Prior Incontinence Surgery Research Articles

Poster 52: Transobturator (TOT) Suburethral Sling: Early U.S. Data on Safety and Efficacy

OBJECTIVE: This study was a report on early U.S. experience, including safety and efficacy of the new transobturator (TOT) sling for stress urinary incontinence. METHODS: This a retrospective case series of the initial 210 consecutive cases of TOT slings from 2 U.S. centers performed from August 2002 to December 2004. Cure was defined as subjective resolution of stress incontinence. QOL data was obtained using the short forms of the IIQ and UDI. RESULTS: Follow-up data were available on 209 patients. The mean (standard deviation) for subjective and objective follow up was 8.7 (4.5) months and 4.1 (3.4) months, respectively. The mean values (range) for age, parity, and body mass index were 58.5 years (30–83), 2.4 (0–8), and 27.96 (15.6–48.7), respectively. Twenty percent (n=42) of patients had prior incontinence surgery. Preoperatively, 45.9% (n=96) had mixed incontinence and 8.6% (n=18) had voiding dysfunction. Forty-two (20%) patients underwent an isolated sling procedure and the remaining had additional procedures. One hundred eighty-four patients (88%, 95% confidence interval: 83–92%) reported cure of SUI, 4 (1.9%) patients were improved, and 22 (10.5%) failed. The statistically significant difference between the cured and failed groups was: 1) failed patients needed longer postoperative catheterization (3.6 days ± 6.5 vs 1.5 ± 2.2, P=0.02) and 2) patients who had other additional procedures were more likely to report a cure (91% vs 76%, P=0.01). Mean duration of postoperative catheterization was 1.2 days. There were 2 (0.9%) intraoperative complications, one cystotomy, and one urethral injury. Nineteen patients (9.1%) had post op complications: 2 hematomas, one erosion, and 16 with groin pain. Five (2.8%) patients developed obstructive voiding dysfunction. Of these, 4 patients underwent sling release and one patient needed intermittent self-catheterization for 4 weeks. Twenty-three (11%) patients developed de novo urge incontinence. Reoperation rate was 6.6% (n=14): 3 sling plications and 5 TVTs for recurrent SUI, 4 sling releases, and 2 vaginoplasties. Postoperative QOL data was available for 137 (65.5%) patients and the mean IIQ-7 score was 1.04 (standard deviation [SD] 2.78) and the mean UDI-6 score was 2.21(SD 2.80). CONCLUSION: Early data suggests that the TOT sling is safe and effective. Longer-term studies are needed.

Paper 31: Pelvic Muscle Strength Decreases with Increasing Age, Parity and Symptoms of Stress Incontinence

OBJECTIVES: To determine whether digital assessment of pelvic muscle strength as rated by the Brink system is associated with patient characteristics and measures of urinary incontinence symptom severity in a cohort of women with stress incontinence scheduled to undergo surgery. METHODS: Baseline data from patients enrolled in the Urinary Incontinence Treatment Network Stress Incontinence Surgical Treatment Efficacy (SISTEr) trial were included in this analysis. At baseline, pelvic floor strength was assessed using the Brink scale (possible score range 3–12). Patient demographic variables included age, race, parity and history of prior incontinence surgery. Severity of urinary incontinence was measured by the Medical, Epidemiological, and Sociological Aspects of Aging (MESA) questionnaire, by standardized pad-weight testing, and by the number of daily incontinence episodes in urinary diaries. ANOVA was used to determine whether the Brink score differed significantly by each categorical independent variable, and linear regression was used to examine associations between the continuous independent variables and Brink scores. RESULTS: Baseline Brink data were available for 643 of the total 655 randomized patients in the UITN SISTEr trial. The sample was predominantly non-Hispanic white (73%). Mean (+/− SD) Brink score was 9 (+/− 2). Although absolute differences were small, the Brink score differed significantly by race (P=0.04), with mean Brink score for non-Hispanic black women being highest. There was a statistically significant difference in Brink score between patients who had prior hysterectomy and those who did not (P=0.004). The magnitude of the correlations between Brink score and the continuous independent variables were all small, but statistically significant in the case of negative correlations with age (r=−0.16, P<0.0001), number of vaginal deliveries (r=−0.10, P=0.01), and MESA scores (r=−0.09, P=0.02). Brink score did not correlate with clinical measures of incontinence severity including pad weights (r=−0.06, P=0.16) and number of accidents per day (r=0.02, P=0.53). CONCLUSION: Overall, pelvic muscle strength as rated by the Brink score was high in this cohort of incontinent patients. Associations between Brink scores and age, parity and MESA score were present but fairly small. The finding that Brink scores did not correlate with other clinical measures of incontinence severity suggests that the scale may be relatively insensitive to clinically important differences.

