Previous Stress Urinary Incontinence Surgery Research Articles

The use of midurethral sling in the correction of low-stage cystoceles: a prospective randomized trial

Introduction and hypothesisThe objective was to assess whether midurethral slings (MUS) can improve both stress urinary incontinence (SUI) and cystoceles. MUS with anterior colporrhaphy (AC) as a treatment for SUI with cystocele is more invasive and carries greater risk than MUS alone.MethodsThis is a prospective randomized study involving women with stage 1 or 2 cystocele and SUI, who were > 21 years of age, who had had no previous surgery for SUI. Predominant SUI, symptomatic anterior pelvic organ prolapse, and informed consent were mandatory. Patients were randomized as to whether AC had been performed. The sling procedure was left to the surgeon’s discretion: pubovaginal sling, tension-free vaginal tape, or trans-obturator tape. Success was defined as a negative stress test and no evidence of cystocele upon local examination.ResultsNinety-eight patients were enrolled, 48 underwent MUS, and 50 underwent MUS and AC. Mean age ± SD was 44.96 ± 8.13 years. Baseline characteristics were similar. Operative time and blood loss were significantly higher in the MUS/AC group (p = 0.01 and 0.02 respectively). At 3 months, success was 79.1% and 77.8% in the MUS and MUS/AC groups respectively. This was maintained until 6 months (79.1% and 77.8% respectively). At 1 year, the results were comparable with success rates of 96.2% and 87.0% in the MUS and MUS and AC groups respectively. Symptom scores were comparable at 6- and 12-month evaluations.ConclusionMidurethral slings correct symptomatic stage 1 or 2 cystoceles without the need for AC, which carries the risk of a significantly longer procedure and more significant blood loss.

Stress Urinary Incontinence After Operations for Uterine Prolapse: A Nationwide Cohort Study.

Concomitant surgery for stress urinary incontinence (SUI) during pelvic organ prolapse (POP) operations are debated. We aimed to assess the risk of an SUI operation after a uterine prolapse operation and compare the risk after the Manchester procedure versus vaginal hysterectomy. We performed a nationwide historical cohort study including women with no history of hysterectomy undergoing the Manchester procedure (n = 6065) or vaginal hysterectomy (n = 9,767) for POP during 1998 to 2018. We excluded women with previous surgery for SUI and POP, concomitant surgery for SUI (n = 34, 0.2%), and diagnosed with gynecological cancer before or within 90 days from surgery. Women were followed up until SUI operation/death/emigration/diagnosis of gynecological cancer/December 31, 2018, whichever came first. Women undergoing the Manchester procedure were censored if they had undergone hysterectomy.We assessed the rate of SUI surgery with cumulative incidence plots. We performed Cox Regression to analyze the risk of SUI surgery, adjusting for age, calendar year, income level, concomitant surgery in anterior and posterior compartments, and diagnosis of SUI before POP operation. We found that 12.4% women with and 1.6% without SUI diagnosed before the POP surgery who underwent SUI surgery within 10 years.During follow-up (median, 8.5 years), 129 (2.1%) underwent SUI surgery after the Manchester procedure and 175 (1.8%) after vaginal hysterectomy (adjusted hazard ratio, 1.06 [0.84-1.35]). Of women diagnosed with SUI before POP operation 1 in 8 subsequently underwent SUI surgery. Few women not diagnosed with SUI subsequently underwent SUI surgery. There was no difference in risk of SUI after the Manchester procedure and vaginal hysterectomy.

Efficacy and safety of onabotulinumtoxin A injection in male patients with detrusor overactivity after stress urinary incontinence surgery

Introduction and objectiveThe use of onabotulinumtoxin A (BoNT-A) injection in male patients with detrusor overactivity (DO) after stress urinary incontinence (SUI) surgery has been scarcely described. Our aim was to assess results of this treatment in this specific population. Materials and methodsRetrospective analysis of men with previous SUI surgery who had been treated with a first injection of 100 U BoNT-A because of DO since 2010 in our department. Treatment response was assessed with the Treatment Benefit Scale: 1) greatly improved; 2) improved; 3) not changed; 4) worsened after treatment (Treatment Benefit Scale 1 or 2: treatment response). Complications were classified according to the Clavien-Dindo classification. Treatment continuation was considered present if, at the last visit, patients had received a BoNT-A injection within the preceding 12 months. Pre- and post-treatment urodynamic variables were compared. ResultsEighteen patients were included, median age 71.1 (59.1–83.5) years. Twelve (66.7%) patients reported response to treatment. Two (11.1%) complications were detected: urinary retention requiring clean intermittent catheterization (Clavien-Dindo 2). No complications related to previous SUI surgery were detected. Fifteen (83.3%) patients had a follow-up >12 months (median follow-up 57 [15–89] months) and all of them had discontinued treatment at the end of follow-up. Urodynamic studies showed significant improvement in terms of DO and bladder compliance. ConclusionAlthough most men with DO after SUI surgery respond to intradetrusor BoNT-A injection, all of them discontinue treatment due to personal reasons. It is a safe procedure, with urinary retention requiring clean intermittent catheterization being the most frequent complication.

