Procedure For Stress Urinary Incontinence Research Articles

PD05-08 SURGICAL MANAGEMENT OF FEMALE STRESS URINARY INCONTINENCE: 22-YEAR POPULATION-LEVEL TRENDS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy I1 Apr 2018PD05-08 SURGICAL MANAGEMENT OF FEMALE STRESS URINARY INCONTINENCE: 22-YEAR POPULATION-LEVEL TRENDS Joseph LaBossiere, Christopher Wallis, Lesley Carr, Refik Saskin, Robert Nam, and Sender Herschorn Joseph LaBossiereJoseph LaBossiere More articles by this author , Christopher WallisChristopher Wallis More articles by this author , Lesley CarrLesley Carr More articles by this author , Refik SaskinRefik Saskin More articles by this author , Robert NamRobert Nam More articles by this author , and Sender HerschornSender Herschorn More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.416AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Available in Canada since 1999, transvaginal sling (TVS) procedures are an effective treatment for women with stress urinary incontinence (SUI). Though rare, complications associated with transvaginal mesh led to warnings from the U.S. Food and Drug Administration (FDA) and Health Canada in 2008 and 2010, respectively. We hypothesized that these warnings would significantly decrease the utilization of TVS procedures for SUI. Therefore, we sought to characterise trends in the surgical management of SUI in a single-payer healthcare system in Ontario, Canada over a 22-year period. METHODS We performed an interrupted time-series analysis using segmented regression among women aged 18 years and older undergoing surgical treatment for SUI between January 1, 1994 and December 31, 2016 in Ontario, Canada. The passage of time was considered the primary exposure. The outcome was the annual population-adjusted rates of SUI surgery over time stratified by modality: urethropexy, TVS, abdominal/vaginal sling and transurethral bulking agents. RESULTS We identified 120 999 women who underwent SUI surgery between 1994 and 2016. The total number of SUI procedures did not significantly change between 1994-2000 (mean 95 per 100 000 population, p=0.89). From 2000-2009, the total number of SUI procedures significantly increased (95 to 147 per 100 000 population, p<0.001) driven by a significant increase in TVS procedures (19 to 129 per 100 000 population, p<0.001). During this time period, the number of urethropexy, abdominal/vaginal sling and bulking agent procedures significantly decreased (p<0.001). After 2009, annual rates of any SUI procedure decreased, a trend which continued during the remainder of the study period (147 to 64 per 100 000 population, p<0.001). This trend was associated with a significant decrease in TVS procedures (130 to 60 per 100 000 population, p<0.001) over the same period as well as significant declines in each of the other SUI treatment modalities (p<0.001). CONCLUSIONS In this large, population-based cohort, we identified a significant influence of the FDA and Health Canada warnings on patient and physician behaviour regarding the management of SUI. Prior to 2009, the overall number of SUI surgeries performed was significantly increasing, driven by increasing utilization of TVS procedures. Following the regulatory warnings, the overall rate of SUI procedures significantly declined, comprising both TVS procedures and other operative interventions. These data suggest that the regulatory warnings had a significant effect on how patients and physicians approach surgical management of SUI. Further, it suggests that many women may be living with untreated SUI. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e147-e148 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Joseph LaBossiere More articles by this author Christopher Wallis More articles by this author Lesley Carr More articles by this author Refik Saskin More articles by this author Robert Nam More articles by this author Sender Herschorn More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cancer Risk After Midurethral Sling Surgery Using Polypropylene Mesh.

To assess whether there is any association between the implantation of synthetic polypropylene mesh slings for the treatment of stress urinary incontinence (SUI) and risk of cancer. We performed a nationwide cohort study based on the general female population in Sweden. All women entered the observational period as unexposed on January 1, 1997, and contributed person-time as unexposed unless they underwent a midurethral sling procedure for SUI, after which they contributed person-time as exposed until first occurrence of any cancer, death, emigration, or end of the observational period (December 31, 2009). Occurrence of primary cancer was ascertained from the Cancer Register. Hazard ratios (HRs) with 95% CIs were calculated by Cox proportional hazards regression. The final study population included 5,385,186 women, including 20,905 exposed, encompassing a total of 44,012,936 person-years at risk. Other than an inverse association with rectal cancer (HR 0.5, 95% CI 0.3-0.8), there were no significant differences in risk between exposed and unexposed women for pelvic organ cancers including ovarian (HR 0.8, 95% CI 0.5-1.2), endometrial (HR 1.1, 95% CI 0.8-1.4), cervical (HR 0.4, 95% CI 0.2-1.0), bladder, and urethra (HR 0.7, 95% CI 0.4-1.2). No significant association was observed between exposed women and primary cancer in any organ system when compared with unexposed women. The relative risk for cancer after exposure showed little variation over time except for an inverse overall correlation within the first 4 years of surgery (HR 0.7, 95% CI 0.7-0.8). The incidence rates per 100,000 person-years (95% CIs) for exposed vs unexposed women were 20.5 (14.3-29.5) vs 21.0 (20.6-21.5) for rectal cancer, 25.5 (18.4-35.3) vs 19.8 (19.4-20.2) for ovarian cancer, 65.0 (53.0-79.8) vs 33.1 (32.6-33.7) for endometrial cancer, 5.7 (2.8-11.3) vs 11.9 (11.6-12.2) for cervical cancer, and 19.1 (13.1-27.8) vs 13.3 (13.0-13.7) for bladder and urethra cancer. Our results suggest that midurethral polypropylene sling surgery for SUI is not associated with an increased cancer risk later in life.

