Midurethral Sling Surgery Research Articles

The relationship between urethral mobility and clinical outcomes after midurethral sling surgery

Objective:To explore the relationship between urethral mobility and clinical outcomes after midurethral sling (MUS) surgery. Methods:This was a retrospective analysis of the patients who had MUS surgery and clinic follow-up with ultrasound exams between 2017 and 2022. The sling location, sling-pubic gap (SPG), bladder neck mobility, and segmental urethral mobility were measured and compared between women with cured SUI, recurrent SUI, de novo VD, and continent women without MUS. The correlations between ultrasound findings and clinical outcomes were tested. Results:Of 198 women with MUS, 176 had a telephone follow-up, and 151 (151/176, 85.8%) were subjectively satisfied. Affected by the epidemic, only 107 patients had clinic follow-up, 92 valid data of 32 cured SUI (Group 1), 37 recurrent SUI (Group 2), and 23 de novo VD (Group 3) were compared with 102 women without MUS. Groups 1 and 2 had significant lower midurethral mobility. In Group 3, the mid and lower urethra was tightly near the symphysis on Valsalva, and the mobility was excessively decreased. SPG was significantly wider in Group 2 than in Group 1 (13.8 ± 3.6 mm vs 11.2 ± 2.7 mm, p = 0.001). SPG was strongly related to midurethral mobility (r=0.32, p=0.002) and clinical outcomes (r=0.45, p<0.001). Multivariable regression showed SPG positively correlated to recurrent SUI [OR: 1.439 (95% CI:1.191–1.738) p<0.001]. Conclusion:Midurethral sling reduced midurethral mobility. A wider SPG indicated a higher midurethral mobility and a higher risk of recurrent SUI.

Trans-Obturator Tension Appliance Tape for failed Mid-Urethral Sling when and how?

Background &amp; Objectives: Female urinary incontinence is a significant health issue affecting adult women, most suffering from stress incontinence. It affects the quality of life. Recurrence after surgery is difficult for the patients and the surgeon. There is no precise data to show how to treat failed Transobturator tape. Transobturator tape with tension may be an alternative method in applying proper tension in the mid urethra to correct the incontinence. We describe our experience to evaluated outcomes of the second mid-urethral sling with tension to treat recurrent incontinence after the failure of the first mid-urethral sling. Methods: A prospective cohort study was conducted between Oct. 2012 to March 2019. A total of 16 patients with failed Transobturator tape surgery underwent second trans-obturator Mid-Urethral Sling surgery. Preoperative data and postoperative complications were recorded. All patients were followed for one year. Results: Sixteen women after failed Mid-Urethral Sling surgery were evaluated. At a mean follow-up of 7.5 months, the cure rate was 62.5% (10 out of 16) patients. Partial cure (improvement) was achieved in 25% ( 4 patients out of 16) and failure in 2 patients, 12.5%. There were statistically significant improvements after surgery in the Q-tip test and the number of the pads. Conclusion: Repeat Transobturator tape with tension treatment tends to result in good outcomes with a reasonable physician-determined success rate.

Impact of Weight Gain on Surgical Outcomes and Quality of Life among Women after Sling Surgeries

To investigate the impact of body weight gain after sling surgeries on outcomes in women with stress urinary incontinence. A single-center, retrospective study. Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taiwan. A total of 248 women who underwent sling surgeries from 2010 to 2015 were reviewed. Patients who gained more than 10% body weight were compared with those with stable body weight. Midurethral sling surgery with single-incision, transobturator, or retropubic slings. Objective success was defined as no urine leakage during the stress test in the filling phase of urodynamic studies. De novo overactive bladder (OAB) was defined as the appearance of urgency, frequency, and/or nocturia, with or without urinary incontinence after midurethral sling surgery persisting after 6 months. Quality of life evaluations included the short forms of the Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7. A total of 248 women who underwent sling surgeries and had complete weight measurement and evaluation data before and after the surgeries were included, of whom 47 gained body weight, and 201 had a stable body weight. The median follow-up duration was 18 months (range, 6-47 months). There were no significant differences in surgical outcomes between the 2 groups regarding objective cure rate (86% vs 87%, p=.834), 1-hour pad test (4.5 ± 17.8 vs 3.6 ± 18.6 g, p=.770), or postoperative quality of life (Urogenital Distress Inventory-6: 1.9 ± 2.8 vs 2.8 ± 3.2, p=.122; Incontinence Impact Questionnaire-7: 1.8 ± 3.9 vs 2.6 ± 4.3, p=.307). A trend toward increased de novo OAB rate was observed, although this finding was not adequately powered. Weight gain after sling surgeries did not influence surgical outcomes, but there was a nonsignificant trend toward increased OAB in the weight gain group. It may be beneficial to counsel patients with regard to body weight maintenance after sling surgeries.

