Recurrent Stress Incontinence Research Articles

Postoperative Activity Restrictions After Slings: A Randomized Controlled Trial.

Restricting activity after midurethral slings is an unproven practice. The objective of this study was to evaluate the effect of postoperative activity restriction on satisfaction and outcomes after slings. This was a multicenter, 2-arm, noninferiority randomized controlled trial. Patients aged 18-85 years undergoing treatment with a midurethral sling were randomized 1:1 to postoperative activity restriction or liberal activity. Restrictions included avoidance of strenuous exercise and heavy lifting. The liberal group was allowed to resume activity at their discretion. Our primary outcome was satisfaction with postoperative instruction at 2 weeks. Secondary outcomes included surgical failure, mesh exposure rates, and other adverse events. In total, 158 patients were randomized with 80 to the liberal group and 78 to the restricted group. At 2 weeks, 54 (80.6%) of patients in the liberal group and 48 (73.9%) of patients in the restricted group were satisfied. We found statistical evidence supporting the hypothesis that postoperative liberal activity instruction is noninferior to activity restriction with regard to patient satisfaction (P = 0.0281). There was no significant difference in strenuous activity at 2 weeks (P = 0.0824). The liberal group reported significantly more moderate activity at 2 weeks (P = 0.0384) and more strenuous activity at 6 weeks and 6 months (P = 0.0171, P = 0.0118, respectively). The rate of recurrent or persistent stress incontinence for liberal versus restricted groups was 18.52% versus 23.53% (P = 0.635). There were no statistically significant differences in complication rates. Postoperative liberal activity was noninferior to activity restriction with regard to patients' satisfaction. There was no evidence supporting a statistically significant association between postoperative instruction and negative surgical outcomes.

MP78-18 PRESSURE REGULATING BALLOONS LOSE PRESSURE AND ELASTICITY IN A TIME-DEPENDENT MANNER

You have accessJournal of UrologyCME1 Apr 2023MP78-18 PRESSURE REGULATING BALLOONS LOSE PRESSURE AND ELASTICITY IN A TIME-DEPENDENT MANNER Kevin Krughoff, Jordan Foreman, and Andrew Peterson Kevin KrughoffKevin Krughoff More articles by this author , Jordan ForemanJordan Foreman More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Artificial Urinary Sphincter (AUS) relies on an elastic pressure regulating balloon (PRB) to generate urethral closure pressure. Reports suggest that material fatigue may be a common driver of device replacement. Our objective was to characterize the nature of material fatigue. METHODS: We compared the pressure and elasticity characteristics of new and used 61-70cmH20 PRBs extracted during AUS removal or replacement surgeries. Pressure-volume curves were generated using commercially available urodynamics equipment in a standardized fashion. PRB pressures were measured at 23cc (standard fill volume) and 30cc (overfill volume). Elastance was calculated by the slope of the tangent line at the inflection point of the pressure-volume curve. Tests were repeated 5 times per PRB and intraclass correlations were used to gauge test-retest reliability. Regression models were used for continuous variables based on data distribution. RESULTS: PRBs from 15 consecutive AUS removal or revision cases were tested. Indications included fluid leak at the cuff (7), sub-cuff atrophy (4) and erosion (4). Time to removal ranged from 0.5 to 16.5 years (mean 7.8±4.7). The mean pressure of all extracted PRBs was 62.2cmH2O (± 4.8) with 7 (46.7%) PRBs below the standard operating range (56-60cmH2O). Each year of PRB use was associated with 0.63cmH20 pressure loss on linear regression (p<0.01 CI -1.04 to -0.22). Pressures were no different whether removed for atrophy (62.8±4.4), cuff fluid leak (60.3±3.1) or erosion (65.0±7.0) (p=0.13). Loss of elastance was non-linear, declining at a rate of approximately 5% per year on Poisson regression (p<0.01, CI -0.07 to -0.03). When compared to pressures generated at standard fill volumes, PRBs less than 1 year old lost pressure when overfilled to 30cc whereas older PRBs gained pressure when overfilled in linear fashion (+1.19cmH20 per year, p<0.01, CI 0.96 to 1.422). The oldest PRB (16 years) exhibited the lowest elasticity and greatest increase in pressure when overfilled (+21cmH2O), while the youngest PRB (0.02 years) exhibited the highest elasticity and lost pressure (-3cmH2O) when overfilled. CONCLUSIONS: In this small series of PRBs tested ex-vivo for pressure-volume characteristics, increasing PRB age was associated with decreased pressure, decreased elasticity and increased pressure when overfilled. These findings have implications for single-component replacement in older devices. The relationship between loss of elasticity and recurrent stress incontinence deserves further investigation. Source of Funding: Boston Scientific Fellowship Grant © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1139 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Krughoff More articles by this author Jordan Foreman More articles by this author Andrew Peterson More articles by this author Expand All Advertisement PDF downloadLoading ...