PD06-06 IMPACT OF ROBOTIC ARTIFICIAL URINARY SPHINCTER IMPLANTATION IN FEMALE PATIENTS ON QUALITY OF LIFE AND PATIENTS-REPORTED OUTCOMES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy I (PD06)1 Sep 2021PD06-06 IMPACT OF ROBOTIC ARTIFICIAL URINARY SPHINCTER IMPLANTATION IN FEMALE PATIENTS ON QUALITY OF LIFE AND PATIENTS-REPORTED OUTCOMES Benoit Peyronnet, Valentine Lethuillier, Louis-Paul Berthelot, Claire Richard, Camille Haudebert, Caroline Voiry, Lucas Freton, Juliette Hascoet, and Andrea Manunta Benoit PeyronnetBenoit Peyronnet More articles by this author , Valentine LethuillierValentine Lethuillier More articles by this author , Louis-Paul BerthelotLouis-Paul Berthelot More articles by this author , Claire RichardClaire Richard More articles by this author , Camille HaudebertCamille Haudebert More articles by this author , Caroline VoiryCaroline Voiry More articles by this author , Lucas FretonLucas Freton More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , and Andrea ManuntaAndrea Manunta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001974.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Artificial urinary sphincter (AUS) is commonly used in France in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). However, female AUS has never been assessed using validated questionnaires so far. The aim of the present study was to assess the functional outcomes of robotic artificial urinary sphincter implantation using validated questionnaires METHODS: The data of all female patients undergoing a robotic AUS implantation at a single academic center between 2014 and 2019 were collected prospectively. Preoperativley, all patients underwent urodynamics and filled out an Urinary Symptoms Profile (USP) questionnaire (SUI subscore /9; overactive bladder subscore /21 ; voiding symptoms subscore /9), a ICIQ-SF questionnaire and a Patient Global Impression of Improvement (PGII). The same questionnaires were filled out at 3 months postoperatively. RESULTS: Over the study period, 57 robotic female AUS implantations were performed by two surgeons. Eight patients had neurogenic SUI (14%). The median patients’ age was 66 years and 84.2% had a history of previous SUI surgery. The median cuff size was 75 mm. There were ten intraoperative complications (5 bladder neck injuries and 5 vaginal injuries ; 17.5%) and 16 postoperative complications (28.1%) all Clavien grades 1 or 2 except three Clavien 3B: two early vaginal erosion with AUS explantation and one suspicion of AUS infection with surgical exploration (major complications rate: 5.3%). The median length of stay was 3 days. All patient-reported outcomes were significantly improved at 3 months. The USP SUI subscore decreased from 7.4/9 preoperatively to 0.7/9 at 3 months (p<0.0001), the USP OAB subscore dwindled from 12.6 to 5.2 (p<0.0001) and the ICIQ-SF from 16.3 to 3.1 (p<0.0001). The AUS implantation improved patients’ quality of life with the ICIQ-qol decreasing from 8.4 preoperatively to 1.3 at 3 months (p<0.0001). The 3-month PGII was 1/7 (very much improved) in 41 patients (74.5%), 2/7 (improved) in 5 patients (9.1%), 3/7 in four patients (7.3%) and 4/7 (unchanged) in five patients (9.1%). CONCLUSIONS: Robot-assisted AUS implantation in female patients has a low morbidity and improves the patients-reported outcomes and quality of life of female patients with SUI due to ISD. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e101-e102 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benoit Peyronnet More articles by this author Valentine Lethuillier More articles by this author Louis-Paul Berthelot More articles by this author Claire Richard More articles by this author Camille Haudebert More articles by this author Caroline Voiry More articles by this author Lucas Freton More articles by this author Juliette Hascoet More articles by this author Andrea Manunta More articles by this author Expand All Advertisement Loading ...

Eficacia y seguridad de la inyección de onabotulinumtoxin A en pacientes varones con hiperactividad del detrusor tras la cirugía para incontinencia urinaria de esfuerzo

Introduction and objectiveThe use of onabotulinumtoxin A (BoNT-A) injection in male patients with detrusor overactivity (DO) after stress urinary incontinence (SUI) surgery has been scarcely described. Our aim was to assess results of this treatment in this specific population. Materials and methodsRetrospective analysis of men with previous SUI surgery who had been treated with a first injection of 100U BoNT-A because of DO since 2010 in our department. Treatment response was assessed with the Treatment Benefit Scale: 1) greatly improved; 2) improved; 3) not changed; 4) worsened after treatment (Treatment Benefit Scale 1 or 2: treatment response). Complications were classified according to the Clavien-Dindo classification. Treatment continuation was considered present if, at the last visit, patients had received a BoNT-A injection within the preceding 12 months. Pre- and post-treatment urodynamic variables were compared. ResultsEighteen patients were included, median age 71.1 (59.1-83.5) years. Twelve (66.7%) patients reported response to treatment. Two (11.1%) complications were detected: urinary retention requiring clean intermittent catheterization (Clavien-Dindo 2). No complications related to previous SUI surgery were detected. Fifteen (83.3%) patients had a follow-up>12 months (median follow-up 57 [15-89] months) and all of them had discontinued treatment at the end of follow-up. Urodynamic studies showed significant improvement in terms of DO and bladder compliance. ConclusionAlthough most men with DO after SUI surgery respond to intradetrusor BoNT-A injection, all of them discontinue treatment due to personal reasons. It is a safe procedure, with urinary retention requiring clean intermittent catheterization being the most frequent complication.