Can obesity impact mesh exposure rate after mid-urethral sling operation? Medium term follow-up

ObjectiveTo study mesh exposure rates among obese (BMI ≥ 30 kg/m2) vs non-obese women after mid-urethral sling (MUS) operation. Study designThis retrospective cohort study included all patients who underwent MUS surgery for stress urinary incontinence April 2014–April 2021 in a tertiary-level university hospital. Data from obese and non-obese patients were compared. ResultsA total of 120 (41 %) obese patients and 172 (59 %) non-obese patients who had mid-urethral sling surgery were compared. Of the cohort, 265 (90.7 %) underwent TVT-obturator, 15 (5.1 %) mini-sling TVT, and 12 (4.1 %) retro-pubic TVT. Diabetes mellitus was significantly more prevalent in the obese group (p =.01), without other demographic differences. Mesh post-operative exposure rate was 5.4 % during the study. The obese group had lower incidence of mesh exposure than the non-obese group (1.6 % vs 8.1 % respectively, p =.018). Mean follow-up was 51 months (range 8–87 months) without significant differences between groups (49.9 ± 21.2 vs 51.5 ± 22.3, p =.548). Pelvic organ prolapse, cystocele, and rectocele stages were significantly higher in non-obese patients. Similar numbers of post-menopausal women were in each group. ConclusionThis follow-up after MUS surgery showed an association between obesity and lower rate of mesh exposure. Further research is needed to evaluate correlations between estrogen and mesh exposure.

Conceptualizing stress urinary incontinence surgery beyond midurethral slings: Very early results from simplified ligament repair without tapes.

To find a simpler cure for stress urinary incontinence (SUI) without tapes. Proposed is a paraurethral operation with incisions in both sulci to plicate pubourethral ligaments (PUL) with thick polyester sutures. VIDEO and ultrasound experiments showed the main cause of SUI was weak PULs extending on effort, allowing the posterior pelvic muscles to open out posterior urethral wall, so urine was lost on effort. Midurethral sling (MUS) tapes prevent PUL extension and SUI. The research question: "Would PUL plication by 0.5or 0.25 mm polyester tapes create sufficient new collagen to cure SUI in the longer term?" Instron-testing of collagen from a rejected polyester aortic graft indicated sufficient potential collagen strength. Five surgeons unrelated to the authors who tested the new operation, reported negative cough tests on 30/31 women before patient discharge; these data were encouraging, but not conclusive. PUL ligament repair by large polyester sutures, like the MUS, appears to prevent PUL elongation and cure SUI in the very short term, thereby validating the predictions of the Integral Theory as regards the role of ligaments in continence. If successful long term, this operation could avoid many problems associated with MUS operations. 1. Simplicity: less surgical skill is required; the local anesthetic methodology makes the operation widely scalable especially in poor countries with few health facilities. 2. Built-in safety: there is no tape to compress urethra, no applicators to damage bladder, nerves, blood vessels, bowel. 3. Cost: a polyester suture.

A modified mid-urethral sling technique for stress urinary incontinence: Three-year results of a prospective randomized trial in comparison with original transobturator tape procedure.

Stress urinary incontinence (SUI) is the most common subtype of urinary incontinence, which causes many social, psychological, and economic problems. Mid-urethral sling (MUS) surgery is popular worldwide for the treatment of SUI. We aimed to define a new modified mid-urethral sling technique (mMUS) in SUI treatment and to compare it with transobturator tape (TOT) surgery in terms of safety and efficiency. A prospective, randomized study was planned with 126 women suffering from SUI. The patients were randomly divided into two groups, TOT and mMUS. In mMUS, the obturator membrane was not perforated. The objective and subjective symptoms, pain, quality-of-life measures, and side effect profiles were assessed in a 3-year follow-up. The visual analogue scale (VAS) was used for postoperative pain assessment. The International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and Patient Global Impression of Improvement (PGI-I) were used for cure assessment scales. In total, 96 patients completed 3-year follow-up (TOT, n = 49 and mMUS, n = 47). There was no statistical difference between the procedures in terms of cure rates (87.75% and 87.23%, respectively; p = 0.614). Mean VAS scores at 8 and 24 h postoperatively were significantly higher in the TOT group (p < 0.05). There was no significant difference between the groups in VAS scores after 24 h. There was no significant difference between groups in terms of pad test results, ICIQ, or PGI scores at baseline and 36 months after surgery. We showed that the mMUS procedure was as safe and effective as TOT, with less postoperative groin pain and complications.

