Previous Midurethral Sling Research Articles

Impact of pelvic floor distress on non-invasive urodynamic findings in women

Objective (s)To compare non-invasive urodynamic findings in women with and without pelvic floor distress and to investigate the patient characteristics affecting maximum flow rates. Study designThis is a retrospective study including data derived from a prospective cohort study evaluating free uroflowmetry findings in asymptomatic and symptomatic women with urinary dysfunction attending the gynecology outpatient clinic for routine annual control, infertility, abnormal uterine bleeding and pelvic floor dysfunction. Data regarding baseline characteristics, questionnaires, urogynecologic examination findings and free uroflowmetry results were retrieved. Women were grouped according to the Turkish validated Pelvic Floor Distress Inventory (PFDI-20); women who scored 0 or 1 points for each item (“no” or “not at all”) were considered as asymptomatic in terms of pelvic floor dysfunction, and women who scored 2 or more points to any item were accepted as symptomatic. Baseline characteristics, clinical examination findings and free uroflowmetry data were compared among the groups using Student’s-t or Mann-Whitney U tests, Chi-square test or Fisher’s exact tests, where appropriate. Correlations and their significance, and patient characteristics affecting Qmax were investigated using the Pearson test. A multiple linear regression model was used to identify independent factors affecting Qmax. ResultsThe study population (n = 186) comprised asymptomatic (n = 70, 37.6%) and symptomatic (n = 116, 62.4%) women according to the scores of the PFDI-20. Corrected Qmax, TQmax, Tvv and PVR were found significantly lower in asymptomatic women (p ≤ 0.001). In asymptomatic women, PVR was <100 mL in 98.5%, and <50 mL in 80%. In multivariate linear regression analysis parity, obstructive subscale score of the UDI-6, previous mid-urethral sling surgery and hysterectomy were found to affect Qmax negatively, whereas VV was found to affect Qmax positively. Conclusion(s)Although significantly different, overlapping wide ranges of non-invasive urodynamic findings have been observed in women with and without pelvic floor distress in the present study population. Maximum urinary flow rates were significantly affected by patient characteristics such as parity, obstructive symptoms, prior incontinence surgery and hysterectomy. There is need for further larger studies considering all possible factors that may affect voiding.

Treatment of idiopathic overactive bladder with botulinum toxin: real-life results and patients' expectations.

Overactive bladder (OAB) is a prevalent syndrome affecting 11% to 16% of the adult population. When first-line pharmacological therapy is not effective, intradetrusorial injections of onabotulinumtoxinA (BTX-A) might have an important role in controlling symptoms. The main aim of this study was to access both the efficacy and safety of intradetrusor injections of 100U BTX-A in real clinical practice, among women with idiopathic OAB (iOAB). Retrospective study, based on clinical diaries in 136 iOAB female patients, with or without urinary incontinence, submitted to BTX-A injections, between 2005 and 2018 in a tertiary university hospital. Positive response was considered only when the patient mentioned she had great improvement after the injection, otherwise, it was considered negative. A positive response was obtained in 90 patients (66%) after the first injection. Women with a positive response after the first treatment had 7.5 times more chances to improve with the second (P = .01). Discontinuation of the therapy after the first injection was neither dependent on the presence of incontinence at baseline (P = .73) nor it was related to age (P = .6). On univariate analyses, none of the parameters evaluated was useful of predicting successful response, although there was a trend in women who had had a previous midurethral sling surgery for stress urinary incontinence, to have a lower chance of having a positive response after the first injection (P = .06).Thirty-nine women (29%) had at least 1 adverse event, urinary tract infection, and straining to void were the most frequent. Women above 65 years old had less risk of developing a urinary tract infection (P = .04). In real clinical practice, BTX-A injection is an effective (66%) and safe treatment, capable of improving quality of life. Moreover, responding to the first injection seems to predict good clinical outcomes in the second treatment. This procedure can be done with minimal restrictions.

Periurethral injection with polyacrylamide after previous TVT surgery.

The aim of this registry study was to assess the clinical utility of using periurethral bulking with polyacrylamide hydrogel in women with stress urinary incontinence (SUI) after previous midurethral sling surgery. The study period was 2007 through 2019. Using data from the Norwegian Female Incontinence Registry we included 57 women who had received Bulkamid® because of insufficient improvement or recurrent SUI after previous retropubic TVT surgery. The primary outcome was cure of SUI, and secondary outcomes were patient satisfaction, degree of leakage, change in urgency incontinence (UUI), free flow rate, postvoid residual volume, and complications. Descriptive statistics were used to characterize data and Wilcoxon signed-rank test to compare pre- and postoperative results for pairs, with level of significance at p < 0.05. Pure SUI was seen in 19 (33.3%) while 38 (66.7%) had mixed incontinence. Postoperatively 72.9% had a negative stress test and 73.7% were satisfied with treatment. There was only 1 complication in 67 injections (1.5%). De novo UUI occurred in five patients, corresponding to 8.8% of the whole study group, but 26.3% among those with no preoperative UUI problems. Among the patients with preoperative UUI, 39.5% were cured of this problem and a further 36.8% were improved. The cure rate and satisfaction rate of periurethral bulking with polyacrylamide after previous MUS are favorable and complications are rare. There seems to be a risk of overactive bladder symptoms developing in women with no such symptoms preoperatively.