A retrospective analysis of perioperative complications associated with retropubic tension-free vaginal tape in 960 women

PurposeThe purpose is to analyse perioperative complications associated with the retropubic tension-free vaginal tape (TVT) procedure and their management.MethodsThis retrospective, monocentric cohort study included 960 women after retropubic TVT procedure performed by one surgeon from 2011 to 2016. Complications were identified up to 6 weeks after the procedure, divided into specific and general complications and classified based on the Clavien–Dindo (CD) Classification. A visit 6 weeks after the surgical procedure was attended by all patients.Results77 complications, of which 74 occurred postoperatively and 3 intraoperatively, affecting 72 (7.5%) out of 960 women. Urinary retention and voiding problems were the most common complication. The mean age of women suffering complications was 3.4 years higher in comparison to the mean age of women without complications (p = 0.036). The Body Mass Index (BMI) of the group of women with perioperative complications had an average BMI which was 0.5 kg/m2 lower than the average BMI of the women without complications. 22 (12.8%) out of 172 women with recurrent stress incontinence had postoperative complications, of which 21 were related to the TVT.ConclusionThe retropubic TVT is a surgical procedure associated with a low number of perioperative complications, even in the group of elderly and overweight women, as well as in cases of recurrent stress incontinence.

Symptom Resolution and Recurrent Urinary Incontinence Following Removal of Painful Midurethral Slings

To evaluate pain improvement and recurrent stress incontinence (SUI) following painful synthetic midurethral sling (MUS) removal. We conducted a retrospective review of patients who underwent synthetic MUS removal at our institution from 2009-2016 for the indication of pain. We recorded sling type (transobturator vs retropubic), complete vs partial removal, and presenting symptoms. Postoperative pain improvement was categorized as resolved (pain resolved, requiring no further therapy), improved (pain less bothersome, may require further therapy), or unresolved (no/minimal improvement, requiring further management). Recurrent incontinence and further reconstructive procedures were assessed. 87 patients (49 complete and 38 partial removal) with pain as the primary indication for removal were included. Median age at intervention was 54 years with median follow-up of 8 months. Overall, pain improved or resolved in 78.1% of cases. Complete removal was associated with significantly greater percentage of pain resolution (63.3%) compared to partial removal (26.3%) (P=0.002) regardless of sling type. No significant differences in recurrent SUI were noted in complete vs partial removal. Additional reconstructive procedures were performed in 28 patients, most commonly sling placement, with no significant difference in complete (20.4%) vs partial (28.9%) removal groups (P=0.36). The overall complication rate was low (5.7%), a majority of which were transfusions (4.6%). Following MUS removal, most patients experienced resolution or improvement of pain. Complete sling removal was associated with significantly greater percentage of pain resolution compared to partial removal in both retropubic and transobturator slings. Rates of recurrent SUI and reintervention for SUI were not related to the extent of sling removal.