Variation in surgical treatment advice for women with stress urinary incontinence: a study using clinical case vignettes

IntroductionThe aim of this study was to determine how recommendations of gynaecologists on surgical treatment for stress urinary incontinence (SUI) were influenced by patient characteristics.MethodsTwo hundred forty-five gynaecologists in the UK fully responded to an online questionnaire including 18 vignettes describing 7 clinical characteristics of women with SUI (age, body mass index, SUI type, previous SUI surgery, frequency of leakage, bother, physical status). The gynaecologists scored recommendations for surgery ranging from 1 ‘certainly not’ to 5 ‘certainly yes’. Mean scores were used to calculate the relative impact (‘weight’) of each clinical characteristic. Latent class analysis was used to distinguish groups of gynaecologists with a particular practice style because they responded to the patient characteristics captured in the case vignettes in a similar way.ResultsThe gynaecologists’ overall average recommendation score was 2.9 (interquartile range 2 to 4). All patient characteristics significantly influenced the recommendation scores (p always < 0.001) but their impact was relatively small. SUI type was most important (weight 23%), followed by previous SUI surgery (weight 21%). Latent class analysis identified five groups of gynaecologists with practice styles that differed mainly with respect to their mean recommendation score, ranging from 1.3 to 4.0.ConclusionsSurgical treatment advice in response to case vignettes was only minimally influenced by patient characteristics. There were five groups of gynaecologists whose inclination to recommend surgical treatment varied. This suggests that there is lack of consensus on the role of surgery as a treatment for SUI. A considerable number of gynaecologists were reluctant to recommend surgery.

Prospective study of a single-incision sling versus a transobturator sling in women with stress urinary incontinence: 3-year results

Long-term safety and efficacy data on use of single-incision slings in stress urinary incontinence are limited. To determine whether the single-incision sling Solyx (Boston Scientific, Marlborough, MA) is noninferior to the transobturator sling Obtryx II (Boston Scientific) in efficacy and safety for treatment of stress urinary incontinence. This 522 post-market surveillance study has been designed in response to a Food and Drug Administration request to evaluate improvement in stress urinary incontinence at 36 months following single-incision sling compared with baseline, as well as provide an assessment of mesh-related complications and subject-reported outcomes, relative to the transobturator sling control. This prospective, nonrandomized, parallel cohort, multicenter postapproval study enrolled subjects to receive single-incision sling or transobturator sling. Study sites were assigned to a cohort group based on documented competency with the cohort device. Patient follow-up was 36 months to compare efficacy and adverse events for noninferiority. Inclusion criteria included stress predominant urinary incontinence, a positive cough stress test, and post-void residual ≤150 cc. Participants were ineligible if they had undergone previous stress urinary incontinence surgery or had a previous mesh complication. Primary endpoint was treatment success defined by composite negative cough stress test and subjective improvement in stress urinary incontinence using Patient Global Impression of Improvement at 36 months. Secondary endpoints included adverse events and indications for retreatment. Noninferiority margins of 15% and 10% were prespecified for the primary efficacy and safety endpoints. Data analysis was performed using intent-to-treat and per-protocol methods. Due to the observational nature of the study, a propensity score methodology was applied to account for differences in patient and surgeon characteristics between treatment groups. The study design and variables to be included in the propensity score model were reviewed and approved by Food and Drug Administration reviewers before outcome analyses were performed. No evidence of imbalance in baseline characteristics was observed between groups after propensity score stratification in the 281 subjects. EBL (72.3±92 vs 73.1±63.9 mL, P=.786), time to spontaneous void (1.1±2 vs 0.8±2.8 days, P=.998), and time to discharge (0.7±0.7 vs 0.6±0.6 days, P=.524) were similar between groups. At 36 months, treatment success was 90.4% in the single-incision sling group and 88.9% in the transobturator sling group (P=.93). At 36 months, mesh-related complications were similar between groups (mesh exposure: 2.8% vs 5.0%, P=.38). Serious adverse events including pain during intercourse (0.7% vs 0%, P=1.00), pelvic pain (0.7% vs 0%, P=1.00), and urinary retention (2.8% vs 4.3%, P=.54) were similar between groups. Single-incision sling was not inferior to transobturator sling for long-term treatment success of stress urinary incontinence. The rates of serious adverse events were acceptably low and similar between groups.

Indications and risk factors for midurethral sling revision.