The influence of age and health status for outcomes after mid-urethral sling surgery—a nationwide register study

Introduction and hypothesisThe efficacy of mid-urethral sling (MUS) surgery in older women and women with a significant disease burden is limited. We aimed to determine the influence of chronological age and physical status (assessed by the American Society of Anesthesiologists Physical Status, ASA) classification on outcomes.MethodsCure rate, change in frequency of lower urinary tract symptoms, satisfaction, impact, and adverse events after MUS surgery were assessed in 5200 women aged 55–94 years with MUS surgery (2010–2017). Data were analysed by multivariate logistic regression and Mantel-Haenszel chi-square statistics.ResultsThe cure rate was 64.2% (95% CI, 60.0–68.4) in the ≥ 75-year cohort compared to 88.5% (95% CI, 87.1–89.8) in the 55–64-year cohort (trend p < 0.0001). The estimated probability of cure, improvement, and satisfaction with the procedure decreased by aOR10yr = 0.51 for cure to aOR10yr = 0.59 for satisfaction (all p < 0.0001). Women with a significant health burden (ASA class 3–4) had lower cure rates and satisfaction than those without (65.5% vs. 83.7%, p < 0.0001 and 65.7% vs. 80.6%, p < 0.0001). Older age was more likely to be associated with de novo urgency (p = 0.0022) and nocturia ≥ 2 (p < 0.0001). Adverse events, readmission, and 30-day mortality rates were low. Women, irrespective of age, were equally satisfied if they experienced a decrease of at least one step in leakage frequency.ConclusionsEven if MUS surgery in older women and those with ASA class 3–4 was associated with a lower cure rate and less satisfactory outcome, a majority were satisfied provided they experienced a reduction of incontinence episodes.

SC104 - Persistent overactive bladder after midurethral sling surgery: Prevalence and risk factors

SC104 - Persistent overactive bladder after midurethral sling surgery: Prevalence and risk factors

SC103 - De novo overactive bladder after midurethral sling surgery: Prevalence, timing and risk factors

SC103 - De novo overactive bladder after midurethral sling surgery: Prevalence, timing and risk factors

Bladder filling test, cystoscopy, or both for checking bladder perforation in tension-free-vaginal tape operations

Background/Aim: Tension-free-vaginal tape (TVT) has been widely used for treatment of stress urinary incontinence as a mid-urethral sling operation. Cystoscopy is routinely performed during tension-free-vaginal tape operations to check for bladder perforation or injury. This study aims to check the applicability and accuracy of the bladder filling test for predicting bladder perforation in tension-free-vaginal tape operations. Methods: Between 2015 and 2020, 285 women who had TVT operations were subject to evaluation. Out of 285 cases, 23 cases were suspected subjectively by the operating surgeons to have visible or occult bladder perforation during the TVT procedure. A routine cystoscopy was performed at the end of all operations. Additionally, before the routine cystoscopy, in cases suspected of a visible or occult bladder perforation, the bladder was filled with 500 ml saline or diluted methylene blue dye through a urinary catheter (bladder filling test) to check for occult bladder perforation that might not be visualized by cystoscopy. Any fluid leakage through the paraurethral dissected canals or from the abdominal incisions was observed for the possibility of bladder perforation. The accuracy of the bladder filling test was compared to cystoscopy to diagnose bladder perforation in suspected cases. In addition, all cases were followed up for three months to record any cases with late or occult bladder perforations missed in the diagnosis using cystoscopy or the bladder filling test perioperatively. Results: Out of 23 cases suspected subjectively by the operating surgeons to have visible or occult bladder perforation, 11 had visible bladder perforations (3.9%) confirmed by both cystoscopy and the bladder filling test. After the filling test, leakage at the abdominal incision site and/or para-urethral dissected canal was observed in all cases with bladder perforation. No leakage was observed in the remaining patients (n = 12) suspected of, but not diagnosed with bladder perforation by cystoscopy. The bladder filling test did confirm the same diagnosis revealed by cystoscopy in all suspected cases. Conclusion: The bladder filling test was found to be very sensitive in predicting bladder perforation at tension-free-vaginal tape operations compared to cystoscopy. This test can decrease the need for routine cystoscopy at tension-free-vaginal tape insertion, and cystoscopy can be limited to cases with leakage in the bladder filling test.

