Primary Sling Research Articles

A method for determining the position of the center of gravity of a bulky cargo for safe reloading on a ship

Based on the analysis of the equilibrium equations of a two-link suspension system for bulky cargo, two methods for determining the position of the center of gravity of this cargo are proposed. The essence of the methods consists in double suspension of this system and measuring the angles of its deviation in the suspended equilibrium position. In this case, the difference in the angles of deviation of the system between suspensions is provided either by changing the height of the primary suspension (the length of the primary slings), or by changing the ratio of the masses of the traverse and the load. A comparative analysis of the accuracy and practical feasibility of both methods is carried out. It is shown that when carrying out cargo operations in a port or on a ship, a method in which the difference in the angles of deviation of the system between suspensions is carried out by changing the length of the primary slings (the height of the primary suspension) is practically feasible and more accurate. The work emphasizes that an important condition for ensuring the stability of the system when hanging and preventing overturning of the load is that the primary slings (connecting the hook and the traverse) must be of such length that the suspended load can virtually be inscribed inside the pyramid (safety pyramid) formed by the traverse and these slings. It is also shown that the length of the secondary slings (connecting the traverse and the load) does not matter, but they must be of equal length and parallel to each other, which will ensure their vertical position after hanging the system. The heavier the traverse (in comparison with the weight of the suspended cargo), the higher the safety pyramid, and therefore the more stable the cargo suspension system as a whole becomes. On the other hand, the longer the primary slings (the higher the safety pyramid), the smaller the angles of deviation of the traverse (and the system as a whole) from the initial position when suspended. To demonstrate the possibilities of the proposed new method for determining the position of the cargo center, a numerical example of its implementation is given.

07: A minimally-invasive modification for fascia lata mid-urethral sling

The aim of this video is to demonstrate modifications which permit an autologous fascial sling to be performed in a minimally-invasive way. Both the Crawford and Masson fascial strippers are demonstrated on a cadaver. A 4cm transverse incision on the lateral aspect of the thigh approximately 6cm superior to the lateral femoral epicondyle is made. The stripper is advanced for fascial harvest. The “sling on a string” is prepared with a 2-0 monofilament suture transfixed at each end. A tie is placed around the suture insertion points to bind the fascia and provide greater tensile strength. A 1cm midline suprapubic incision is made in preparation for a single trocar exit site. Bilateral tunnels are created extending from the mid-urethra to the inferior aspect of the pubic symphysis in the usual fashion. The monofilament suture leader is then placed in a groove on the retropubic sling trocar. The trocar is advanced through the vaginal incision, aiming initially for the ipsilateral shoulder. Once the tip reaches the abdominal fascia, but before it pierces it, the trocar is directed medially to allow exit via the 1cm midline suprapubic incision. The sling is placed flat under the mid-urethra. A clamp resting between the mid-urethra and graft ensures the desired degree of tension. The sutures are tied suprapubically to each other across the midline over the fascia while the desired loose placement is maintained at the mid-urethra. These are techniques which preserve both function of the leg and maintain high patient satisfaction. Loose placement of “sling on a string” at the mid-urethra likely lowers risk of voiding dysfunction and urinary retention compared to urethrovesical junction under tension. This minimally-invasive technique is appropriate to consider as a primary sling for patients seeking to avoid mesh.

Trends in urodynamic testing prior to midurethral sling placement-What was the value of the VALUE trial?