Immediate Artificial Urinary Sphincter (AUS) Reactivation at the Time of Urethral Cuff Exchange is Not Associated with Increased Erosion Rate

ObjectiveTo retrospectively evaluate the outcomes of immediate artificial urinary sphincter (AUS) reactivation in patients after urethral cuff replacement. It is common practice to delay reactivation of an AUS for four to six weeks following surgery to replace a failed urethral cuff. This is due to concerns about local tissue edema risking obstruction and concerns for urethral erosion. Despite these concerns, there are no published data to support this practice. MethodsRetrospective chart review of single surgeon procedures performed from 2005-2020. Patients with urethral cuff replacement for recurrent stress incontinence due to compression or mechanical failure were included. ResultsThirty-four patients were identified who had immediate reactivation of the AUS following urethral cuff exchange. Thirty of these patients (88.2%) had radical prostatectomy and five patients also underwent further radiation therapy (14.7%). At 6 months follow-up, there was no reported events of erosion. Likewise, 32/34 (94%) of patients had no complications and reported expected urinary function of the AUS. Urinary retention was not observed. One patient required further re-exploration for a complication within his AUS system (2.9%), and another was ultimately unsatisfied with their unchanged baseline continence despite a fully functioning AUS (2.9%). ConclusionIn this series, we observe that immediate reactivation of the AUS after urethral cuff exchange is a safe and reasonable management approach. Limitations of this analysis include a single institution, retrospective study. However, early AUS reactivation after device revision has not been reported in the literature and warrants further investigation given the impact on patient quality of life.

Approach to Laparoscopic Colposuspension in Cases of Failed Tension-Free Vaginal Tape

Video Objective To demonstrate a modified technique of performing a laparoscopic colposuspension in a patient with a failed tension-free vaginal tape (TVT). Setting Tertiary urogynecology department at a University Hospital. Interventions A 58-year old woman with a previous TVT inserted presents with recurrent stress incontinence. Patient declined further use of mesh and bulking agents. Conclusion Mid-urethral slings (MUS) have equivalent cure rates to the more invasive colposuspension. They are preferentially used for stress urinary incontinence (SUI) despite a mesh erosion rate of 3.5% with 2.5% requiring further surgery, sling removal, or revision over 9 years. [1][2] Recent negative publicity concerning synthetic mesh tape has led to a resurgence of interest in mesh free alternatives, including urethral bulking agents, rectus fascia slings and colposuspension. Laparoscopic colposuspension is a well-established minimally-invasive surgery that avoids synthetic mesh, with a quicker recovery, less scarring, and equivalent success to an open approach. [3] Bladder neck mobility is an important marker during selection of this technique. In this video, we demonstrate our transperitoneal technique of colposuspension in the case of a failed TVT. This technique allows clear visualization of the operating field and is faster and less bloody than a full dissection. As complications can ensue from extensive excision and extraction, unless the previous TVT has caused problems such as pain, we normally leave it in situ. Careful dissection is undertaken into Retzius space to the paravaginal tissues where the iliopectineal ligament is located. On each side, we apply two extracorporeally tied non-absorbable Ethibond sutures as recommended [4], caudal and lateral to the TVT, lifting the paravaginal tissues to the ligament. The knot placed on the ligament side to minimize erosion risk. The peritoneal defect is closed with vicryl 2.0. This technique offers a viable mesh free option for treatment of recurrent stress incontinence in women who have had failed TVT.

Predictors of Device-related Complications After Exchange of the Pressure-regulating Balloon in Men With an Artificial Urinary Sphincter

OBJECTIVETo identify patient and component specific factors that predispose patients to device-related complications when undergoing pressure-regulating balloon (PRB) exchange in men with an artificial urinary sphincter (AUS). METHODFrom 2009 to 2018, 55 patients underwent AUS revision with placement of a higher pressure 71-80 cm H2O PRB to treat recurrent stress incontinence. Patient demographics, perioperative data, and postoperative outcomes were examined and multivariable logistic regression analyses performed to identify predictors of erosion and mechanical failure. RESULTAfter a median follow-up of 26.4 months (range: 6-103.7 months), 21 of 55 (38.1%) patients developed a device-related complication that required operative repair or removal of the AUS. Four (7.3%) patients developed erosion after the PRB pressure increase and 5 patients showed evidence of impending erosion on follow-up and underwent successful revision surgery. Twelve patients developed mechanical failure (cuff leak, n = 7; pump malfunction, n =4; unidentified fluid loss, n = 1). Multivariable logistic regression analysis found that increasing body mass index was a predictor of mechanical failure. Hypertension and lower body mass index were found to increase the risk of cuff erosion whereas radiotherapy was not. CONCLUSIONIn the carefully selected patient, PRB exchange can be performed to treat recurrent incontinence in patients with an AUS, including those treated with pelvic radiotherapy. Our data suggest that this technique is susceptible to a high rate of revision surgery. As such, when revising a functional AUS system, meticulous preoperative screening, comprehensive informed consent, and follow-up protocols are essential in minimizing adverse events.