To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement. This was a case-control study of all women undergoing midurethral sling placement for stress urinary incontinence (SUI) between January 2003 and December 2013. Cases were patients who underwent midurethral sling placement followed by sling revision (incision, partial or complete excision). Controls were patients who underwent sling placement only. Once all subjects had been identified, the electronic medical record was queried for demographic and perioperative and postoperative data. Of 3,307 women who underwent sling placement, 89 (2.7%, 95% CI 1.9 - 3.4) underwent sling revision for one or more of the following indications: urinary retention (43.8%), voiding dysfunction (42.7%), recurrent urinary tract infection (20.2%), mesh erosion (21.3%), vaginal pain/dyspareunia (7.9%), and groin pain (3.4%). The median time from the index to the revision surgery was 7.8 months (2.3 - 17.9 months), but was significantly shorter in patients with urinary retention. The type of sling placed (retropubic or transobturator) was not associated with indication for revision. Patients who underwent revision surgery were more likely to have had previous SUI surgery (adjusted odds ratio 4.4, 95% CI 1.7 - 6.5) and to have undergone concomitant vaginal apical suspension (adjusted odds ratio 2.4, 95% CI 1.4 - 4.5). The rate of sling revision after midurethral sling placement was 2.7%. Urinary retention and voiding dysfunction were the most common indications. Patients with a history of previous SUI surgery and concomitant apical suspension at the time of sling placement may be at higher risk of requiring revision surgery.

Functional outcomes of adjustable continence therapy (ACT™) balloons in women aged >80 years and suffering from stress urinary incontinence caused by intrinsic sphincter deficiency.

To determine the functional outcomes of adjustable continence therapy (ACT™) balloons in elderly women suffering from stress urinary incontinence (SUI) caused by intrinsic sphincter deficiency (ISD). A monocentric retrospective study included all non-neurological women aged >80 years who suffered from SUI due to ISD and undergoing ACT™ balloon placement between 2000 and 2013. Early post-operative complications were reported according to the Clavien-Dindo classification. Continence was assessed subjectively by the patients. A total of 52 female patients were included, median age 83 years (IQR 81-85). Among them, 35 (67.3 %) had already undergone previous surgery for SUI. Balloon implantations were achieved under local anaesthesia for 33 (63.5 %) patients. Clavien grade I-II early post-operative complications occurred in five (9.6 %) patients. Median follow-up was 10.5 months (IQR 3-24.25). Eleven patients (21.1 %) were lost to follow-up. At last follow-up, seven patients (13.5 %) declared themselves fully continent after the first implantation, 13 patients (25 %) had an >80 % improvement rate (10 patients after first implantation, two after second implantation and one after third implantation). Four patients (7.7 %) found the procedure unsuccessful even after several consecutive implantations. Ten patients (19.2 %) reported a partial result and were still having successive balloon inflations. Explantation occurred in 22 patients, caused by infection, erosion or balloon migration. In intention-to-treat analysis, the failure rate was 42.3 %. Although the success rate of ACT™ balloons in women aged >80 years is lower than that reported for younger women, it remains satisfactory because these patients would not otherwise have benefited from another surgical treatment.

Do predictive parameters exist for therapy with duloxetine in women with stress urinary incontinence?

To determine whether predictive parameters exist for successful duloxetine therapy in women with stress urinary incontinence (SUI). Secondary analysis was performed of 1,714 women who received duloxetine in the Stress Urinary Incontinence Treatment (SUIT) study, a 12-month longitudinal observational study to evaluate the results and direct costs of SUI treatment. Data of 1,087 women were analyzed. Univariate and multivariate analyses (stepwise forward logistic regression) were performed to investigate factors for discontinuation of treatment. Parameters that significantly reduced the probability of treatment termination were smoking and a body mass index (BMI) <20, while obesity (BMI >30) increased the probability in the univariate analysis. In the multivariate analysis significantly reduced likelihoods of duloxetine treatment discontinuation were found for an age >65 years, country, and 7 to 13 incontinence episodes per week. Co-medication, particularly anti-cholinergics, was significantly associated with therapy termination. Previous SUI surgery had no effect. Identification of predictive parameters for successful therapy with duloxetine in women with SUI is desirable, and co-medications should be critically considered.

Analysis of female voiding dysfunction: a prospective, multi-center study

Female voiding dysfunction lacks clear definitions or objective data even to this day due to the relatively low prevalence and complex etiologies of voiding dysfunction in women compared to men. The prevalence varies widely from 2.7 to 23 % (Nitti et al. in J Urol 161(5):1535-1540, 1999; Rees et al. in Br J Urol 47(7):853-860, 1975; Groutz et al. in Neurourol Urodyn 19(3):213-220, 2000; Farrar et al. in Br J Urol 47(7):815-822, 1975; Massey and Abrams in Br J Urol 61(1):36-39, 1988; Chassagne et al. in Urology 51(3):408-411, 1998). Diagnostic criteria and management of female voiding dysfunction have not yet been established. We performed a prospective, multi-center study at nine hospitals to investigate the characteristics and prevalence of female voiding dysfunction. A total of 1,415 women visited urology clinics in nine hospitals from September to December 2005. Among them, 792 patients presented with lower urinary tract symptoms (LUTS). We analyzed their urinary symptoms with an International Prostate Symptom Score (IPSS) and obtained objective data using uroflowmetry, residual urine volume, and urinalysis. The authors hereby define female voiding dysfunction as maximum flow rate (Q max) of 15 ml/s or less, which may be due to either bladder outlet obstruction (BOO) or bladder dysfunction caused by detrusor underactivity. BOO was defined as Q max <15 ml/s with detrusor pressure >20 cmH2O at Q max, and detrusor underactivity was defined as Q max <15 ml/s with detrusor pressure <20 cmH2O at Q max on pressure flow studies. Hundred and two patients (12.8 %) from a total of 792 LUTS patients complained of voiding difficulty. Mean total IPSS score, mean IPSS subscores for voiding and storage symptom was 19.5 ± 7.9, 12.0 ± 5.0, and 8.4 ± 3.4, respectively. Among the seven categories of IPSS, incomplete emptying was the most common symptom followed by weak stream. Eighty-nine patients (87.2 %) from a total of 102 voiding dysfunction patients showed BOO, while 13 patients (12.8 %) showed detrusor underactivity. Concomitant diseases observed with voiding dysfunctions were overactive bladder (32 patients), stress urinary incontinence (25), detrusor underactivity (13), previous stress urinary incontinence surgery (12), pelvic organ prolapse (4), and anatomical obstruction (3 patients). The prevalence of voiding difficulty in female urology patients who visit urologic office clinic was 7.2 and 12.8 % in female LUTS patients. Voiding symptoms were more common than storage symptoms, while functional BOO was more prevalent than detrusor underactivity in female voiding difficulty patients. We may expect alpha blockers to be an effective treatment option in female voiding difficulty due to functional BOO.