Transobturator-tape outside in (TVT-O) as saviour for female stress urinary incontince without available cystoscope for gynecologist: A case series

SUI affects quality of life. Ulmsten and Petros reported mid urethral sling operations using Tension-free Vaginal Tape (TVT) and Delorme used Transobturator Tape (TOT). Cystoscopy is often used in retropubic sling procedures to identify lower urinary tract injury. Cystoscopy protects patients and accurately identifies iatrogenic injuries. The goal is to evaluate the efficacy of a standard Trans-Obturator (TOT-O) mid urethral sling for female Stress Urinary Incontinence (SUI) without intraoperative cystoscopy. A total of 120 female SUI patients from 2014 to 2019 were studied. Stress-related incontinence and diaper use were preoperative variables. Under spinal anesthesia, the procedure improved stress incontinence, sexual dysfunction, complications, and overall satisfaction. All patients improved after the procedure, and 116 (96.6%) completely resolved. Post-operative complications included urinary retention in 3 patients (2.5%), increased daytime urinary frequency in 3 (2.5%), urge incontinence in 4 (3.33%), groin/thigh pain in 2 (1.66%), and local mesh excision for mesh erosion in 1 (0.83%). Open EPI software calculated insignificant p values for clinical profile and satisfaction with symptom resolution. Brief Index of SF for Women was used to assess sexual function. At 6-month followup, all patients were satisfied with sexual function. TOT-O technique for female stress urinary incontinence is easy to learn and reproducible for beginners.

Tension-Free Vaginal Tape and Polyacrylamide Hydrogel Injection for Primary Stress Urinary Incontinence: 3-Year Followup from a Randomized Clinical Trial.

We sought to determine whether polyacrylamide hydrogel (PAHG) is noninferior to tension-free vaginal tape (TVT) in the treatment of women with primary stress urinary incontinence (SUI). In this noninferiority trial, 223 women eligible for operative SUI treatment were randomized for TVT (110) or PAHG (113). Primary outcome was patient satisfaction and the noninferiority margin for the difference was 20%. Secondary outcomes were effectiveness and complications. At 3 years, 188 (84.3%) women attended the followup. The satisfaction score (visual analogue scale 0-100) median was 98.5 (IQR 90-100) in the TVT group and 90.0 (IQR 70-100) in the PAHG group, whereas a score ≥80 was reached in 87 (94.6%) and 65 (67.7%), respectively (difference 26.9%, 95% CI 16.7% to 36.8%). Thus, PAHG did not meet the noninferiority criteria set in our study. The cough stress test was negative in 88 (95.7%) of TVT patients vs 75 (78.1%) of PAHG patients (difference 17.5%, 95% CI 8.6% to 26.9%). Any peri- or postoperative complication before crossover between the groups was detected in 40 (43.5%) women in the TVT group and 23 (24.0%) women in the PAHG group (difference 19.5%, 95% CI 6.8% to 31.4%). In midterm followup, PAHG did not reach in patient satisfaction the noninferiority set in our study. Furthermore, mid urethral TVT slings show better subjective and objective cure rates than PAHG. However, complications were more often associated with TVT. Since the majority of PAHG treated women were also cured or improved, primary SUI women can be offered PAHG as a safe and durable alternative treatment.

Effect of hysterectomy on re-operation for stress urinary incontinence: 10 year follow-up