Interventions for treating recurrent stress urinary incontinence after failed minimally invasive synthetic midurethral tape surgery in women.

Surgery is a common treatment modality for stress urinary incontinence (SUI), usually offered to women for whom conservative treatments have failed. Midurethral tapes have superseded colposuspension because cure rates are comparable and recovery time is reduced. However, some women will not be cured after midurethral tape surgery. Currently, there is no consensus on how to manage the condition in these women.This is an update of a Cochrane Review first published in 2013. To assess the effects of interventions for treating recurrent stress urinary incontinence after failed minimally invasive synthetic midurethral tape surgery in women; and to summarise the principal findings of economic evaluations of these interventions. We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 9 November 2018). We also searched the reference lists of relevant articles. We included randomised and quasi-randomised controlled trials in women who had recurrent stress urinary incontinence after previous minimally invasive midurethral tape surgery. We included conservative, pharmacological and surgical treatments. Two review authors checked the abstracts of identified studies to confirm their eligibility. We obtained full-text reports of relevant studies and contacted study authors directly for additional information where necessary. We extracted outcome data onto a standard proforma and processed them according to the guidance in the Cochrane Handbook for Systematic Reviews of Interventions. We included one study in this review. This study was later reported in an originally unplanned secondary analysis of 46 women who underwent transobturator tape for recurrent SUI after one or more previous failed operations. We were unable to use the data, as they were not presented according to the nature of the first operation.We excluded 12 studies, five because they were not randomised controlled trials (RCTs) and four because previous incontinence surgery was not performed using midurethral tape. We considered a further three to be ineligible because neither the trial report nor personal communication with the trialists could confirm whether any of the participants had previously undergone surgery with tape.We had also planned to develop a brief economic commentary summarising the principal findings of relevant economic evaluations but supplementary systematic searches did not identify any such studies. There were insufficient data to assess the effects of any of the different management strategies for recurrent or persistent stress incontinence after failed midurethral tape surgery. No published papers have reported exclusively on women whose first operation was a midurethral tape. Evidence from further RCTs and economic evaluations is required to address uncertainties about the effects and costs of these treatments.

Imaging Features and Complications of Female Urethral Diverticula

A female urethral diverticulum is a focal outpouching of the urethra into the urethrovaginal potential space.1 The reported incidence of urethral diverticula in women is approximately 1% to 6%, with the diagnosis typically occurring between the third and sixth decades of life.2 In symptomatic women, the classic clinical triad of dysuria, dyspareunia, and postvoid dribbling is present (the “three Ds”).1 However, women with urethral diverticula are more commonly asymptomatic or present with an array of nonspecific genitourinary symptoms such as urinary frequency and urgency, chronic or recurrent urinary tract infections, hematuria, and stress or urge incontinence. More atypical presentations include urinary retention, urethral pain, purulent urethral discharge, pelvic or suprapubic pain, or a tender mass.1 , 3 Because of the varied clinical presentation, a urethral diverticulum should be considered in all women with unexplained lower genitourinary tract symptoms.3 Other differential diagnoses for women presenting with unexplained lower genitourinary symptoms include interstitial cystitis, urethral syndrome (ie, urinary urgency and frequency with negative urine cultures); Skene's gland abscess; Gartner duct cyst; ectopic ureterocele; periurethral fibrosis; urethrocele; endometrioma; urethral or vaginal neoplasm; and collagen bulking agents used for the treatment of stress urinary incontinence.1 , 3 The correct diagnosis of a urethral diverticulum is critical, as potential complicating features include recurrent infection, calculus formation, and intradiverticular malignancy.2 Moreover, late diagnosis of urethral diverticulum is associated with high risk of postoperative complications, high recurrence rate after surgery, and, if malignancy is present, early metastases.1