Influence of body mass index on short-term subjective improvement and risk of reoperation after mid-urethral sling surgery.

The objective was to evaluate the impact of body mass index (BMI) on the subjective improvement and risk of reoperation after first-time mid-urethral sling surgery. Data were retrieved from the national Danish Urogynaecological Database, including women with first-time surgery with mid-urethral polypropylene slings from 2011 to 2016. The subjective improvement was assessed by the difference in symptoms based on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) completed pre- and 3months postoperatively. A reoperation was defined as any new surgical procedure for stress urinary incontinence performed within the study period. During the study period, 6,414 mid-urethral sling procedures were performed; 80.0% of these women filled out both pre- and post-surgical International Consultation on Incontinence Questionnaire (ICI-Q) forms. 42.4% had a BMI < 25, 34.6% had BMI 25-30, 16.9% had BMI 30-35, and 6.0% BMI >35. The subjective improvement after surgery was high in all BMI categories and there were no differences between the categories. The overall cumulative hazard proportion at 2years of follow-up was 1.9% (CI 95%: 1.6-2.3) and after 5years 2.4% (CI 95%: 2.0-2.9). Adjusted for age, smoking, and use of alcohol, the cumulative hazard proportion after 2years of follow-up was 3.2% (CI 95%: 1.6-6.2) for women with BMI >35 and after 5years 4.0% (CI 95%: 2.0-7.7), which was the highest proportion of reoperation in the study. The crude hazard ratio was 1.84 (CI 95%: 0.89-3.83) women with BMI >35 and the adjusted hazard ratio was 1.94 (CI 95%: 0.92-4.09). We found high subjective improvement after the first-time surgery unrelated to BMI. Women with a BMI over 35 had the highest proportion of reoperations, although this was not statistically significant.

14: Perioperative outcomes in patients with autoimmune connective tissue disorders (AICTDs)

To compare rates and severity of perioperative complications following pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery in patients with and without autoimmune connective tissue disorders (AICTD). The secondary objective was to evaluate pre- and postoperative pelvic floor symptoms including a POP and SUI symptom recurrence. In this retrospective cohort study, we identified patients with AICTDs by ICD-9 codes and those known to surgeons. Controls without AICTDs were matched to the primary POP or SUI procedure and surgeon. Primary outcome was complication rate up to 6 weeks postoperative. Secondary outcomes were preoperative and postoperative pelvic floor symptoms including symptoms of a bulge or stress incontinence, and need for reoperation or pessary placement for recurrent POP or SUI. A sample size of 88 patients with AICTDs and 88 controls was calculated to detect a 20% difference in complications with 80% power and a significance level of 0.05. We identified 84 patients with AICTDs and 84 matched controls. The distribution of AICTDs included rheumatoid arthritis (50%), Sjögren’s disease (17%), systemic lupus erythematosus (9%), psoriatic arthritis (5%), polymyositis (4%), mixed connective tissue disorders (4%), scleroderma (2%), and other autoimmune connective tissue disorders (9%). Race, ethnicity, age (mean 62.3 years old), tobacco use (6%), prior POP (7.1%), and SUI (19.1%) surgery, and prior hysterectomy (6%) were similar between groups. AICTD patients and controls were mostly post-menopausal (79.2%) and had similar vaginal parity (mean 2.2). AICTD patients had higher BMI (30.1 vs. 27.4, p < 0.0050) and baseline Charlson Comorbidity scores (2.5 vs. 1.1, p < 0.0001). Eighty-eight percent of patients had POP surgery comprised of 73% apical support procedures, 79% posterior repairs, and 58% anterior repairs. Forty-eight percent had concomitant hysterectomy and 62% had SUI surgery with the majority being mid-urethral slings (54%). Patients with AICTDs had more blood loss (128.2 vs. 93.9 ml, p = 0.0196) and more total perioperative complications (25% vs. 10%, p = 0.0079). However, there were no differences between groups in rates of specific categories of preoperative complications (see Table 1). For those with at least one postoperative complication, there was no difference in Clavien-Dindo grades between groups. Seventy-five percent of complications were classified as grade I, 13% as grade II, 8% as grade III, 4% as grade IV, and there were no grade V complications. Of the 84 patients with AICTDs, 17 (20%) are on daily systemic oral steroids, 25 (30%) are on immunomodulators or disease-modifying medications, and 9 (11%) are on both. Use of systemic oral steroids, immunomodulators, or disease-modifying medications did not impact the rates of complications. There were no differences in POP recurrence (4%), SUI recurrence (9%), de novo SUI (4%), additional SUI treatment (1%), and preoperative and postoperative symptoms or anatomic outcomes between groups. Patients with AICTDs have more severe medical co-morbidity as defined by the Charlson Comorbidity score, and higher overall complication rates following surgery for POP and SUI compared with matched controls.