Many urologists use urodynamic testing (UDS) to assist clinical decision-making. The VALUE study, a multi-institutional, randomized controlled trial published in 2012, demonstrated that UDS prior to midurethral sling placement for uncomplicated stress urinary incontinence (SUI) did not change management. We sought to determine whether use of UDS for evaluation of SUI diminished thereafter. Records of patients who underwent isolated mid-urethral sling surgery at our tertiary-care referral center from 2008 to 2009 (pre-VALUE) and 2014 to 2016 (post-VALUE) were reviewed. Comorbidities, presenting symptoms, surgeon specialty, use of UDS, UDS results and sling type were recorded. Patients with neurologic comorbidities or prior anti-incontinence procedures were excluded. Descriptive statistics were calculated and multivariable logistic regression analyses performed. Three hundred and eighty-seven patients met inclusion criteria. Median age was 54 years. Patients most frequently presented with stress urinary incontinence (56% pre, 50% post), followed by stress predominant mixed urinary incontinence (40% pre, 48% post, P = 0.09). Before VALUE, UDS was performed in 70% of patients prior to primary sling; in the later cohort, this decreased to 41% (P < 0.0001). On multivariable analysis, provider specialty (P < 0.0001) and belonging to the pre-VALUE cohort (P = < 0.0001) predicted use of UDS prior to sling. It is paramount that new data be incorporated into diagnostic and treatment algorithms. We found that the rate of preoperative urodynamic testing decreased after publication of a randomized-controlled trial demonstrating that these studies did not change procedural decision-making. Future studies that identify instances of over-testing may have the ability to positively impact patient care and contain costs.

Concurrent midurethral sling excision or lysis at the time of repeat sling for treatment of recurrent or persistent stress urinary incontinence

Limited evidence guides operative technique in primary midurethral sling (MUS) lysis or excision at the time of repeat sling placement for persistent or recurrent stress urinary incontinence (SUI). Our objective is to compare subjective improvement in patients undergoing repeat MUS placement with and without concurrent primary sling lysis or removal. This was a retrospective cohort study with a prospective survey of patients who underwent two MUS placements for SUI at a single institution from January 1996 to December 2015. After patient identification, the electronic record was queried for demographic and perioperative data. Subjects then completed the Urogenital Distress Index, (UDI-6), Incontinence Severity Index (ISI), and the Incontinence Impact Questionnaire (IIQ-7). Subjects were also asked if they would choose to undergo repeat MUS surgery again. Sixty-one patients were included. 17 out of 61 (28%) underwent concomitant primary sling lysis or excision, and 44 out of 61 (72%) did not. Fifty-seven percent (n=35) completed the survey. Of the respondents, the median ISI score was 4 (1-8), with no difference between groups; 14 out of 35 (40%) reported the presence of bothersome urge incontinence, 11 out of 35 (31%) reported bothersome stress urinary incontinence, and 8 out of 35 (23%) reported symptoms of voiding dysfunction, with no difference between groups. 57% of patients (20 out of 35) would undergo repeat MUS placement again. In a small cohort, concurrent excision of the primary sling at the time of repeat MUS did not improve subjective outcomes. Many patients reported urinary urgency and voiding symptoms, and only about half of patients would choose to undergo the surgery again if given the choice.

Clinical Case Discussion: Repeat Sling Surgery—Should We Offer a Second Sling?

Advantages of secondary sling surgery for persistent or recurrent stress urinary incontinence include low complexity and short operation time, low blood loss, and short hospitalization. Rates of perioperative complications, erosion, and postoperative voiding difficulties are comparable with primary sling surgery. The presence of urethral (hyper)mobility after primary midurethral sling seems to be an important factor affecting success rates of repeat sling surgery.

Predictors of vaginal mesh exposure after midurethral sling placement: a case-control study.

Female stress urinary incontinence is highly prevalent, and synthetic midurethral sling placement is the most common type of anti-incontinence surgery performed in the USA. We aimed to identify risk factors associated with surgery used to treated vaginal mesh exposure after midurethral sling placement for stress urinary incontinence. We identified women who underwent anti-incontinence procedures from January 2002 through December 2012. Patients with vaginal mesh exposure undergoing surgical repair after midurethral sling placement were compared with a control group without mesh exposure in a 1:3 ratio. Patients with ObTape sling placement (Mentor Corporation) were excluded. Logistic regression models were used to evaluate associations between clinical risk factors and vaginal mesh exposure. Overall, 2,123 patients underwent primary sling placement, with 27 (1.3%) having vaginal mesh exposure necessitating surgical repair. Patients with mesh exposure were more likely to have undergone previous bariatric surgery (P = 0.008), hemoglobin <13g/dL (P = 0.006), premenopausal status (P = 0.008), age <50years (P = 0.001), and the retropubic approach to sling placement (P = 0.03). Multivariate analysis identified these risk factors: previous bariatric surgery (odds ratio [OR], 7.0; 95% CI, 1.1-61.4), retropubic approach (OR, 5.7; 95% CI, 1.1-107.0), preoperative hemoglobin <13g/dL (OR, 2.8; 95% CI, 1.1-7.5), and premenopausal status (OR, 2.6; 95% CI, 1.0-7.3). Among postmenopausal patients, those with mesh exposure were significantly more likely to receive preoperative estrogen therapy (OR, 12.4; 95% CI, 2.7-57.8). Previous bariatric surgery, retropubic approach, premenopausal status, and lower preoperative hemoglobin were associated with a significantly increased risk of surgery for vaginal mesh exposure after midurethral sling placement. Recognizing these factors can improve preoperative patient counseling.