PurposeHysterectomy and mid-urethral sling (MUS) are common operations, but little is known about how hysterectomy after MUS affects the risk for stress urinary incontinence (SUI) relapse.MethodsWe included 49 women with a MUS before hysterectomy and 41 women with a MUS concomitant with hysterectomy. The controls, matched by age (± 2 years), MUS type (retropubic vs transobturator) and operation year (± 2 years), included 201 women who underwent the MUS operation without a subsequent hysterectomy. We used health care registers for follow-up of 12.4 years in median (IQR 10.9–14.7) after the MUS operation to compare the number of SUI re-operations and hospital re-visits for urinary incontinence.ResultsThe re-operation rates for SUI did not differ between the women with MUS before hysterectomy (n = 2, 4.1%), women with MUS concomitant with hysterectomy (n = 2, 4.9%) and their controls (n = 4, 4.9%, p = 0.8 and n = 6, 5.0%, p = 1.0, respectively). There were significantly fewer urinary incontinence re-visits among women who had a MUS concomitant with the hysterectomy compared to their matched controls (n = 2 and 31, 5 and 31%, p < 0.01) and to the women with a MUS prior to hysterectomy (n = 2 and 10, 5 and 20%, respectively, p = 0.03).ConclusionHysterectomy after or concomitant with MUS does not seem to increase the risk for SUI re-operation or hospital re-visits for urinary incontinence. These results can be used to counsel women considering hysterectomy after MUS operation or concomitant with MUS operation.

Femistina versus Canephron as a prevention of urinary tract infections after midurethral sling surgery – Non-inferiority study

ObjectiveUrinary tract infection (UTI) is relatively common post-operative complication following midurethral sling placement (MUS), even in cases where intraoperative antibiotic prophylaxis was given. The primary aim of this study was to investigate the non-inferiority of Femistina as compared with Canephron in reducing symptomatic UTI in first six months following surgery. Study designA sample size of 144 patients per group was established, to provide at least 90% power to demonstrate the non-inferiority of phytodrug Femistina versus Canephron as a prevention of post-MUS urinary tract infection. ResultsWomen suffering from stress urinary incontinence and mixed urinary incontinence (MUI) with predominant SUI symptoms as confirmed by urodymamics (n = 320) were randomized in a 1:1 ratio to Femistina (40 mg, oral, twice daily for 20 days) or Canephron (3 × 5 ml taken orally-three times daily for 4 weeks). Both groups were homogenous for age, type of operation (only TOT outside-in) and severity of illness as indicated by ICIQ-SF questionnaire. We found that symptoms of UTI were significantly lower in patients receiving Femistina. During first 6 months after surgery UTI was confirmed in only 10 patients receiving Femistina (6,25%) when compared to 25 (15,63%) subjects receiving Canephron, p < 0.007. ConclusionFemistina is not inferior to Canephron in preventing lower urinary tract infection after midurethral sling surgery.

Quality of Pre-operative Assessment for Mid Urethral Slings in Women Who Present With Mesh Complications

ObjectiveTo study quality of pre- and post-operative evaluation in women undergoing mid-urethral synthetic sling surgery who subsequently have complications. Materials and methodsStudy inclusion was chart availability for preoperative clinical history, examination, urodynamics and/or post-operative visit in women with mesh complications 2014-2021 in a tertiary practice. The primary outcome was compliance with quality indicators and guidelines for preoperative and post-operative clinical evaluation and urodynamics. Results122 women had preoperative, 102 urodynamic reports and 108 post-operative charts available for review. Only clinical history and examination showed moderate compliance (71% nature, 57% severity, 87% exam) with quality indicators, all other quality indicators were low. including documentation of counselling of mesh risks (11%) and risks of incontinence surgery (17%) . Compliance with guidelines (optimal care) was also low (bladder diary 61%, all others ≤41%). Post-operative evaluation did not comprehensively screen for complication e.g., flow rate/post-void residual performed in 9%. A significant proportion had an early adverse symptom (55%) or intervention e.g. trimming of exposure (40%) ConclusionCompliance with quality indicators and guidelines was generally low for pre-operative evaluation and urodynamic testing. There was inadequate content and length of post-operative evaluation despite a significant proportion presenting with adverse symptoms at first postoperative follow-up. Future research could target these areas for development of tools to improve compliance and education of health providers.

Short-medium term outcomes of Altis® single-incision sling for stress urinary incontinence in an Asian single-centre