Efficacy and Safety of Tension-Free Vaginal Tape Compared With Transobturator Tape Among Obese Women With Stress Urinary Incontinence: A Retrospective Cohort Study

ObjectiveTo determine the efficacy and safety of tension-free vaginal tape (TVT) compared with transobturator tape (TOT) in obese women with stress urinary incontinence (SUI). MethodsWe performed a retrospective chart review of patients who underwent insertion of TVT or TOT for stress urinary incontinence between January 2003 and October 2009. Women were excluded if they had had previous surgery for SUI or had a diagnosis of intrinsic sphincter deficiency. ResultsOne hundred eighty obese women (BMI >30 kg/m2) with SUI and with follow-up for at least one year were identified (90 had TVT and 90 had TOT). The rates of success on the objective criteria were 91% for the TVT group and 88% for the TOT group (P = 0.46) and 87% versus 80% (P = 0.23) on subjective assessment. ConclusionOur retrospective cohort study demonstrated similar rates of cure for obese women with SUI who underwent insertion of TVT and TOT.

1190 OUTCOMES OF TREATMENT OF STRESS URINARY INCONTINENCE ASSOCIATED WITH FEMALE URETHRAL DIVERTICULA

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy II1 Apr 20121190 OUTCOMES OF TREATMENT OF STRESS URINARY INCONTINENCE ASSOCIATED WITH FEMALE URETHRAL DIVERTICULA Ahmed El-Zawahry, Ross Rames, and Eric Rovner Ahmed El-ZawahryAhmed El-Zawahry Charleston, SC More articles by this author , Ross RamesRoss Rames Charleston, SC More articles by this author , and Eric RovnerEric Rovner Charleston, SC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1435AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Female Urethral diverticula (UD) may present with different symptoms (sx) including stress urinary incontinence (SUI). Surgical repair of SUI may be done concomitantly with urethral diverticulectomy. However, in some patients (pts) with UD, differentiation of SUI from post-void dribbling is difficult. Additionally, some surgeons may be reluctant to repair SUI at the time of transvaginal urethral diverticulectomy (TVUD) due to the additional surgical time required and potential morbidity of anti-incontinence surgery. We assessed surgical outcomes of the concomitant treatment of SUI at the time of TVUD. METHODS Following IRB approval, we identified pts with a concomitant diagnosis of SUI among 34 consecutive pts at Medical University of South Carolina who underwent TVUD between 2004 and 2009. Sx and the diagnosis of SUI were documented before and after surgery using subjective and objective parameters. Martius flap and autologous pubovaginal slings (APVS) were used selectively based on surgeon and pts preference. Postoperatively, all pts were imaged prior to catheter removal with voiding-cystourethrogram (VCUG). Pts were followed per standard office protocol with follow-up visits at a minimum of 1 week, 3 months (mo) and 15 mo postoperatively. Pts were followed selectively and expectantly thereafter. RESULTS There were 22 pts (65%) with UD and concomitant SUI. Mean age was 52 yo (range 35-77). There were 9 Caucasians, 12 African American and 1 Hispanic. Mean follow-up from TVUD was 18 mo (Range 1-71). Seven pts had previous surgery for SUI including bladder neck suspension (2), a pubovaginal sling surgery (1), transobturator mid-urethral sling +/− perirurethral bulking agent (4). 19/22 underwent APVS in addition to TVUD. 18/22 pts had improvement or resolution of SUI. 3/4 pts with postoperative SUI underwent subsequent APVS, One pt developed de-novo SUI following TVUD. Surgery resulted in the improvement or resolution of the majority of preoperative sx including recurrent urinary tract infection (UTI) (68% vs. 9.5%, p=0.00002), dyspareunia (72% vs. 9.5%, p=0.000004), and frequency (41% vs. 9.5%, p= 0.018) (preoperative vs. postoperative). Complications included one pt with urinary retention following APVS requiring sling lysis and one pt with a recurrent UD 18 mo postoperatively. CONCLUSIONS SUI is often associated with female UD. Surgical reconstruction of UD often results in satisfactory control of urinary sx including SUI when both are treated concomitantly. Treatment of SUI with APVS when undergoing TVUD is feasible with satisfactory outcomes. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e482 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed El-Zawahry Charleston, SC More articles by this author Ross Rames Charleston, SC More articles by this author Eric Rovner Charleston, SC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Exploratory Study Assessing Efficacy and Complications of TVT-O, TVT-Secur, and Mini-Arc: Results at 12-Month Follow-Up