Translabial US: Preoperative Detection of Midurethral Sling Erosion in Stress Urinary Incontinence.

Purpose To evaluate the performance of translabial (TL) US in preoperative detection of sling erosion into pelvic organs with cystourethroscopic and surgical correlation. Materials and Methods The study cohort included women who underwent surgery at a subspecialty center (from 2008 to 2016) for suspected mesh complications in the setting of previous midurethral sling placement for stress urinary incontinence (from 1999 to 2012) with available preoperative TL US imaging. Clinical information, the finding of sling erosion identified intraoperatively and at cystourethroscopy, and blinded dual-reader radiologic analysis of the TL US studies for mesh location (intraluminal, mural, or extramural) relative to pelvic organs (bladder, urethra, vagina, or rectum) were evaluated. The diagnostic performance of TL US was correlated with the reference standard of surgical findings. The consensus of two radiologists was recorded, and interobserver agreement was evaluated with the κ statistic. Results Of the 124 women who were suspected of having sling erosion (mean age, 57.5 years ± 11.1 [standard deviation]), 15 women (12.1%) had sling erosion into the urethra or bladder at surgery. Sensitivity and specificity for erosion at TL US were 53% (95% confidence interval: 45%, 62%) and 100% (95% confidence interval: 97%, 100%), respectively, when erosion was defined as only intraluminal mesh products. Sensitivity and specificity for erosion at TL US were 93% (95% confidence interval: 89%, 98%) and 72% (95% confidence interval: 65%, 80%), respectively, when erosion was defined as visualizing either intraluminal or intramural mesh products. Interobserver agreement (κ value) was 0.95. Cystourethroscopy had 67% sensitivity and 100% specificity for sling erosion. Conclusion Preoperative translabial US can be used to detect sling erosion into the lower urinary tract, with sensitivity up to 93% and specificity up to 100%. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Benson and Phillips in this issue.

Management of Recurrent Stress Urinary Incontinence After Failed Mid-Urethral Sling Placement

Our objective is to review the current literature on recurrent stress urinary incontinence after mid-urethral sling placement, focusing on evidence-based management considerations for this complex clinical problem. Conservative, minimally invasive surgical therapies are currently available for management of persistent or recurrent SUI after a previous mid-urethral sling (MUS). Our review of the literature does not show a clear benefit of one approach over others and emphasizes that the ideal management for these complex patients should be determined using an individualized approach with a detailed discussion of patient symptoms, past surgical history, and goals. For symptomatic patients who are surgical candidates and desire intervention, trans-urethral bulking agents, repeat retropubic (RP) MUS, or salvage autologous pubovaginal (PV) sling appear to be the most well-described management strategies.

Urethral bulking for recurrent stress urinary incontinence after previous midurethral sling

Urethral bulking for recurrent stress urinary incontinence after previous midurethral sling

Urethral bulking for recurrent stress urinary incontinence after midurethral sling failure.

To assess the effectiveness of a polyacrylamide hydrogel (PAHG; Bulkamid®) in treating recurrent stress urinary incontinence (SUI) following a previous midurethral sling (MUS) implant. This observational study, conducted since 2009, included 60 patients with recurrent SUI or mixed urinary incontinence (MUI) after a previous MUS and who chose to be treated with PAHG. Objective and subjective outcomes were assessed at 1, 6, and 12 months after the initial injection. Patients were classified as cured based on a negative cough test (supine and standing) and <2 g urine on 1-hr pad test and a VAS score improved by ≥90%. Improved were those with the loss of only a few drops of urine during the cough test and 2-10 g urine on 1-hr pad test or a reduction >50% compared with preoperative urine loss and a VAS score improved by ≥75%. The volume of PAHG injected in the current study ranged from 1-3 ml. Cured/improved rates were 93.3% (56/60), 88.3% (53/60), and 83.6% (46/55) at 1, 6, and 12 months, respectively. Patients with MUI had a cured urgency urinary incontinence rate of 36.8%, 47.4%, and 38.9%, respectively. Voiding dysfunction rates were 13.3% (8/60), 8.3% (5/60), and 1.8% (1/55) at 1, 6, and 12 months and urinary tract infection rates were 5% (3/60), 11.7% (7/60), and 3.6% (2/55), respectively. Other adverse events were short-term and/or observed in <4% of patients. PAHG can be used to treat recurrent SUI after MUS failure with good outcome and low complication rates. Neurourol. Urodynam. 36:722-726, 2017. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.