POST-VOID RESIDUAL URINE VOLUME IN WOMEN WITH OVERACTIVE BLADDER SYMPTOMS

Most patients with overactive bladder symptoms initially present to their primary care provider for treatment. It is currently recommended that post-void residual urine (PVR) should be measured during the assessment of women complaining of overactive bladder symptoms and anticholinergic medication should be used if PVR is low. However, many primary care providers are reluctant to measure PVR and, therefore, they may delay treatment or even inappropriately treat patients who have a high PVR. We identified clinical factors that are associated with increased PVR that could be used to select which patients are at risk for this. The charts of women presenting to our clinic with complaints of urinary frequency, urgency and/or urge incontinence were retrospectively reviewed. Patient demographics, physical examination and PVR were analyzed to determine if any factor was associated with increased PVR (100 ml or greater). The charts of 201 patients with complete data were reviewed. Patient age was 20 to 90 years (mean 55). Overall 19% of patients were found to have elevated PVR. Univariate analysis identified that older age, prior incontinence surgery, history of multiple sclerosis, greater American Urological Association Symptom Score, vaginal parity greater than 2, greater pad use and stage 2 or greater vaginal prolapse were associated with elevated PVR. Multivariate analysis identified age older than 55 years, prior incontinence surgery, a history of multiple sclerosis and vaginal prolapse stage 2 or greater as independent predictors of elevated PVR. It is possible to identify patients with overactive bladder symptoms who are at risk for elevated PVR based on history and physical examination. This could result in fewer patients needing PVR measurement prior to initiating treatment.

Long-term results of the Burch procedure combined with abdominal sacrocolpopexy for treatment of vault prolapse.

The aim of the study was to determine the long-term results of Burch procedures combined with vault prolapse repair by abdominal sacrocolpopexy. Between 1986 and 1997 82 women (mean age 46.0 years, range 27-79) underwent sacrocolpopexy combined with a Burch procedure. All patients presented with urinary incontinence and vault prolapse. The surgery consisted of a Burch procedure using non-absorbable suture material, and abdominal sacrocolpopexy with a non-absorbable mesh. The mesh was placed anteriorly and posteriorly in 66 cases, posteriorly (rectovaginal) in 12, and anteriorly (vesicovaginal) in 4. Additional procedures included hysterectomy (34 cases), enterocele repair (79 cases), and posterior repair with perineorrhaphy (65 cases). Failure was defined as the presence of persistent or worsened postoperative stress urinary incontinence (SUI). At a mean follow-up of 86 months (range 24-133) 34% (28/82) of patients were dry, and another 46% (38/82) were improved compared to their preoperative status. The postoperative SUI rate (persistent, worsened) after the placement of a single anterior mesh (4 failures out of 4) was higher than the postoperative SUI rate after combined meshes (41 failures out of 66) (log rank P = 0.05). All the patients with a history of prior surgery had worsened or persistent stress urinary incontinence (7/7), but 63% (47/75) of those with no prior surgery for stress urinary incontinence had worsened or persistent stress urinary incontinence (log rank P = 0.01). One case of recurrent rectocele was observed (after 20 months) and treated by transvaginal Richter sacrospinous fixation. At a mean follow up of 7 years, the Burch procedure combined with abdominal sacrocolpopexy appears to be less effective than previously published long-term results for the Burch procedure alone.