70: Long-term improvements in physical activity levels and physical functioning after midurethral sling for female stress urinary incontinence

To estimate the long-term effect of the midurethral sling on leisure physical activity (PA) levels and physical functioning (PF) in women 5 or more years after surgery for stress urinary incontinence (SUI). We conducted a long-term follow-up study of a previously published prospective, observational study of women undergoing outpatient midurethral sling for SUI from 2009 to 2011. For the primary study, and this follow-up study, women completed validated questionnaires for incontinence, leisure PA, and PF at baseline and postoperatively. The questionnaires included the UDI-6, International Physical Activity Questionnaire (IPAQ), Pelvic Floor Distress Inventory-20 (PFDI-20), Body Image Scale (BIS), and the NIH Patient-Reported Outcomes Measurement Information System measure for physical functioning (PROMIS-PF). Women were categorized as having sedentary, insufficient, or sufficient leisure PA levels by metabolic equivalents (MET-min/week on the IPAQ). They were also categorized as having low, moderate, or high overall PA levels using IPAQ scoring rules. For this follow-up study, all patients who consented to participating in future studies at the time of enrollment in the initial study were contacted via telephone to complete questionnaires through mail or e-mail. PA and PF levels were compared pre-operatively and at 5 or more years follow-up. Paired T-tests, signed-rank tests, and linear regression were used to estimate the effect of improvements in urinary symptoms on PA levels and PF scores at long-term follow-up. Of the 85 women enrolled in the primary study, 48 consented to being contacted for future studies. Of these, 28 completed surveys through mail or e-mail (58% response rate) and the long-term follow-up range was 5 to 7.5 years. The baseline mean age of the 28 participants was 51 years (SD 8), 64.3% had comorbidities, mean baseline UDI score was 50.3 points (SD 22.4). At baseline, no patients were categorized as having low overall PA, 26.9% were categorized as moderate, and 73.1% were categorized as high. 26.9% were categorized as having sedentary baseline leisure PA levels, 15.3% as insufficient, and 57.7% as sufficient. At long-term follow-up, 57.1% of women with low baseline leisure PA levels improved to moderate or high levels and 50.0% of women with moderate leisure PA improved to high leisure PA levels (P = 0.6). For overall PA levels, 7.7% improved their overall level of PA, while 53.8% maintained the same level of overall PA (P > 0.05). PROMIS-PF scores improved significantly between baseline and long-term follow up (mean 44.8 vs 52.9, P < 0.0001). When comparing 6 month post-operative results to long-term follow-up, BMI remained stable (29.78 vs 29.23), as did PFDI (11.98 vs 14.06), and BIS (4 vs 3) scores (all P > 0.05). On multiple linear regression, each 11- point improvement in UDI was associated with a mean improvement of 1.32 points in PF scores (P = 0.04), adjusting for age, comorbidity and baseline PA level at long-term follow up. Midurethral sling procedures for SUI are associated with long-term improvements in PA levels and PF.

32: Reoperation rates for stress urinary incontinence and pelvic organ prolapse in women undergoing a mid-urethral sling in academic centers within the United States