Aims:This study describes our initial experience with the Altis® Single Incision Sling (SIS) for the treatment of female Stress Urinary Incontinence (SUI) and its efficacy. Methods:In this retrospective study, the data of 83 women who underwent surgery with Altis® SIS by a single surgeon at our centre from August 2017 to December 2018 were analysed. The pre-operative, intra-operative, post-operative and the 1, 6, 12 and 24 months follow-up data of these patients were evaluated. Results:The median age of patients was 60 years old. 19 patients (22.9%) had Altis® SIS surgery alone while the rest had concomitant procedures such as vaginal hysterectomy (65.1%), vaginal mesh augmentation (43.4%), posterior pelvic floor repair (68.7%) and sacrospinous ligament fixation (41.0%). The mean duration for Altis® SIS surgery alone was 15.0 min with an median blood loss of 10.0 mls. There were no significant intraoperative complications such as bladder perforation or major bleeding requiring transfusion.83 (100%), 79 (95.2%), 75 (90.4%) and 59 (71.1%) out of 83 patients attended their 1, 6, 12 and 24 month appointments respectively. Subjective cure was noted in 80 (96.4%), 77 (97.5%), 74 (98.7%) and 55 (93.2%) patients at 1, 6, 12 and 24 months respectively. Urodynamic study (UDS) was repeated at 6 months postoperatively and the objective cure rate was 91.0%. 1 patient (1.2%) had voiding difficulty post-operatively and required tape loosening. Conclusion:The short-medium term cure rates and perioperative complications for Altis® SIS were comparable to other studies on mid-urethral sling surgery. It appears to be safe and effective. Brief summary:In this retrospective study, the data of 83 women who underwent surgery with Altis® Single-incision sling at our centre were analysed and evaluated for its efficacy and safety.

Retropubic trocar modified with a load cell to verify contact with pubic bone

BackgroundVital injuries during midurethral sling surgery are avoided by maintaining constant trocar contact with bone, and yet this is challenging for a teaching surgeon to monitor during this blind procedure. We modified a retropubic trocar with a load cell to distinguish on-bone and off-bone movement and tested it on a midurethral sling surgery 3-dimensional surgery simulator. MethodsTwo experts and 3 novice surgeons performed retropubic trocar passage on the physical pelvic floor model using the modified trocar. Biofidelity was assessed comparing expert performance on a Thiel-embalmed cadaver and the physical model. The test-retest was assessed comparing performance on the physical pelvic model 2 weeks apart. The force variables were analyzed with paired and independent t tests. We performed post hoc analyses comparing the experts to novices on the physical model. ResultsThe root-mean-squared force was similar between the cadaver and model (24.3 vs 21.1 pounds, P = .62), suggesting biofidelity. Root-mean-squared force was also similar between the test and retest (14.0 vs 19.1 pounds, P =. 30). The expert surgeons exhibited a larger maximum force amplitude (51.2 vs 22.7 pounds, P = .03), shorter time to maximum force (2.7 vs 9.5 seconds, P = .03) and larger maximum rate of force development (171.5 vs 54.0 pounds/second, P = .01). ConclusionThis study suggested high test-retest reliability and adequate biofidelity of the modified trocar used on our midurethral sling surgery 3-dimensional surgery simulator. This innovative trocar can be used both in simulation and in the operating room to help the novice surgeons stay on the bone and to help the attending surgeon monitor safe surgery.

LONG-TERM EFFECTIVENESS AND COMPLICATIONS OF MID-URETHRAL SLINGS: CLINICAL CASE

Approximately 50% of all women suffer from urinary incontinence at least once in their lifetime. A majority of these women experience a type of urinary incontinence that is called stress urinary incontinence. Women of all ages are susceptible to this disease, however, it mostly affects older and overweight women. Even though this is not a life-threatening disease, it is important to find the most effective treatment methods to lessen the so­cial and psychological damage that is associated with this disease. Stress urinary incontinence is treated con­servatively, however, if the treatment is not successful, surgical options can be utilized. In the last few decades, surgical methods for stress urinary incontinence have changed dramatically. Burch colposuspension has long been a gold standard for surgical stress urinary inconti­nence treatment, however, its popularity has started to drop. Instead, mid-urethral slings have become the more mainstream option. Mid-urethral sling operations are not only less invasive and cause fewer complications, but are also more effective at treating stress urinary incontinence. Aim: To analyse the newest publications that review the long-term effectiveness and complications of mid-urethral slings and to also present a clinical case. Methods: A scientific literature review was conducted utilizing the following databases: Pubmed, ScienceDi­rect, UpToDate. Keywords for the search were urinary stress incontinence, Burch colposuspension, mid-urethral sling, tension-free vaginal tape. The most relevant scien­tific articles and scientific publications on the topic were selected. This article presents a generalized analysis of the scientific literature on the topic “Long-term effecti­veness and complications of mid-urethral slings: clinical case and literature review”. Results: Mid-urethral sling operations are an effective tre­atment option for stress urinary incontinence in women. Mid-urethral sling operations have lower complication risk than popular alternatives. According to the literature analysed in the study, there is no significant difference in effectiveness and complication rates between retropubic and transobturator mid-urethral slings. However, these are both quite not old treatments methods and so far there is not enough data to make a definitive conclusion.