The Outcome of Repeated Mid Urethral Sling in SUI Treatment after Vaginal Excisions of Primary Failed Sling: Preliminary Study.

Mid urethral sling is the standard in SUI treatment. Nevertheless, the risk of reoperation reaches 9%. There is no consensus as to the best treatment option for complications. A question is raised: what is the optimal way to achieve the best result in patients after primary failure? The aim of the study was to evaluate the outcomes of repeat MUS surgery in patients after excision of the sling with recurrent SUI. We compared its effectiveness with uncomplicated cases treated with TVT. 27 patients who underwent the repeated MUS and 50 consecutive patients after primary TVT were enrolled in the study. After 6 months, we have found that 24 (88.46%) patients from repeat sling group and 48 (96%) patients after primary sling were dry (1-hour pad test, 2 g or less). The difference between groups was not significant. We showed statistically significant improvement of quality of life in both groups. In conclusion, we showed that repeated sling after MUS excision is almost as effective as primary MUS. We postulate that sling excision and repeated MUS may be the best option for persistent SUI and/or complications after MUS procedures. Further multicenter observations are ongoing as to provide results on bigger group of cases.

This Month in Adult Urology

No AccessJournal of UrologyThis Month in Adult Urology1 Oct 2015This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.06.086AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Adult Urology." The Journal of Urology, 194(4), pp. 861–862 References 1 : Active surveillance is superior to radical nephrectomy and equivalent to partial nephrectomy for preserving renal function in patients with small renal masses: results from the DISSRM registry. J Urol2015; 194: 903. Link, Google Scholar 2 : Primary endoscopic realignment of urethral disruption injuries—a double-edged sword?. J Urol2015; 194: 1022. Link, Google Scholar 3 : Compliance with American Urological Association guidelines for post-percutaneous nephrolithotomy antibiotics does not appear to increase rates of infection. J Urol2015; 194: 992. Link, Google Scholar 4 : Robotic level III inferior vena cava tumor thrombectomy: initial series. J Urol2015; 194: 929. Google Scholar 5 : The artificial urinary sphincter is superior to a secondary transobturator male sling in cases of a primary sling failure. J Urol2015; 194: 1038. Link, Google Scholar 6 : Age and obesity promote methylation and suppression of 5α-reductase 2: implications for personalized therapy of benign prostatic hyperplasia. J Urol2015; 194: 1031. Link, Google Scholar © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 194Issue 4October 2015Page: 861-862 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. Smith More articles by this author Expand All Advertisement PDF downloadLoading ...

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure

We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling. We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis. A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31). In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

Intravesical midurethral sling mesh erosion secondary to transvaginal mesh reconstructive surgery

Abstract Objective We sought to evaluate the feasibility and the outcomes of correcting the intravesical mesh erosion after secondary mesh augmented pelvic reconstructive surgery pervaginally. Methods We evaluated a case of mesh erosion following midurethral sling that occurred 4 years after secondary mesh surgery. Prior to second surgery, ultrasound and cystoscopy examination were performed to exclude mesh complication. Serial examinations during follow-up after the operation were uneventful until the patient presented 4 years after the second surgery with a history of dysuria and hematuria. Cystoscopy examination discovered intravesical mesh erosion 4 years after the secondary surgery. Removal of the midurethral sling mesh erosion and bladder repaired were done vaginally. Results The patient was still symptom free and continent 1 year following tape excision. Urodynamic evaluation 6 months post-tape excision was also normal. Conclusion Repeated vaginal reconstructive surgery may jeopardize a primary mesh or sling, and pose a high risk of mesh erosion, which may be delayed for several years. Removal of the mesh erosion and bladder repair are feasible pervaginally with good outcome.