BackgroundContemporary surgical treatment of female stress urinary incontinence (SUI) includes retropubic and transobturator (TO) midurethral slings (MUS). Case series of single-incision slings (SIS) have shown similar outcomes with lower morbidity. ObjectiveOur aim was to assess the cure rates, complications, and quality-of-life impact of one standard TO MUS and two SIS. Design, setting, and participantsNinety consecutive patients with clinically and urodynamically proven SUI were enrolled in an exploratory randomised phase 2 trial. Patients with previous SUI surgery, major pelvic organ prolapse, mixed incontinence, or detrusor overactivity were excluded. InterventionsPatients were treated randomly with TVT-O, TVT-Secur, or Mini-Arc. MeasurementsPostoperative visits were scheduled at 6 and 12 mo. The King's Health Questionnaire (KHQ) was repeated at 6 mo. Cure was defined as the absence of urine leakage, no pad use, and a negative cough test at 12 mo. Pain and other complications were also investigated. Results and limitationsCure rate was 83% after TVT-O, 67% after TVT-Secur, and 87% after Mini-Arc. Improvement was found in 10%, 13%, and 7% of the patients, respectively. Failures were 7% after TVT-O and Mini-Arc and 20% after TVT-Secur.TVT-O and Mini-Arc improved at least 15 points in >80% of the patients in six KHQ domains, whereas TVT-Secur could only achieve improvement in three of the nine domains. The pain score was lower in the Mini-Arc group. Complications were more numerous after TVT-O. This study has the limitations inherent in a phase 2 trial with a follow-up limited to 12 mo. ConclusionsMini-Arc offers cure and improvement rates similar to TVT-O, whereas TVT-Secur may yield an inferior outcome. These findings recommend the urgent launch of large randomised phase 3 studies comparing conventional MUS with SIS, with Mini-Arc the advised option.

Tension-Free Vaginal Tape—A Suitable Procedure for Patients With Recurrent Stress Urinary Incontinence

In a recent report, the 10-year reoperation rate for stress urinary incontinence (SUI) after primary failure of anti-incontinence surgery was 17%. A tension-free vaginal tape (TVT) procedure has been effective for primary surgical treatment of SUI and long-term results have been promising. A number of studies have investigated repeat surgery with TVT for recurrent SUI but only one—a retrospective study—used a control group. Moreover, the follow-up period after a repeat TVT has been short; there has been only one uncontrolled prospective 4-year study. This prospective follow-up study investigated the use of the TVT procedure in women with recurrent SUI and those with primary SUI with respect to cure rates, complications, and safety. All participants had a TVT—60 in the study group (recurrent SUI)—and 70 in the control group (primary SUI). The initial follow-up was at 2 months after surgery and patients completed a questionnaire 3 years later evaluating the success of the operation and urinary symptoms. At a mean of 8 years (range, 6–10 years), patient records were examined for data on any subsequent visits or additional surgery. The primary outcome measures were subjective cure, complications, and voiding symptoms. The rate of transient postoperative retention was similar in the 2 groups (recurrent SUI, 17% vs. primary SUI, 19%, P = 0.78). No significant difference was found between the groups in the number of complications (recurrent SUI, 20% vs. primary SUI, 13%, P = 0.27). Spontaneous micturition resumed in all patients by the 10th postoperative day. At the 2-month follow-up visit, 85% of the patients in recurrent SUI group and 94% of those in the primary SUI group were free of SUI and completely satisfied with the outcome (P = 0.096). These data were almost identical at 3 years. Major complications following surgery were rare. At 2 months, 22% of the recurrent SUI patients and 19% of the primary SUI patients had de novo urge symptoms (P = NS); at 3 years, the rate of voiding difficulties was 17% in the primary SUI group and increased to 33% in the recurrent SUI group (difference between groups, P = 0.037). Subjective voiding dysfunction (feeling of incomplete emptying with or without recurrent urinary tract infections) was reported by 5 patients (8.3%) in the recurrent SUI group and in 17 patients (24%) in the primary SUI group at 3 years after the operation (P = 0.022). These findings suggest that TVT is safe and effective when performed for primary or recurrent SUI. There are no apparent differences in cure and complication rates after TVT between patients with and without previous SUI surgery.

Readjustable sling procedure for the treatment of female stress urinary incontinence with intrinsic sphincter deficiency: preliminary report.