Postoperative Utilization of Opioids After Midurethral Sling Surgery: A Prospective Clinical Practice Study.

This study was performed to understand opioid consumption after midurethral sling (MUS) procedures to provide surgeons with guidelines on appropriate prescription regimens. This study aimed to evaluate postdischarge narcotic use (PDNU) after MUS surgery using a restrictive postdischarge opioid regimen. This prospective clinical practice study included women undergoing MUS surgery from December 2018 to October 2019. Patients were discharged with an electronic prescription for 5 tablets of an oral narcotic. Brief Pain Inventory (BPI) surveys were collected preoperatively. Patients answered questions regarding remaining number of opioid tablets, BPI scores, and patient satisfaction on day 1, week 1 (postoperative week [POW] 1), and 4-6 weeks (POW4-6) postoperatively. Electronic records were reviewed to determine narcotic refills. Primary outcome was PDNU measured in morphine milligram equivalents (MME). Secondary outcomes evaluated refill rate, BPI scores, and patient satisfaction. Standard statistical tests were applied. Fifty-six patients were included in the analysis. Total median (interquartile range) PDNU was 12.5 (0-37.5) MME at POW1 and 15.0 (0-37.5) MME at POW4-6, which is approximately equivalent to 2 oxycodone (5 mg) tablets. Eighteen patients (32.1%) took 0 narcotics postdischarge. Brief Pain Inventory scores showed that "worst pain" was highest on postoperative day 1 with a median (interquartile range) score of 6 (4-8). At the POW1 and POW4-6 mark, 94.3% and 92% of patients, respectively, were satisfied or extremely satisfied with their pain control. Seven patients (11.8%) required a refill. Most patients undergoing MUS surgery used no more than 2 oxycodone (5 mg) tablets during their 6-week postoperative course, with almost a third not requiring any narcotics. Low pain scores and high patient satisfaction rates were noted.

Cost-effectiveness of prophylactic retropubic sling at the time of vaginal prolapse surgery

Prophylactic midurethral sling placement at the time of prolapse repair significantly reduces the risk for de novo stress urinary incontinence, but it is associated with some small but significant morbidities. Because there has not been a standardized approach to midurethral sling utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying midurethral sling placement strategies in addressing the risk for de novo stress urinary incontinence. We aimed to compare the cost effectiveness of the 3 midurethral sling utilization strategies in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. The 3 approaches are (1) staged strategy in which prolapse repair is done without prophylactic midurethral sling placement, (2) universal sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement, and (3) selective sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement only in patients with a positive prolapse-reduced cough stress test. We created a decision analysis model to compare staged strategy, universal sling placement, and selective sling placement. We modeled probabilities of de novo stress urinary incontinence, patients choosing subsequent midurethral sling surgery for de novo stress urinary incontinence, and outcomes related to midurethral sling placement. De novo stress urinary incontinence rates were determined for each strategy from published data. The likelihood of patients with de novo stress urinary incontinence choosing midurethral sling surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic midurethral sling placement at their index prolapse repair. Finally, outcomes related to midurethral sling placement, including recurrent or persistent stress urinary incontinence, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications, were all derived from publicly available data. All midurethral sling placement procedures were assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or from previous literature with convertion to 2020 equivalent US dollar prices using the Consumer Price Index. The primary outcome was modeled as the incremental cost-effectiveness ratio. We performed multiple 1-way sensitivity analyses to assess model robustness. The lowest-cost strategy was the staged strategy, which cost $1051.70 per patient, followed by $1093.75 for selective sling placement and $1125.54 for universal sling placement. The selective sling approach, however, had the highest health utility value; therefore, universal sling placement was dominated by selective sling placement because it is both less costly and more effective. When compared with the staged strategy, selective sling placement was cost effective with an incremental cost-effectiveness ratio of $2664 per quality adjusted life-years, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent midurethral sling surgery for de novo stress urinary incontinence after the index surgery. Only when this proportion exceeded 62% did universal sling placement become the cost-effective option because selective sling placement surpassed the predetermined incremental cost-effectiveness ratio threshold and became dominated. Selective sling placement was the preferred and cost-effective strategy in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo stress urinary incontinence after prolapse repair, as well as on the benefits and risks of prophylactic midurethral sling placement surgery.