PD24-11 THE ARTIFICIAL URINARY SPHINCTER IS SUPERIOR TO A SECONDARY TRANSOBTURATOR MALE SLING IN CASES OF A PRIMARY SLING FAILURE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2015PD24-11 THE ARTIFICIAL URINARY SPHINCTER IS SUPERIOR TO A SECONDARY TRANSOBTURATOR MALE SLING IN CASES OF A PRIMARY SLING FAILURE Divya Ajay, John Selph, Michael Belsante, Ngoc-Bich Le, Aaron Lentz, George Webster, and Andrew Peterson Divya AjayDivya Ajay More articles by this author , John SelphJohn Selph More articles by this author , Michael BelsanteMichael Belsante More articles by this author , Ngoc-Bich LeNgoc-Bich Le More articles by this author , Aaron LentzAaron Lentz More articles by this author , George WebsterGeorge Webster More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1466AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The male transobturator sling (TOS) is a minimally invasive treatment for postprostatectomy stress urinary incontinence (PPSUI). Reported success rates for the male transobturator sling (TOS) are 41-76%. In the case of a failed primary sling, many surgeons offer a secondary sling; however, there is no literature describing the success of a secondary TOS placement in these situations. Our objective was to assess the success of secondary TOS in comparison to AUS for PPSUI patients who failed a primary TOS. METHODS We retrospectively reviewed all patients undergoing salvage procedures after failure of TOS from 2006 to 2012 at our institution. Demographic and follow-up data were extracted by chart review. Post-operative success was defined as the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g/day. Cox regression model and Kaplan-Meier survival analysis were performed. RESULTS 61 men were included. All had a TOS for PPSUI and presented with persistent incontinence after initial sling placement. 32 subsequently underwent placement of an AUS and 29 had a secondary TOS at a median of 10(IQR 6-29) and 14(IQR 7-19) months from primary TOS surgery, resp. The mean ages of the AUS and secondary TOS cohorts were not significantly different. 47% of the AUS cohort had received prior external beam radiation therapy versus 18.5% of the secondary TOS (p<0.01). Average pre-operative 24 hour pad weight was higher in the AUS cohort (517g) versus the TOS cohort (274g; p<0.01). The median follow-up for the AUS and TOS patients was 5 (IQR 4-16) and 4 (IQR1-5) months, resp. Treatment failure was seen in 55% (16/29) of secondary TOS versus 15% (5/32) of AUS patients with a hazard ratio of 2.9 (95%CI 1.1-8.3). 6 (21%) patients who failed a secondary TOS went on to receive an AUS. Figure 1 shows improved treatment success rates for TOS failures who received an AUS versus a secondary TOS (p=0.03). CONCLUSIONS In this cohort of patients with PPSUI who failed TOS, those who underwent a secondary TOS were 2.9 times as likely to have persistence incontinence in comparison to those who underwent AUS placement. This finding was noted despite the fact that there was a higher likelihood of radiation therapy in the AUS group. This data may be very useful in counseling patients and surgical planning. We currently recommend placement of an AUS for patients who have failed an initial TOS. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e490 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Divya Ajay More articles by this author John Selph More articles by this author Michael Belsante More articles by this author Ngoc-Bich Le More articles by this author Aaron Lentz More articles by this author George Webster More articles by this author Andrew Peterson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

468 The artificial urinary sphincter is superior to a secondary transobturator male sling in cases of a primary sling failure

468 The artificial urinary sphincter is superior to a secondary transobturator male sling in cases of a primary sling failure

Evaluation of Salvage Male Transobturator Sling Placement Following Recurrent Stress Urinary Incontinence After Failed Transobturator Sling