Is urethral mobility really being assessed by the pelvic organ prolapse quantification (POP-Q) system?

To estimate the relationship between Q-tip measurement of urethral hypermobility and visual assessment of the urethrovesical junction as assessed by points Aa and Ba of the pelvic organ prolapse quantification (POP-Q) system. A total of 274 patients with pelvic organ prolapse or urinary incontinence had preoperative Q-tip test straining angles and POP-Q staging measurements. By the Q-tip test, urethral hypermobility was defined as a straining angle of 30 degrees or greater relative to the horizontal. As defined in the POP-Q system, point Aa is located in the midline of the anterior vaginal wall 3 cm from the external urethral meatus and represents the urethrovesical junction. Point Ba represents the most dependent position of the anterior vaginal wall. The correlation between point Aa of the POP-Q system and the Q-tip test was assessed using the Spearman correlation coefficient. Similar assessments were made for point Ba. Mean age of the 274 subjects was 58.5 +/- 11.8 years; mean parity was 3.1 +/- 1.6. A total of 104 patients reported prior surgery for prolapse or incontinence. Mean Q-tip straining angle was 61 +/- 20 degrees; 258 (94%) had urethral hypermobility. Values of point Aa ranged from -3 cm to +3 cm, with median 0 cm. The correlation coefficient between the Q-tip straining angle and point Aa was r = 0.47 (P <.001). Urethral hypermobility was observed in 95% of patients with stage II prolapse at point Aa and in 100% of patients with stages III and IV prolapse at point Aa. The correlation coefficient between the Q-tip straining angle and point Ba was r = 0.32 (P <.001). Although the correlation between the Q-tip straining angle and point Aa of the POP-Q was moderately strong, one value cannot be predicted from the other. The Q-tip test may be unnecessary in patients with stages II, III, and IV prolapse at point Aa as virtually all such patients demonstrate urethral hypermobility.

Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization.

The study was a clinical series of 95 ambulatory women with urinary incontinence. After voiding, each subject was scanned with a BladderScan BVI 2500, then catheterized for postvoid residual (PVR) and then scanned again. The mean PVR obtained by ultrasound was 49 ml, significantly larger than the mean PVR of 32 ml obtained by catheterization. Correlation analysis showed that the difference was not related to age, weight, body mass index, parity, pelvic prolapse or prior incontinence surgery, but was associated with prior hysterectomy and uterine prolapse. Regression analysis revealed that the difference was independently related to prior hysterectomy only. Postcatheterization ultrasound detected a mean of 22 ml, suggesting that the difference between the PVR values may be due to residual urine not removed by catheterization. Finally, ultrasound had a sensitivity of 66.7% and a specificity of 96.5% in detecting PVR > or = 100 ml. Portable ultrasound scanners are quick, easy to use, reasonably sensitive, and very specific for determining elevated PVR.

Myosin isoforms in female human detrusor.

The aim of this study was to document the relative proportions of two isoforms of myosin heavy chain in detrusor smooth muscle of women with detrusor overactivity and in asymptomatic controls. Women aged 35-65 with documented detrusor overactivity and without a history of neurologic disease, prior incontinence surgery, elevated post-void residual urine volume, or indwelling urinary catheter were eligible for the study. Full-thickness biopsies of extraperitoneal bladder dome were obtained at the time of laparotomy in six patients with documented detrusor overactivity and in a control group of eight continent patients. Biopsies were frozen in liquid nitrogen, crushed with a frozen mortar and pestle at -80 degrees C, and homogenized in buffer, and the extracts were electrophoresed on 6% polyacrylamide sodium dodecyl sulfate gels and stained with Coomassie blue. The gels were de-stained and then the protein bands were scanned with a densitometer. The mean patient age was 48 years (range, 36-59). Seven patients were Caucasian and seven patients were African American. Detrusor smooth muscle contains a mean of 34% (range, 27-43%) SM1 and 66% (range, 57-73%) SM2 isoforms. There was no difference in isoform composition when patients were compared according to urogynecologic diagnosis or according to race. In detrusor biopsies from women, approximately 34% of myosin is of the SM1 isoform and approximately 66% is of the SM2 isoform. This ratio is relatively constant in the two races studied and unchanged in women with detrusor overactivity. Animal models utilizing outlet obstruction of the bladder to provoke detrusor instability and detrusor hypertrophy are known to alter myosin isoform distribution and may not be appropriate models of detrusor instability in human females.