PurposeThe Remeex (Mechanical External Regulation) sling is a mid-urethral sling that allows adjustment of the sling tension in the postoperative period. We evaluated the early outcomes of the procedure in patients in whom the success rate of tension-free slings is low, such as with intrinsic sphincter deficiency (ISD).Materials and MethodsWe included 17 women with urodynamically proven stress urinary incontinence (SUI) who underwent the Remeex procedure and were followed for at least 12 months. The patients were considered to have ISD on the basis of a Valsalva leak point pressure (VLPP) <60 cmH2O or a maximum urethral closure pressure (MUCP) <20 cmH2O. We analyzed parameters including history taking, urodynamic study (UDS), and postoperative clinical outcomes. Patient's success and satisfaction rates were evaluated after the procedure. Also, we asked about lower urinary tract symptoms (LUTSs) with a questionnaire, and the severity of LUTSs was assessed with the Visual Analog Scale (VAS) before and 12 months after the operation.ResultsThe patients' mean age was 55.6±9.58 years. Four (23.5%) patients had mixed incontinence. Five patients (29.4%) had undergone previous surgery for SUI. At a mean follow-up of 13.3 months (range, 12-16 months), 14 patients (82.3%) were cured and 3 patients (17.6%) were improved. Four patients (23.5%) answered very satisfied and 13 patients (76.4%) answered satisfied on the satisfaction questionnaire. Also, LUTSs were improved except voiding pain (p<0.05).ConclusionsThis procedure provides high cure and satisfaction rates. Our results demonstrate that the Remeex procedure is suitable for women with SUI with ISD.

Clinical and demographic factors associated with valsalva leak point pressure among women undergoing burch bladder neck suspension or autologous rectus fascial sling procedures

Many parameters have been utilized to try to estimate severity of stress urinary incontinence (SUI). Valsalva leak point pressure (VLPP) measurements, have been proposed as a reliable means of gauging the severity of SUI during urodynamic studies (UDS). Certain, non-invasive, measures of incontinence severity have been proposed, but the correlation of these measures with VLPP is not known. In addition, the correlation of other important UDS measures and VLPP has not been evaluated. In this study we sought to define the relationship between demographic characteristics, physical exam findings, and non-sphincteric UDS measures with VLPP in a large multicenter randomized surgical trial comparing Burch urethropexy and fascial sling for the treatment of SUI. Pre-surgical, standardized urodynamic measures were obtained in all participants in the Stress Incontinence Treatment Efficacy Trial (SISTEr) trial. All UDS were assessed for quality assurance and protocol compliance. VLPP was assessed using a <8 Fr water transducer catheter during graded Valsalva maneuvers at 200 ml, and then at 100 ml intervals and bladder capacity if no SUI was noted earlier. Only data from women who had SUI on at least two of three consecutive valsalva maneuvers was utilized for this analysis. Delta VLPP was determined as the average value, and the baseline vesical pressure was subtracted from the absolute vesical pressure to arrive at the reported VLPP value. Independent variables studied to assess their relationship to VLPP value included demographic characteristics (age, number of pregnancies, # vaginal deliveries, hormone usage, previous hysterectomy, previous SUI surgery), physical exam parameters [body mass index--BMI, Pelvic Organ Prolapse-Quantified POPQ stage, POPQ Aa measurement, Q-tip angle (rest) and Q-tip angle (strain), and change in angle], and other urodynamic parameters (volume of first leakage, volume at first sensation, presence of detrusor overactivity, maximum cystometric capacity--MCC, maximum flow rate--Q(max), and detrusor pressure at maximum flow rate--pdet.Q(max)). Among the 655 women randomized, 424 were found to have evaluable VLPPs. Thirty-four had stage 3 or 4 prolapse and were excluded from the VLPP analysis. The remaining 390 women had a mean VLPP of 81.1 cm H(2)O. On bivariate analysis, there were significant positive associations with VLPP and BMI (P = 0.026), Q-tip straining angle (P = 0.0002) change in Q-tip angle (P = 0.0046), MCC (P < 0.0001) and pdet.Q(max) (P = 0.0003). Age was negatively associated with VLPP (P < 0.0001). For categorical values, lower POPQ stage (0/1), post menopausal status, and use of hormones were all associated with lower VLPP values. For example, patients with stage 2 had, on the average, VLPP values that were more than 10 cm H(2)O greater than those with stage 0/1. On multivariate analysis, however, only lower age, greater BMI, greater MCC, greater pdet.Q(max), and lower Q(max) were found to be independent associated with higher delta VLPP. Advancing age, lower BMI, higher maximum flow rate, and lower voiding pressures are all independently associated with lower VLPP in women undergoing surgery for SUI. Lower voiding pressures and higher flow rates among women with more severe SUI may reflect the chronic loss of urethral resistance associated with SUI. Interestingly, urethral hypermobility as assessed by Q-tip testing angle does not achieve a statistically significant association with VLPP on multivariate testing when controlling for POP-Q stage. Thus, as clinically suspected, the Q-tip test is not predictive of VLPP in women with urethral hypermobility and SUI.