To evaluate the outcome of patients treated with a salvage AdVance male sling after a failed primary transobturator sling placement. Retrospective review of patients treated at our center with a primary and subsequent salvage AdVance sling. Success was defined as a dry safety pad or no pads (cured), or >50% improvement in pads used per day and patient satisfaction (improved). Early primary sling failures (<6 months) were compared with late (≥6 months) failures with regard to continence outcomes. We identified 18 patients who underwent a salvage AdVance sling placement at our institution. Overall success was 72% at 6 months postoperatively and 56% at a mean follow-up of 17.5 months, including 50% and 39% of patients who were dry at those same time periods. Patients failing late after their primary sling (n = 8) enjoyed improved outcomes with salvage sling placement compared with patients who failed early (n = 10) after the primary sling. At 6 months, more patients in the late primary failure group were cured (75% vs. 30%; P = .031). These improved cure rates remained significant through final follow-up with cure rates of 63% and 20%, respectively (P = .041). Salvage AdVance male sling is a viable treatment option after a failed primary sling procedure, especially in patients who demonstrated a prolonged efficacy period before primary sling failure.

MP38-16 COMPARISON OF OUTCOMES OF MINIARC AND MONARC SLINGS: UPDATE OF A SINGLE-CENTER SURGICAL SERIES

INTRODUCTION AND OBJECTIVES: Previous studies showed that Single incision MiniArc slings are a safe procedure associated with high success and low complications rates. Furthermore, comparative studies, suggest that MiniArc and Monarc perform equally in the treatment of stress urinary incontinence (SUI). A pilot study conducted by our group confirmed similar results between MiniArc and Monarc. However, a larger population with a longer follow-up is needed to validate such results. In this context we aimed at assessing the rate of favourable outcomes and the rate of complications of MiniArc compared to Monarc slings in a large cohort of patients with a long follow up at a single tertiary referral center METHODS: The study includes 381 patients treated with primary sling for SUI between 2003 and 2012 at our center. Of them 166 (44%) underwent a MiniArc sling procedure, and 215 (56%) a Monarc procedure. All surgeons had adequate experience in sling surgery. The choice of sling was left at the discretion of the surgeon. All patients had complete data including age, history of diabetes mellitus (DM), BMI, presence of Mixed Urinary Incontinence (MUI). Postoperative outcomes were: persistent or recurrent stress incontinence rate (PoRSUI), surgical failure (SF) (i.e. need of second surgery for PoRSUI), subjective cure (SC), subjective improvement (SI), and no pads usage over 24 h (zero pad) rates. SC was defined as a negative response to the question “do you still experience any urinary leakage during activities?” while SI was considered in women who responded yes to the question “are you satisfied with the results?”. Finally we assessed post operative pain and erosion rates in both groups. Chisquare and Wilcoxon rank test were used to compare the outcomes between groups RESULTS: Mean follow up was 66 months (range 12-138). MiniArc and Monarc groups resulted homogeneous in terms of age, DM, BMI and MUI. The rate of PoRSUI in MiniArc and Monarc group was 6% and 13% respectively (p1⁄40.02). SF rate was 9% (n1⁄415) in MiniArc and 13% (n1⁄428) in Monarc patients (p1⁄40.22). SC, SI and no pads usage were 87%, 86%, 90% and 89%, 88%, 91% in MiniArc and Monarc respectively (all p>0.05), while post-operative pain and erosion rate were significantly higher in Monarc patients (14% vs 7% and 6% vs 0.6% respectively, all p<0.01) CONCLUSIONS: This study confirms the similar performance of both slings in terms of post-operative outcomes, with difference in erosion and pain rates, in a large cohort of patients with a longer follow up. Our results highlight, once again, the optimal outcomes of MiniArc not only in the short term but also with a mid-term follow-up

MP33-11 THE MALE TRANSOBTURATOR SLING HAS A HIGH REOPERATION RATE AND INCREASED COST IN MEN WITH A HISTORY OF RADIATION AFTER PROSTATECTOMY: A COST-BASED ANALYSIS