The aim of this study was to look at reoperation rates for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women who underwent a primary mid-urethral sling with or without concurrent POP repair. We hypothesized that women undergoing an SUI procedure with concurrent prolapse repairs would have decreased rates of reoperation for both prolapse and stress urinary incontinence. We also theorized that concurrent hysterectomy would be associated with lower rates of reoperation for POP and SUI, while prolapse repair with mesh would be associated with higher complication rates but lower rates of reoperation. The Faculty Practice Solutions Center (FPSC) is an academic hospital consortium database with information from over 60,000 physicians. This database was used to identify a cohort of patients who were treated surgically for SUI with a mid-urethral sling, with or without concurrent prolapse repair between 2009 and 2011. These patients were followed until 2014 for any subsequent SUI or POP surgeries and for any mesh complications that occurred during this time period. Patient variables (age, region, insurance) as well as surgeon volume were analyzed. Concurrent prolapse repair was analyzed based on anatomic involvement (anterior, apical, posterior, or “complete”). Sub-analyses were performed to evaluate the differences in secondary procedures. Of the 20,484 patients who underwent an SUI repair with or without concurrent POP repair, 7.2% required reoperation within the follow up period. There was a significantly higher rate of reoperation in those women who underwent concurrent prolapse repair (8.6 vs 6.3%). Women who had a concurrent prolapse repair had a 2-to-5-fold higher hazard of undergoing a repeat prolapse repair. Concurrent hysterectomy was performed in 15% of patients. While its addition did not lower the hazard of requiring any secondary surgery, it lowered the rate of repeat prolapse surgery in patients who received a concurrent ‘complete’ repair (HR = 0.48). Prolapse mesh was placed in 5% of patients. Its use resulted in a higher hazard of requiring any additional surgery (HR = 1.4), and specifically, increased the hazard of requiring repeat prolapse repair (HR = 1.5). Post-operative fistula, although rare (0.4%), had a significant association with older patients (HR = 2.1) and prolapse mesh (HR = 2.7) placement. Medicaid insurance was associated with higher risk of requiring secondary surgery (HR = 1.3). With over 20,000 patients and up to a 5 year follow-up, this is one of the largest cohort studies performed on the surgical outcomes of mid-urethral slings with or without prolapse repair surgery. While the overall reoperation rate was low, the addition of prolapse repair surgery with the initial sling procedure was associated with higher reoperation rates. In contrast, the addition of a hysterectomy lowered the risk of secondary surgery in some patients. This data allows for a clearer understanding of reoperative rates for patients undergoing mid-urethral sling placement with or without prolapse repair.

The Effects of Outside-in Versus Inside-out Transobturator Tapes, for Stress Urinary Incontinence, on Sexual Function and Quality of Life: A Prospective Study

Objective: To assess the effects of outside-in versus inside-out transobturator tapes for stress urinary incontinence on sexual function, quality of life and psychosocial state. Material and Methods: The study was performed on a total of 101 females, who underwent transobturator tape outside-in or inside-out procedures for stress urinary incontinence with no concomitant prolapse repair, between September 2014 and October 2015 at the clinic in Istanbul, and completed a validated quality of life, sexual function, and psychosocial state questionnaires before and after surgery. The scales used for the assessment included the Hospital Anxiety and Depression Scale, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 and Sexual Quality of Life Questionnaire-Female. Results: The HADS scores showed a statistically significant decrease (an indicator of improvement of anxiety and depression) in the postoperative period in both the groups (p<0.05). The PISQ-12 scores increased in both the groups in the postoperative period, indicating improvement (p<0.05). The preoperative sexual and partner relationship SQoL-F scores were significantly higher in the inside-out group than in the outside-in group (p<0.05). Conclusion: The results of this study suggest that transobturator tape procedures for stress urinary incontinence have a positive outcome on female sexual function and quality of life. However, further prospective studies, with more participants, are warranted to support these preliminary findings to be able to compare the impact of transobturator tape outside-in or inside-out routes on female sexual function, quality of life and psychosocial state more precisely.

Postoperative urinary symptoms after transobturator tape in normal-weight compared with overweight and obese woman.

ObjectivesTo examine the clinical outcome of obesity in women who underwent the transobturator tape procedure for stress urinary incontinence and to compare postoperative urinary symptoms after transobturator tape surgery between normal-weight women and overweight and obese women.MethodsWe performed a retrospective cohort study of the risk of postoperative urinary symptoms, including recurrence after transobturator tape surgery, in normal-weight women compared with overweight and obese women at our institution from January 2009 through October 2011. We compared the body mass index (BMI) among the four groups. The primary outcome was the occurrence of postoperative urinary symptoms.ResultsThree hundred ten patients who underwent transobturator tape surgery were reviewed. At the 1-year follow-up, 281 women were analyzed: 89 (34%) normal-weight women, 78 (25%) overweight women, 101 (37%) obese 1 women, and 13 (3%) obese 2 women. There was a significant difference in the occurrence of postoperative urinary symptoms. They occurred in 3.4% (n=3) of normal-weight women, 5.1% (n=4) of overweight women, and 12.9% (n=13) of obese 1 women (P=0.038). The most common postoperative urinary symptom was frequent urination (n=14). There was a significant difference in leakage; it occurred in 1.1% (n=1) of normal-weight women, 3.9% (n=3) of overweight women, and 7.9% (n=8) of obese 1 women (P=0.139). Postoperative urinary symptoms were almost four times more likely to occur in obese 1 women than in normal-weight women.ConclusionTransobturator tape surgery seems effective regardless of BMI, but obese women had a higher occurrence of postoperative urinary symptoms than did normal-weight women.

Prospective and randomized clinical trial comparing transobturator versus retropubic sling in terms of efficacy and safety.

