trial of Midurethral Slings study, the Data Safety Monitoring Board regularly reviewed summary reports of all adverse events using the Dindo Surgical Complication Scale. Logistic regression models were created to explore associations between clinicodemographic factors and surgical complications. A total of 383 adverse events were observed among 253 of the 597 women (42%). Seventy-five adverse events (20%) were classified as serious (serious adverse events); occurring in 70 women. Intraoperative bladder perforation (15 events) occurred exclusively in the retropubic group. Neurologic adverse events were more common in the transobturator group than in retropubic (32 events vs 20 events, respectively). Twenty-three (4%) women experienced mesh complications, including delayed presentations, in both groups. Adverse events vary by procedure, but are common after midurethral sling. Most events resolve without significant sequelae.

Dynamic MRI confirms support of the mid-urethra by TVT and TVT-O surgery for stress incontinence

To study changes in mid-urethral function with dynamic MRI in stress urinary incontinent women undergoing either tension-free vaginal tape (TVT) or TVT-obturator sling operations. Prospective clinical study. University hospital. Forty-two parous women with stress urinary incontinence recruited to dynamic magnetic resonance imaging before and after mid-urethral sling surgery. Control group of 16 healthy women. Dynamic magnetic resonance imaging at rest, during pelvic floor muscle contraction, coughing and voiding with a bladder volume of 200-300 ml. X- and Y- coordinates were used to determine the location of the mid-urethra during these activities. Changes in mid-urethral position after TVT and TVT-obturator operations during the different activities. Postoperatively the women could elevate their mid-urethra by pelvic floor muscle contraction significantly higher than before the operation (p<0.05). Despite a different support angle between the TVT and the TVT-O mid-urethral slings, we could not see any differences in the movement patterns. Mid-urethral slings support the mid-urethra and restrict downward movement during different activities. Movement patterns are similar after TVT and TVT-O operations.

Demographic and Clinical Predictors of Treatment Failure One Year After Midurethral Sling Surgery

To identify clinical and demographic factors predictive of midurethral sling failure. Overall treatment failure was defined by one or more of the following objective outcomes: a positive stress test, positive 24-hour pad test or retreatment for stress urinary incontinence (SUI); subjective outcomes: self reported SUI by the Medical, Epidemiologic and Social Aspect of Aging questionnaire, incontinent episodes by 3-day diary, or retreatment for SUI, or a combination of these. Logistic regression models adjusting for sling type and clinical site were used to predict odds of overall treatment failure after univariable analysis. Models were also fit to compare factors associated with objective failure and subjective failure only. Previous UI surgery (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.14-3.47); maximum Q-tip excursion<30° (OR 1.89, 95% CI 1.16-3.05); Medical, Epidemiologic and Social Aspect of Aging questionnaire urge score per 10 points (OR 1.97, 95% CI 1.21-3.21); and pad weight per 10 g (OR 1.06, 95% CI 1.02-1.10) were predictors of overall failure. Having concomitant surgery (OR 0.44, 95% CI 0.22-0.90) was predictive of subjective failure only rather than objective failure. Age per 10 years (OR 1.48, 95% CI 1.14-1.90); Urogenital Distress Inventory score per 10 points (OR 1.09, 95% CI 1.02-1.17); pad weight per 10 g (OR 1.05, 95% CI 1.01-1.10) were predictive of objective failure compared with subjective failure only. Associations of risk factors and failure were similar independent of sling type (retropubic or transobturator). Twelve months after surgery, risk factors for overall and objective treatment failure were similar in women undergoing retropubic and transobturator sling procedures. This information may assist in counseling patients regarding efficacy of sling procedures and in setting expectations for women at increased odds for treatment failure. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00325039. II.

Force of Stream After Sling Therapy: Safety and Efficacy of Rapid Discharge Care Pathway Based on Subjective Patient Report

We evaluated the safety of a mid urethral sling postoperative care pathway using patient subjective reporting of force of stream to minimize length of stay and catheter placement. Women undergoing solitary mid urethral sling surgery were prospectively enrolled in our study. Force of stream after the sling therapy protocol consisted of retrograde bladder filling with 300 ml fluid within 1 hour after surgery. Patients rated force of stream compared to baseline on a visual analog scale. Those with a force of stream of 50% or greater were immediately discharged home regardless of post-void residual urine volume. Only those unable to void and those rating force of stream less than 50% with post-void residual urine volume greater than 500 ml were discharged home with a catheter. Patients were telephoned within 1 week of surgery and seen 4 to 6 weeks postoperatively. The primary outcome was unexpected visits to the emergency room or office for voiding dysfunction or urinary retention. A total of 114 women were prospectively enrolled in our study, of whom 105 (92.1%) passed the protocol and were discharged home without a catheter. Of the patients 14 were discharged home with increased post-void residual urine volume (range 152 to 427 ml) but no catheter, representing those who would have been discharged with a catheter by many traditional voiding protocols. According to protocol 9 patients were discharged with a catheter. No patient presented to the emergency room or office in urinary retention or with voiding dysfunction before the scheduled visit. Patients who report a force of stream of 50% or greater can be safely and rapidly discharged home after an uncomplicated mid urethral sling procedure regardless of post-void residual urine volume. Scanned post-void residual urine volume does not add much value in those who can void. By following the force of stream after sling therapy protocol patients can be discharged home less than 3 hours after mid urethral sling surgery.