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence Therapy I1 Apr 2014MP33-11 THE MALE TRANSOBTURATOR SLING HAS A HIGH REOPERATION RATE AND INCREASED COST IN MEN WITH A HISTORY OF RADIATION AFTER PROSTATECTOMY: A COST-BASED ANALYSIS Shubham Gupta, Aaron Lentz, Ngoc-Bich Le, George Webster, and Andrew Peterson Shubham GuptaShubham Gupta More articles by this author , Aaron LentzAaron Lentz More articles by this author , Ngoc-Bich LeNgoc-Bich Le More articles by this author , George WebsterGeorge Webster More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.962AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The male transobturator sling (TOS) has diminished outcomes when used in patients who have undergone prior radiation therapy. We evaluated the need for additional treatment and associated procedural costs after placement of the TOS in men with post prostatectomy stress incontinence and a history of radiation. METHODS We conducted a retrospective review of post prostatectomy, post radiotherapy patients who had undergone surgical implantation of the TOS at a single institution. Patients were evaluated preoperatively with video-urodynamics, three day voiding diary, flexible cystourethroscopy, and 24-hour pad number and weight. Postoperatively, patients were evaluated at 6 weeks, 3 months, 6 months and yearly thereafter. Success was defined as cured (0 or 1 security pad use) or improved (>50% reduction in incontinence) and lack of any secondary incontinence operation. We performed bivariate statistical analysis in order to determine variables associated with success. The need for secondary operation for incontinence was evaluated, and cost data for the primary sling and secondary operations were analyzed. RESULTS Thirty patients were included in our analysis with a median follow-up of 12.38 months. Five patients (16.67 %) were cured, seven (23.33 %) improved, while 18(60%) failed the surgery. One patient (3.3%) had a complication referable to sling placement. 13 patients (43.3%) underwent one or more secondary procedures for continued incontinence (12 artificial urinary sphincters and 2 repeat slings). The mean direct cost per patient for sling implantation was $5,555 and for an artificial urinary sphincter (AUS) placement was $10,314. All of the patients undergoing a secondary AUS at our institute had cure of incontinence. For patients who had a secondary AUS placed after sling failure, the mean aggregate cost in order to achieve continence (direct sling cost + direct AUS cost) was $16,018. CONCLUSIONS The efficacy of the male TOS is decreased in patients who have undergone post-prostatectomy radiation therapy, and a large proportion of these patients will seek secondary intervention for continued incontinence. A secondary AUS placement is associated with cure of incontinence but increases the aggregate cost to achieve satisfactory results. Patients should be thoroughly counseled that the male sling is associated with low efficacy, a high rate of secondary procedures, and increased cost in the setting of prior radiation. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e342 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Shubham Gupta More articles by this author Aaron Lentz More articles by this author Ngoc-Bich Le More articles by this author George Webster More articles by this author Andrew Peterson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD33-10 OUTCOMES AND PREDICTORS OF REOPERATION AFTER SLING RELEASE SURGERY