The midurethral sling is the most commonly performed surgical procedure for stress urinary incontinence (SUI). We compared the efficacy of transobturator tape (TOT) and retropubic (RP) slings by evaluating objective and subjective cure rates at 12months postsurgery and evaluate the impact on quality of life (QoL) and record intra- and postoperative complications. This was a randomized, controlled, prospective, clinical trial with analysis of noninferiority. The hypothesis was that the TOT sling is not inferior to the RP sling. A total of 92 women with SUI were selected and randomized into two groups: TOT and RP slings. Eighty-one patients maintained follow-up 12months postoperatively. In the per-protocol analysis, the objective cure rates were 100% for the RP sling and 93% for the TOT sling (p=0.029). The subjective cure rates were 92% for the RP sling and 90% for the TOT sling (p=0.02). Because none of the upper limits of the confidence interval (CI) were above the noninferiority margin, noninferiority of the TOT sling could be concluded. In contrast, the intention-to-treat analysis could not show that the TOT sling was not inferior to the RP sling, because the upper limit of the CI surpassed the noninferiority margin. Postoperative complications were similar for both groups, except for higher urinary retention rates in the RP group. Regarding QoL, there was a significant improvement. The cure rates of the per-protocol analysis showed the noninferiority of the TOT relative to the RP sling. The RP sling group exhibited higher urinary retention. Quality of life improved significantly in both groups.

Complications following vaginal mesh procedures for stress urinary incontinence: an 8 year study of 92,246 women

Complications of surgical mesh procedures have led to legal cases against manufacturers worldwide and to national inquiries about their safety. The aim of this study was to investigate the rate of adverse events of these procedures for stress urinary incontinence in England over 8 years. This was a retrospective cohort study of first-time tension-free vaginal tape (TVT), trans-obturator tape (TOT) or suprapubic sling (SS) surgical mesh procedures between April 2007 and March 2015. Cases were identified from the Hospital Episode Statistics database. Outcomes included number and type of procedures, including those potentially confounded by concomitant procedures, and frequency, nature and timing of complications. 92,246 first-time surgical mesh procedures (56,648 TVT, 34,704 TOT, 834 SS and 60 combinations) were identified, including 68,002 unconfounded procedures. Peri-procedural and 30-day complication rates in the unconfounded cohort were 2.4 [2.3–2.5]% and 1.7 [1.6–1.8]% respectively; 5.9 [5.7–6.1]% were readmitted at least once within 5 years for further mesh intervention or symptoms of complications, the highest risk being within the first 2 years. Complication rates were higher in the potentially confounded cohort. The complication rate within 5 years of the mesh procedure was 9.8 [9.6:10.0]% This evidence can inform future decision-making on this procedure.

Cumulative Incidence of a Subsequent Surgery After Stress Urinary Incontinence and Pelvic Organ Prolapse Procedure.

To assess the 5-year risk and timing of repeat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures. We conducted a retrospective cohort study using a nationwide database, the 2007-2014 MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases (Truven Health Analytics), which contain deidentified health care claims data from approximately 150 employer-based insurance plans across the United States. We included women aged 18-84 years and used Current Procedural Terminology codes to identify surgeries for SUI and POP. We identified index procedures for SUI or POP after at least 3 years of continuous enrollment without a prior procedure. We defined three groups of women based on the index procedure: 1) SUI surgery only; 2) POP surgery only; and 3) Both SUI+POP surgery. We assessed the occurrence of a subsequent SUI or POP procedure over time for women younger than 65 years and 65 years or older with a median follow-up time of 2 years (interquartile range 1-4). We identified a total of 138,003 index procedures: SUI only n=48,196, POP only n=49,120, and both SUI+POP n=40,687. The overall cumulative incidence of a subsequent SUI or POP surgery within 5 years after any index procedure was 7.8% (95% confidence interval [CI] 7.6-8.1) for women younger than 65 years and 9.9% (95% CI 9.4-10.4) for women 65 years or older. The cumulative incidence was lower if the initial surgery was SUI only and higher if an initial POP procedure was performed, whether POP only or SUI+POP. The 5-year risk of undergoing a repeat SUI or POP surgery was less than 10% with higher risks for women 65 years or older and for those who underwent an initial POP surgery.

Review of surgical implant procedures for male incontinence after radical prostatectomy according to IDEAL framework.

Most aspects of surgical therapy for stress urinary incontinence (SUI) after radical prostatectomy (RP) are under debate or poorly studied. A systematic review was conducted and a literature search was carried out through PubMed database for articles on the surgical procedures for male SUI after RP published from Jan 2010 to Nov 2016. The efficacy results (pad count, 24h pad test), complications, and quality of life (QoL) were reported. The included studies were categorized in accordance with the IDEAL framework of surgical innovation. Only Stage 0-2 IDEAL studies were revealed by systematic review of the literature. Randomized and long-term trials are missing. The current evidence on male SUI therapy is low. IDEAL-conform evaluation of new therapies should be applied in the future.

Recurrence of Stress Urinary Incontinence After Midurethral Sling Revision: A Retrospective Cohort Study.