Results of a nationwide survey on practice patterns of Canadian obstetricians and gynaecologists regarding the mode of delivery after pelvic floor surgery

It is not uncommon to be challenged with the dilemma of deciding the best mode of delivery in a patient with a history of previous pelvic floor surgery. We hypothesized that the trend would be a predilection towards cesarean section delivery in the context of a previous pelvic floor surgery, especially amongst Urogynaecologists. A nation-wide survey was sent through the Society of Obstetrics and Gynaecology of Canada to all physician members to assess the practice patterns regarding the preferred mode of delivery after pelvic floor surgery. A hundred and three members replied. Forty-seven percent would recommend a cesarean section (CS) when pregnant after a previous midurethral sling (MUS), 27.2 % would allow vaginal delivery, 10.7 % would not be affected in their decision by the MUS, 9.7 % would strongly advise against pregnancy and 4.9 % would suggest a cesarean section with a sterilization procedure. With a history of previous pelvic organ prolapse surgery (POP), 54.4 % would suggest a CS when pregnant, 21.4 % would strongly advise against pregnancy and only 15.5 % would allow the patient to deliver vaginally. Urogynaecologists are significantly more likely to strongly advise a patient with a previous MUS against pregnancy, compared to their peers practicing general obstetrics and gynaecology (OBGYN) (p = 0.04) or maternal fetal medicine (MFM) (p = 0.05). Larger studies and clear guidelines advising physicians to the optimum mode of delivery following a history of previous pelvic floor surgery are strongly needed.

Randomized trial of a single incision versus an outside-in transobturator midurethral sling in women with stress urinary incontinence: 12 month results

The objective of the study was to evaluate objective and subjective outcomes of MiniArc and Monarc (American Medical Systems, Minnetonka, MN) midurethral sling (MUS) in women with stress incontinence at 12 months. A total of 225 women were randomized to receive MiniArc or Monarc. Women with intrinsic sphincter deficiency, previous MUS, or untreated detrusor overactivity were excluded. Objective cure was defined as negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with coughing or exercise on questionnaire. Validated questionnaires, together with urodynamic and clinical cough stress test, were used to evaluate the objective and subjective outcomes following surgery. Participants and clinicians were not masked to treatment allocation. Outcomes were compared with exact binomial tests (eg, Fisher exact test for dichotomous data) for categorical data and Student t tests or exact versions of Wilcoxon tests for numerical data as appropriate. There was no statistically significant difference in the subjective (92.2% vs 94.2%; P = .78; difference, 2.0%; 95% confidence interval, -2.7% to +6.7%) or objective (94.4% vs 96.7%; P = .50; difference, 2.3%; 95% confidence interval, -1.5% to +6.1%) cure rates between MiniArc and Monarc at 12 m, respectively, with a significant improvement in overactive bladder outcomes and incontinence impact from baseline in both arms. MiniArc outcomes are not inferior to Monarc MUS outcomes at 12 months' follow-up in women without intrinsic sphincter deficiency.

The autologous fascia pubovaginal sling for complicated female

Introduction: The purpose of this study is to review our contemporary experience with autologous fascia pubovaginal slings (AF-PVS) in the era of the midurethral sling.Methods: A retrospective review was completed to identify allpatients who underwent an AF-PVS between 2002 and 2009. Across-sectional questionnaire was used to assess postoperative urinary- specific quality of life (consisting of the Urogenital Distress Inventory [UDI-6] and the Incontinence Impact Questionnaires [IIQ-7]).Results: We identified 33 patients. They had failed a median oftwo previous incontinence treatments. Of these patients, 16 (48%) had failed a previous midurethral sling, and of these half had experienced a significant mesh erosion necessitating mesh removal. Preoperative median incontinence pad usage was 5/day. After a median follow-up of 16 months from the time of AF-PVS, the median pad usage had decreased to 1/day (p = 0.003). A third of the patients had postoperative urgency, and only 1 patient continues to use intermittent catheterization. The median IIQ-7 score was 19/100, and the median UDI-6 score was 44/100. Overall quality of life was mixed-to-delighted in 62% of patients.Conclusions: The AF-PVS has reasonable outcomes in a diversepopulation of patients, despite failure of other treatment modalities.

The autologous fascia pubovaginal sling for complicated female stress incontinence.

The purpose of this study is to review our contemporary experience with autologous fascia pubovaginal slings (AF-PVS) in the era of the midurethral sling. A retrospective review was completed to identify all patients who underwent an AF-PVS between 2002 and 2009. A cross-sectional questionnaire was used to assess postoperative urinary-specific quality of life (consisting of the Urogenital Distress Inventory [UDI-6] and the Incontinence Impact Questionnaires [IIQ-7]). We identified 33 patients. They had failed a median of two previous incontinence treatments. Of these patients, 16 (48%) had failed a previous midurethral sling, and of these half had experienced a significant mesh erosion necessitating mesh removal. Preoperative median incontinence pad usage was 5/day. After a median follow-up of 16 months from the time of AF-PVS, the median pad usage had decreased to 1/day (p = 0.003). A third of the patients had postoperative urgency, and only 1 patient continues to use intermittent catheterization. The median IIQ-7 score was 19/100, and the median UDI-6 score was 44/100. Overall quality of life was mixed-to-delighted in 62% of patients. The AF-PVS has reasonable outcomes in a diverse population of patients, despite failure of other treatment modalities.