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology I1 Apr 2014PD33-10 OUTCOMES AND PREDICTORS OF REOPERATION AFTER SLING RELEASE SURGERY Marisa Clifton, Sherif A. El Nashar, Deborah Lightner, and Daniel Elliott Marisa CliftonMarisa Clifton More articles by this author , Sherif A. El NasharSherif A. El Nashar More articles by this author , Deborah LightnerDeborah Lightner More articles by this author , and Daniel ElliottDaniel Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2293AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Lower urinary tract symptoms are well-documented complications of sling placement and can occur in 5-20% of patients. Urethrolysis is a common procedure utilized to relieve these symptoms. We aimed to report on the outcomes after sling release surgery and to evaluate the predictors of reoperation. METHODS A retrospective review of 143 consecutive female urethrolysis procedures at the Mayo Clinic from January 1, 2000 through August 1, 2012 was performed. Only patients who underwent primary sling placement prior to urethrolysis were included. The clinical features and outcomes of this cohort were recorded. Survival analysis and regression modeling were utilized to calculate the cumulative reoperation rate and detect potential predictors of reoperation after sling release surgery. RESULTS During our study duration, 93 women had sling release after sling placement. Eight had initial transobturator slings, 47 had autologous or cadaveric pubovaginal slings (A/C-PVS) and 38 had synthetic retropubic slings. Indications for sling release included de novo urge in 13(14%), obstruction in 76 (82%) and infections in 4 (4%). The mean age (SD) of patients at the time of sling release was 58.1 (13.2) years with a mean followup after sling release of 39.3 (range, 1 to 124) months. During followup, 22 (24%) women required an additional surgery for persistent or de novo symptoms with a 5 year cumulative reoperation rate of 26.3 % (95%CI 15.8, 36.9). Reoperation for recurrent stress urinary incontinence occurred in 13 (14%) patients and included A/C-PVS in 7, synthetic sling in 2, and bladder neck bulking injection in 4. Reoperation for persistent obstructive symptoms occurred in 9 (10%) patients and included repeat sling release in 3, InterStim placement in 2, Botox injection in 2, and urethral dilation in 2 patients. At last follow up, 28 (32%) patients were taking anticholinergic medication and 18 (21%) required continued intermittent catheterization. In the 76 women who had sling release for obstructive symptoms, those with excision or complete removal tended to have lower reoperation rates (6 /35 or 17%) compared to those who had sling incision (10/41 or 24%)(P=0.44). CONCLUSIONS One in four women who had sling release surgery required an additional operative procedure within 5 years. Patients who had sling incision for obstructive symptoms tended to require reoperation more frequently than those who had excision or complete removal of their sling. This information is invaluable during patient counselling prior to proceeding to sling release surgery. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e844 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Marisa Clifton More articles by this author Sherif A. El Nashar More articles by this author Deborah Lightner More articles by this author Daniel Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Repeat versus primary slings in patients with intrinsic sphincter deficiency

Our goal was to compare outcomes of repeat vs. primary synthetic slings in patients with stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). We reviewed patients who underwent a sling for SUI with ISD from 2003 to 2010. The patients were divided into two groups according to whether they underwent primary or repeat sling. Surgical success was defined as no incontinence and no reintervention (i.e., urethral bulking) during follow-up. Statistical analysis included the unpaired t test, Wilcoxon rank sums test, chi-squared/Fisher's exact tests, and logistic regression to identify risk factors associated with failure. Six hundred and thirty-seven patients with ISD underwent a sling procedure at our institution; 557 (87 %) a primary sling and 80 (13 %) a repeat sling. Patient demographics were similar. Preoperatively, patients with recurrent SUI reported more subjective bother. Mean follow-up was 66.5 weeks (24-374). Success was achieved in 81 % of primary compared with 55 % of repeat slings (p<0.0001). Repeat patients were 3.4 times more likely to fail surgery [odds ratio (OR) =3.43, 95 % confidence interval (CI) 2.1-5.6]. Additionally 30 % of the repeat group underwent urethral bulking postoperatively compared with 8.6 % in the primary group (OR=4.4, 95 % CI 2.5-7.7). Prior incontinence procedures, a positive supine stress test, and transobturator sling were independent risk factors for failure. Among the types of slings placed (transobturator, retropubic, tensioned pubovaginal), pubovaginal slings were most successful (OR=2.7, 95 % CI 1.4-5.2). In women with ISD, repeat slings are associated with lower success rates compared with primary slings. Pubovaginal slings resulted in the highest success rate compared with both transobturator and retropubic slings.

A repeat mid-urethral sling as valuable treatment for persistent or recurrent stress urinary incontinence