The primary objective is to determine the relative risk (RR) of reoperation for stress urinary incontinence (SUI) recurrence after midurethral sling (MUS) division or excision. Our secondary objective is to determine the RR of SUI symptom recurrence according to differing techniques of revision. This is a retrospective cohort study of all women who underwent surgical revision of an MUS by the Division of Urogynecology at the Women & Infants' Hospital during a 10-year period between October 1, 2004, and October 1, 2014. Sling division technique separates the sling from the urethra enough to permit transection either in the midline or lateral to the urethra. Revision was categorized as excision if a portion or the entirety of the sling was removed. Patients who underwent any operative procedure for SUI after revision were considered to have received reoperation. Subjectively, patients were considered to have postrevision recurrence of SUI if it was reported during routine evaluation/interviews or in the incontinence severity index questionnaire. There were 102 patients who underwent revision of a type 1 mesh MUS; 45 underwent sling division, and 57 underwent mesh excision. After sling division, 4.4% of the patients underwent reoperation for recurrent SUI compared with 28.1% after sling excision (RR, 0.16; 95% confidence interval, 0.04-0.65). Stress urinary incontinence symptoms recurred in 13% after sling division versus 56% after excision (RR, 0.24; 95% confidence interval, 0.11-0.52). The choice of technique may be dictated by the clinical scenario, but in situations in which sling division is an option, repeat operations and symptoms of SUI occur less frequently.

Long-term outcomes of autologous fascia lata sling for stress incontinence secondary to intrinsic sphincter deficiency in women

ObjectiveTo report our long-term pubovaginal sling (PVS) outcomes using fascia lata for stress urinary incontinence (SUI) secondary to intrinsic sphincteric deficiency (ISD). Methodology and methodsFollowing Institute Review Board approval, charts from women undergoing PVS with fascia lata, with at least 6 months of follow up, were reviewed. Preoperative and postoperative data collected included demographics, validated questionnaires, prior anti-incontinence procedures, associated repairs, urodynamic findings, and reoperation procedures for SUI. Success was defined as cure of SUI (no pad, UDI-6 Question 3 related to SUI at ≤ 1, and no SUI reoperation). ResultsBetween 1997 and 2013, 22 women met the inclusion criteria with mean age of 73 (52–88) years, mean BMI 29 (17–38) and mean parity 2.7 (1–4). Mean follow up was 96 months (8–190). Indication for fascia lata sling included obesity (13) and prior abdominal procedures (9), including abdominoplasty. Fifteen women had received one or more prior antiincontinence procedures and five a prior injectable agent. No perioperative complications were noted. Overall, 14 of 22 women met success criteria [UDI-6 Question 3 at 0 (10) and at 1 (4)]. Three women underwent a subsequent procedure for residual SUI with periurethral bulking agent and one is awaiting an artificial urinary sphincter. ConclusionAt long-term follow-up of over 8 years after fascia lata sling, women who underwent fascia lata sling had acceptable continence outcomes with minimal complications.

Characteristics of Providers Performing Urogynecologic Procedures on Medicare Patients 2012-2014.

To analyze the characteristics of providers performing stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures in the United States. The Centers for Medicare Services public database, released for years 2012 through 2014, was queried for SUI-related and POP-related Healthcare Common Procedure Coding System. Providers were categorized as Female Pelvic Medicine and Reconstructive Surgery (FPMRS) providers and non-FPMRS providers, using a list of FPMRS board-certified providers compiled through the American Board of Medical Subspecialties website. Other physician specialties that submitted SUI and POP procedures claims were tabulated. Six hundred twenty-nine FPMRS and 833 non-FPMRS providers submitted claims for SUI and POP procedures. The SUI procedures claims had the following provider specialty distribution: obstetrics and gynecology (OB/GYN)-FPMRS, 46.7%; urology, 26.3%; OB/GYN, 12.2%; and urology-FPMRS, 13.9%, with the remaining 0.9% being performed by other specialties. The POP procedures had the following specialty distribution: OB/GYN-FPMRS, 63.4%; OB/GYN, 16.7%; urology, 8.3%; and urology-FPMRS, 7.1%, with the remaining 4.5% being performed by other specialties.Provider distribution was compared between transvaginal mesh and sling insertion procedures to transvaginal mesh and sling removal procedures. The FPMRS providers claimed 63.6% of sling and transvaginal mesh insertion procedures and performed 84.9% of mesh and sling removal procedures. Medicare reimbursement data provides a unique insight into the distribution of provider specialties performing SUI-related and POP-related procedures in the Medicare population. The OB/GYN-FPMRS providers submitted the majority of claims for SUI and POP procedures from 2012 to 2014. The FPMRS providers are also performing the majority of mesh removal procedures.

Long-term outcomes of TOT and TVT procedures for the treatment of female stress urinary incontinence: a systematic review and meta-analysis.