Suburethral sling procedures after previous surgery for urinary incontinence or pelvic organ prolapse

Objective. To compare the outcome of suburethral sling procedures (tension-free vaginal tape (TVT), obturator tape (Ob-tape)) for stress urinary incontinence (SUI) in women with previous surgery for SUI or pelvic organ prolapse (POP). Methods. A comparative, descriptive, retrospective study was done using information drawn from a urogynaecological database of 195 women with urinary incontinence. We divided 195 women into a group with previous surgery for urinary incontinence or POP (study group, N = 106) and a group without previous incontinence surgery (control group, N = 89). All women underwent a TVT (86%) or Ob-tape procedure (14%). The mean follow-up in the study group was 25 months (range 2 - 61 months) and in the control group 24 months (range 1 - 49 months). Since a urodynamic evaluation facility was not available for most women, the diagnosis of SIU and other types of incontinence was made clinically. Results. On admission 43 women in the study group presented with SUI (40.6%), compared with 34 in the control group (38.2%) (95% confidence interval (CI) -11.3%; 15.7%). Urge incontinence was present in 10 women in the study group (9.4%) and 6 in the control group (6.7%) (95% CI –5.7%; 10.6%). Mixed incontinence was present in 47 (44.3%) of the study group and 39 (43.8%) of the control group (CI –13.3%; 14.2%). The diagnosis was unknown in 6 women in the study group and 10 in the control group. Following surgery, SUI recurred in 25 (23.6%) women in the study group and 12 (13.5%) in the control group (95% CI –1.0%; 20.6%). Overactive bladder symptoms were present postoperatively in 43 women in the study group women (40.6%) and 39 controls (43.8%) (95% CI –16.9%; 10.4%). Follow-up surgery was performed in 14 women in the study group (13.2%) and 6 controls (6.7%) (95% CI –2.4%; 15.0%). Included were mesh removals (4 study group, 1 control), Burch colposuspension (1 and 2, respectively), and TVT or Ob-tape (2 and 1, respectively). Conclusion. Statistically, previous surgery was not a risk factor for recurrent SUI, but a tendency was observed towards more SUI in these women. South African Journal of Obstetrics and Gynaecology Vol. 13 (2) 2007: pp. 64-67

Résultats à trois ans de la prise en charge d'une incontinence urinaire d'effort avec pression de clôture urétrale basse par fronde sous-urétrale TVT

The aim of this study was to assess, with long-term outcome, the effectiveness of TVT for stress urinary incontinence (SUI) with low maximum urethral closure pressure (MUCP) and to identify predicting factors for failure in this case. This is a bicentric retrospective study including women who underwent a TVT procedure for grade 3-SUI according to the Ingelman-Sundberg's scale. All patients had a low MCUP defined by PCUM < 30 or by the formula 110-the age+/-20% cmH2O. Urethral hypermobility was defined on physical examination and urodynamic investigations. TVT was the only operation performed. Patients were assessed at three months then at longer term with an average follow-up of three years and ever less than one year. A total of 60 women 30 to 78 years old (mean age 55) were so operated. More than third of them (38%) had already been operated for incontinence. Thirty-eight percent had SUI without urethral hypermobility. Thirty percent presented bladder overactivity. The short-term evaluation found that, out of 58 patients, 70,6% cured, 10,3% improved and 18,9% classified as failure. The long-term evaluation, concerning 44 patients, found that 57% remained cured, 16% improved and 27% were classified as failure. Bladder overactivity was cured or improved in more than half of the cases (60%). Ten percent of de novo urgencies were noted, all of which persisted later on. For all that, as much as two thirds of these patients were satisfied with the TVT. Mean age of patients classified as failure, was higher (65 years). Previous SUI surgery did not modify the results. When the MUCP was < 20 cmH2O, success was present only one time out of two. The absence of urethral hypermobility decreased to a significant degree the probability of cure (38 vs. 82,6%, P < 0.01), and more still when bladder overactivity was associated (16,6 vs. 66,6%, P < 0.01). Postoperative voiding troubles constituted a pejorative factor for success of surgery. Even if results of TVT with low MCUP are worse, they do not remain less appreciable. When we confront the benefits awaited with this technique compared to the usually described complications, TVT must represent the first treatment of this indication.

Tratamiento de la incontinencia urinaria mediante sustancias inyectables: Análisis de nuestra serie

To determine the efficacy of endoscopical injections for the treatment of stress urinary incontinence (SUI), evaluating its low invasiveness and positive impact on quality of life. Belween 1997--2003 30 procedures of periurethral injection of various substances for urinary incontinence were performed at our department in women between 47-80 years. All patients were evaluated before surgery, clinically and urodynamically, in accordance to international standardized parameters (filling pressure/flow studies, maximum urethral closure pressure, LPP-leak point pressure). The kind of material employed for injection, surgical technique and satisfaction degree were also evaluated. The indication for surgery was SUI in 17 cases (56.6%), and mixed urinary incontinence in 73 cases (43.3%). 16 cases (53.3%) had history of previous surgery for SUI. Regarding urodynamic parameters, 19 patients (63.3%) have a maximum urethral closure pressure below 25 H2O cm, and 22 patients (73.3%) had a leak point pressure below 60 H2O cm. Collagen was employed in six cases (20%) and macroplastic in 24 (80%) (14 of them with the MIS system). 22 patients had three injection sites (73.3%). Mean follow-up was 38 months. Continence outcomes were evaluated in relation to complete continence (12 cases, 40%), mild incontinence and patient satisfaction (11 cases, 36.6%), and severe incontinence (7 cases, 23.3%). 1-To achieve acceptable results it is mandatory to do the best possible indication (Mc Guire type III SUI). 2.-There is an excellent relationship between minimal invasiveness and good results.