Failure of allograft suburethral slings.

To report our experience of using freeze-dried irradiated fascia lata allografts for suburethral sling procedures. Between December 1996 and September 1998, 35 patients (mean age 60.25 years, range 37-79) underwent suburethral sling placement with fascia allograft. These patients were reviewed, with the findings at the time of any surgical re-exploration. Eleven (31%) had undergone prior surgery for genuine stress incontinence and 32 (91%) had a preoperative diagnosis of intrinsic sphincter deficiency. On re-operation for persistent or recurrent stress incontinence, the allograft was present but grossly degenerated in two (6%) patients and completely absent in five (14%) patients. Histology of a retrieved graft fragment showed both fibroblast proliferation and degeneration within the graft. The use of freeze-dried, irradiated fascia lata for suburethral sling procedures was associated with a material failure rate of >/=20%. We caution against its use in this setting.

LONG-TERM RESULTS OF THE STAMEY BLADDER NECK SUSPENSION: DIRECT COMPARISON WITH THE MARSHALL-MARCHETTI-KRANTZ PROCEDURE

Purpose We performed followup of a cohort of women who underwent the Stamey endoscopic needle suspension (group 1) or the Marshall-Marchetti-Krantz vesicourethropexy (group 2) between 1975 and 1983. Materials and Methods Telephone interviews were performed to assess current continence status and time to failure. Risk factors for recurrence of incontinence were correlated with long-term results. Results Long-term data were obtained for 32 of 41 women (78%) in group 1 and 36 of 54 (67%) in group 2. Range of followup was 9.4 to 19.9 years (median 15.0, mean 15.2) in group 1 and 13.2 to 21.9 (median 16.8, mean 17.0) in group 2. Of group 1 patients 44% remained dry compared to 33% of group 2 patients. Persistent local side effects were reported by 9% of group 1 and 0% of group 2. Urinary urgency was present in 70% of group 1 patients and 23% of group 2. There was no relationship between long-term operative success and age at surgery, degree of preoperative incontinence, parity, obesity, prior incontinence surgery or prior hysterectomy for either procedure. Conclusions The Stamey and the Marshall-Marchetti-Krantz procedures yield high initial cure rates with progressive, parallel declines in continence status with time.

Laparoscopic burch repair compared to laparotomy Burch for cure of urinary stress incontinence

Sixty-two women underwent either laparoscopic Burch urethropexy or open Burch urethropexy for surgical correction of genuine stress urinary incontinence. Only patients with no prior incontinence surgery and with demonstrated genuine stress incontinence were included. Clinical evaluations were done preoperatively, at 3 months and 1 year postoperatively for objective cure. The preoperative evaluation included a 24-hour urolog, urology questionnaire, Q-tip test, cough stress test, perineal ultrasound, cystourethroscopy and simple-channel cystometrics. At follow-up all patients had repeat Q-tip test, perineal ultrasound and cough stress test. If there was any sign of leaking a repeat single-channel cystometrogram was done. Only patients with a negative objective study were considered cured. Differences in laparoscopic versus laparotomy cure rates at 1 year were insignificant (94% versus 93%). Both procedures stabilized the urethrovesical junction and prevented its descent during straining, as demonstrated by the postoperative Q-tip test and the perineal ultrasound. The two bladder procedures had comparable operative times but patients with laparoscopy voided earlier, were outpatients, and returned to work earlier. In conclusion, short-term results suggest that the laparoscopic Burch urethropexy can give similar results to laparotomy Burch urethropexy for correction of genuine stress incontinence.