One of the most relevant topics in the field of pelvic floor dysfunction treatment is the long-term efficacy of surgical procedures, in particular, the use of prosthesis. Hence, a systematic review and meta-analysis was conducted to evaluate the long-term effectiveness and safety of midurethral sling (MUS) procedures for stress urinary incontinence (SUI), as reported in randomised controlled trials (RCTs) and non-randomised studies. This systematic review is based on material searched and obtained via PubMed/Medline, Scopus, and the Cochrane Library between January 2000 and October 2016. Peer-reviewed, English-language journal articles evaluating the long-term (≥5years) efficacy and safety of MUS in women affected by SUI were included. A total of 5,592 articles were found after the search, and excluding duplicate publications, 1,998 articles were available for the review process. Among these studies, 11 RCTs (0.6%) and 5 non-RCTs (0.3%) could be included in the qualitative and quantitative synthesis. Objective and subjective cumulative cure rates for retropubic technique (TVT) and transobturator tape (TOT; both out-in and in-out) were 61.6% (95% CI: 58.5-64.8%) and 76.5% (95% CI: 73.8-79.2%), and 64.4% (95% CI: 61.4-67.4%) and 81.3% (95% CI: 78.9-83.7%) respectively. When considering TOT using the out-in technique (TOT-OI) and TOT using the in-out technique (TVT-O) the objective and subjective cumulative cure rates were 57.2% (95% CI: 53.7-60.7%) and 81.6% (95% CI: 78.8-84.4%), and 68.8% (95% CI: 64.9-72.7%) and 81.3% (95% CI: 77.9-84.7%) respectively. Furthermore, this article demonstrates that both TVT and TOT are associated with similar long-term objectives (OR: 0.87 [95% CI: 0.49-1.53], I 2 = 67%, p = 0.62) and subjective (OR: 0.84 [95% CI: 0.46-1.55], I 2 = 68%, p = 0.58) cure rates. Similarly, no significant difference has been observed between TTOT-OI and TVT-O) in objective (OR: 3.03 [95% CI: 0.97-9.51], I 2 = 76%, p = 0.06) and subjective (OR: 1.85 [95% CI: 0.40-8.48], I 2 = 88%, p = 0.43) cure rates. In addition, this study also shows that there was no significant difference in the complication rates for all comparisons: TVT versus TOT (OR: 0.83 [95% CI: 0.54-1.28], I 2 = 0%, p = 0.40), TOT-OI versus TVT-O (OR: 0.77 [95% CI: 0.17-3.46], I 2 = 86%, p = 0.73). Independent of the technique adopted, findings from this systematic review and meta-analysis suggest that the treatment of SUI with MUS might be similarly effective and safe at long-term follow-up.

Female sexual function associated with the use of tension free vaginal tape for stress urinary incontinence

IntroductionFemale urinary incontinence is a common problem in middle-aged women. Up to 50% of the adult female population have stress urinary incontinence, and the prevalence of sexual dysfunction in these women is around 50%. The aim of this study is to evaluate sexual function before and after a urinary incontinence surgical procedure using tension-free vaginal tape (TVT) or transobturator tape (TOT). Material and methodsA prospective study was conducted on 22 sexually active women who underwent TVT or TOT procedures for stress urinary incontinence by assessing the Female Sexual Function Index (FSFI) before, and 3 and 6 months after surgery. ResultsThe study included 22 women with a mean age of 48.3±6.46 years, who underwent TVT or TOT for stress urinary incontinence. The median abdominal leak point pressure (ALPP) was 85.5±17.2cm H2O, with a median pelvic organ prolapse quantification (POPQ) of 0.28±0.45. Female sexual function assessed with the FSFI improved in all the aspects of the questionnaire. The mean total FSFI score before surgery was 21.57±3.53, at 3 months after surgery it was 26.05±3 (P=0.0001), and at 6 months post-op it was 27.28±5.03 (P=0.001). Coital incontinence improved in 90% of the participants, and 95% responded that they were satisfied with the results of the procedure. ConclusionSexual function in women who underwent TVT and TOT procedures improved considerably up to 6 months after surgery. Coital urinary incontinence improved in most of the women. Despite the evidence being variable as regards the outcomes in terms of sexual function after TVT and TOT, it is considered that these procedures substantially improve sexual function in women with stress urinary incontinence.

Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997–2016: a population-based cohort study

Concerns have been raised about the safety of surgery for stress urinary incontinence and pelvic organ prolapse using transvaginal mesh. We assessed adverse outcomes after first, single mesh procedures and comparable non-mesh procedures. We did a cohort study of women in Scotland aged 20 years or older undergoing a first, single incontinence procedure or prolapse procedure during 1997-98 to 2015-16 identified from a national hospital admission database. Primary outcomes were immediate postoperative complications and subsequent (within 5 years) readmissions for later postoperative complications, further incontinence surgery, or further prolapse surgery. Poisson regression models were used to compare outcomes after procedures carried out with and without mesh. Between April 1, 1997, and March 31, 2016, 16 660 women underwent a first, single incontinence procedure, 13 133 (79%) of which used mesh. Compared with non-mesh open surgery (colposuspension), mesh procedures had a lower risk of immediate complications (adjusted relative risk [aRR] 0·44 [95% CI 0·36-0·55]) and subsequent prolapse surgery (adjusted incidence rate ratio [aIRR] 0·30 [0·24-0·39]), and a similar risk of further incontinence surgery (0·90 [0·73-1·11]) and later complications (1·12 [0·98-1·27]); all ratios are for retropubic mesh. During the same time period, 18 986 women underwent a first, single prolapse procedure, 1279 (7%) of which used mesh. Compared with non-mesh repair, mesh repair of anterior compartment prolapse was associated with a similar risk of immediate complications (aRR 0·93 [95% CI 0·49-1·79]); an increased risk of further incontinence (aIRR 3·20 [2·06-4·96]) and prolapse surgery (1·69 [1·29-2·20]); and a substantially increased risk of later complications (3·15 [2·46-4·04]). Compared with non-mesh repair, mesh repair of posterior compartment prolapse was associated with a similarly increased risk of repeat prolapse surgery and later complications. No difference in any outcome was observed between vaginal and, separately, abdominal mesh repair of vaginal vault prolapse compared with vaginal non-mesh repair. Our results support the use of mesh procedures for incontinence, although further research on longer term outcomes would be beneficial. Mesh procedures for anterior and posterior compartment prolapse cannot be recommended for primary prolapse repair. Both vaginal and abdominal mesh procedures for vaginal vault prolapse repair are associated with similar effectiveness and complication rates to non-mesh vaginal repair. These results therefore do not clearly favour any particular vault repair procedure. None.

Función sexual femenina asociada al uso de cintas libres de tensión para el manejo de la incontinencia urinaria de estrés

IntroductionFemale urinary incontinence is a common problem in middle-aged women. Up to 50% of the adult female population have stress urinary incontinence, and the prevalence of sexual dysfunction in these women is around 50%. The aim of this study is to evaluate sexual function before and after a urinary incontinence surgical procedure using tension-free vaginal tape (TVT) or transobturator tape (TOT). Material and methodsA prospective study was conducted on 22 sexually active women who underwent TVT or TOT procedures for stress urinary incontinence by assessing the Female Sexual Function Index (FSFI) before, and 3 and 6 months after surgery. ResultsThe study included 22 women with a mean age of 48.3±6.46 years, who underwent TVT or TOT for stress urinary incontinence. The median abdominal leak point pressure (ALPP) was 85.5±17.2cm H2O, with a median pelvic organ prolapse quantification (POPQ) of 0.28±0.45. Female sexual Function assessed with the FSFI improved in all the aspects of the questionnaire. The mean total FSFI score before surgery was 21.57±3.53, at 3 months after surgery it was 26.05±3 (P=.0001), and at 6 months post-op it was 27.28±5.03 (P=.001). Coital incontinence improved in 90% of the participants, and 95% responded that they were satisfied with the results of the procedure. ConclusionSexual function in women who underwent TVT and TOT procedures improved considerably up to 6 months after surgery. Coital urinary incontinence improved in most of the women. Despite the evidence being variable as regards the outcomes in terms of sexual function after TVT and TOT, it is considered that these procedures substantially improve sexual function in women with stress urinary incontinence.

Medium-term results of Mini-arc for urinary stress incontinence in ambulatory patients under local anesthesia.

ObjectiveTo evaluate the medium-term outcome and patient's satisfaction after Single-incision mini-sling (SIMS) procedure done under local anesthesia in ambulatory set up for patients with stress urinary incontinence (SUI).Materials and MethodsThis is a retrospective cohort study, including all patients submitted to SIMS procedure for SUI with MiniArc (AMS, U.S.A) without concomitant surgery between January 2011 and March 2013. Patients were followed up during 12 months after surgery and once a year subsequently. Telephone interviews were conducted to evaluate patient satisfaction. Outcome masseurs included: SUI cure rate, urinary urge incontinence (UUI) cure rate in patients with mixed urinary incontinence (MUI), intra and post-operative complications and patient satisfaction.ResultsNinety-three patients were included with mean follow-up of 23 months. Fifty percent had MUI with predominant SUI. The cure rates of SUI (objective and subjective) were 89%. UUI was cured in 40% of patients. No major complications occur, neither voiding obstruction or groin pain. Telephone interviews conducted after 26 months on average revealed high satisfaction rate from the procedure (8.8 out of 10) and from the local anesthesia. Visual analog scale (VAS) rating was low during and after the procedure (2.38 and 2.69 respectively).ConclusionsThe SIMS procedure is safe and highly effective for SUI and it can be performed successfully under local anesthesia in an ambulatory setup.