The value of a repeat mid-urethral sling (MUS) after a failed primary sling is not generally accepted. We hypothesize that repeat MUS can be performed with favorable results and acceptable complication rates. We reviewed the medical records of 80 women (mean age 62 ± 12.3 years) who underwent repeat MUS surgery from January 2000 to January 2009 at a single tertiary academic centre. Mean follow-up was 44.8 months (range 3-104). Three of these 80 patients were lost to follow-up. Twenty-six (33%) transobturator (TOT), 25 (31%) retropubic (TVT) and 16 (20%) minislings were placed as secondary slings. Thirteen slings (15%) were biological (Pelvicol™). In 4 patients (5%) a release of the primary sling was performed, and in 6 (7.5 %) the extruded sling fragment was totally excised prior to secondary sling placement. The overall subjective cure rate was 61.0%. Of the study group 74.0% reported subjective improvement. The amounts of pads reduced from a mean of 3.8 pads a day to a mean of 0.75 pads a day postoperatively. The objective cure rate was 63.5%. The incidence of de novo urgency was 8.2% (4 patients). When comparing different secondary sling types no difference was found in the overall continence rate, except for the biological sling. More than half (7 out of 13) of the patients from whom the secondary sling was a biological sling, were not satisfied (p=0.01). The subjective improvement rates in patients with recurrent or persistent stress urinary incontinence (SUI) were 68.2% and 75.0% respectively. This difference is not statistically significant (p=0.94). Excision versus release of the MUS showed a slightly higher satisfaction rate after excision, 84.6% and 74.0 % respectively (p=0.63). Cure rates and improvement rates of a repeat MUS are favorable and complication rates are acceptable. It should be offered to patients with persistent or recurrent SUI after a failed primary sling, even after previous release or excision.

Repeat mid-urethral sling for recurrent female stress urinary incontinence

The aim of the study was to assess the effectiveness of repeat mid-urethral sling after a failed primary sling for stress urinary incontinence. A total of 112 women with recurrent stress incontinence after primary mid-urethral sling underwent a repeat procedure between 2000 and 2011. All patients had a preoperative clinical and urodynamic evaluation. Outcomes were divided into three groups: cured (no more leaks), improved (decrease of leaks), or failed. All patients had urethral hypermobility and 12.9 % had intrinsic sphincter deficiency [maximum urethral closure pressure (MUCP) ≤ 20 cmH2O]. Median MUCP was 41 cmH20. Overactive bladder was found in 5.7 % of women. The second sling placed was one of the following: retropubic Tension-free Vaginal Tape (49 %), transobturator tape (48 %), or mini-sling (3 %). No intraoperative morbidity was reported. After the second sling was placed, 68 (60.7 %) patients were subjectively cured and 18 (16.1 %) improved (76.8 % success overall) with a mean follow-up of 21 months. Success rates were 72.2 and 81.8 % for transobturator and retropubic slings, respectively, with no significant difference. Multivariable analysis showed higher odds of cure and improvement with the retropubic approach after adjusting for MUCP. Late complication rates were comparable to those observed after a first sling. Urodynamic parameters were not associated with postoperative success. Repeat mid-urethral sling for recurrent female stress urinary incontinence is nearly 77 % successful in a group of patients with persistent urethral hypermobility. A retropubic approach might be preferred for patients with low urethral closure pressures.

Long-Term Results of Bulking Agent Injection for Persistent Incontinence in Cases of Neurogenic Bladder Dysfunction

We evaluated the effectiveness of bladder neck injection as a supplementary treatment for persistent low pressure incontinence after unsatisfactory fascial sling procedures in patients with neurogenic lower urinary tract dysfunction. A total of 89 patients with neurogenic lower urinary tract dysfunction underwent fascial sling procedures between 1992 and 2005. Because of unsatisfactory results, 27 patients received endoscopic injection of a bulking agent. All patients included in the study underwent urodynamic examination after the sling procedure, which revealed persistent low pressure transurethral leakage of urine. We retrospectively analyzed the endoscopic approach used to administer the bladder neck injection, method of postoperative catheterization and number of injections given. Efficacy of bladder neck injection was graded by the patient and the urologist. After a median followup of 8 years (range 2.5 to 14) only 2 patients (7%) were continent after having received a single injection of bulking agent. A total of 12 patients (44%) were given a second injection and 8 (30%) were given a third injection but these subsequent injections did not result in continence. Of the patients 16 (59%) eventually underwent bladder neck surgery, 2 (7%) were dry and 8 (30%) accepted the inconvenience. Two patients underwent ileocystoplasty and 1 patient underwent botulinum A toxin (Botox(R)) injection due to decreased bladder capacity and poor bladder compliance. Neither the endoscopic approach nor the method of postoperative catheterization affected the success rate. Bladder neck injection after failure of primary sling procedures has limited value in patients with neurogenic lower urinary tract dysfunction. Repeat bladder neck injection yields no additional benefits.