Laparoscopic Colposuspension for Recurrent Stress Incontinence after Tension-free Vaginal Tape

To demonstrate laparoscopic colposuspension for recurrent stress incontinence after failed tension-free vaginal tape (TVT). A technical video showing laparoscopic colposuspension for previously surgically treated stress incontinence (Canadian Task Force classification III). A university hospital. A 58-year-old woman with previous TVT presents with recurrent stress urinary incontinence. Midurethral slings have equivalent cure rates to the more invasive colposuspension. They are preferentially used for stress urinary incontinence despite a mesh erosion rate of 3.5% with 2.5% requiring further surgery, sling removal, or revision over 9 years [1,2]. Recent negative publicity concerning synthetic mesh tape has led to a resurgence of interest in mesh-free alternatives, including urethral bulking agents, rectus fascia slings, and colposuspension. Laparoscopic colposuspension is a well-established minimally invasive surgery that avoids synthetic mesh, with a quicker recovery, less scarring, and equivalent success to an open approach [3]. Bladder neck mobility is an important marker during selection of this technique. In this video, we demonstrate our transperitoneal technique of colposuspension in the case of failed TVT. This technique allows clear visualization of the operating field and is faster and less bloody than a full dissection. Because complications can ensue from extensive excision and extraction, unless the previous TVT has caused problems such as pain, we normally leave it in situ. Careful dissection is undertaken into the Retzius space to the paravaginal tissues where the iliopectineal ligament is located. On each side, we apply 2 extracorporeally tied nonabsorbable Ethibond (Johnson and Johnson Medical NV, Bruxelles, Belgium) sutures as recommended [4], caudal and lateral to the TVT, lifting the paravaginal tissues to the ligament. The knot is placed on the ligament side to minimize erosion risk. The peritoneal defect is closed with a Vicryl 2.0 (Johnson and Johnson Medical NV) suture. This technique offers a viable mesh-free option for the treatment of recurrent stress incontinence in women who have had failed TVT.

Does assessing urethral function allow the selection of the optimal therapy for recurrent SUI? Report from the ICI-RS 2017.

The management of recurrent stress urinary incontinence following failed previous continence surgery remains challenging. Whilst the role of urodynamic investigations has been questioned in the management of primary stress incontinence there is a widely held view that women with recurrent symptoms require further investigation although there is no agreement regarding which tests are required. We sought to understand what testing is recommended prior to managing this difficult cohort of patients. This research proposal was presented at the International Consultation on Incontinence Research Society (ICI-RS) in order to clarify our current knowledge regarding the assessment of urethral function and to set research priorities for the future. Whilst the majority of clinicians would advocate urodynamic evaluation of women with recurrent stress incontinence following previous surgery there is no consensus of opinion as to which tests should be performed, on whom or where. The available evidence to date suggests that urethral function tests do have a role with regard to prognosis following surgery and also in planning the most appropriate surgical intervention. The ICI-RS developed a list of research questions which may be able to assist in improving the investigation and management of women with recurrent SUI. Questions included whether patients felt the information gained via urethral function tests had an important role in their counseling regarding outcome of repeat SUI surgery.

A re-adjustable sling for female recurrent stress incontinence and intrinsic sphincteric deficiency: Long-term results in 205 patients using the Remeex sling system.

To evaluate the outcomes and complications at long-term follow-up after a Remeex re-adjustable sling for recurrent stress urinary incontinence (rSUI) and intrinsic sphincteric deficiency (ISD) in women. Two hundred thirty women with SUI were evaluated after undergoing a re-adjustable sling operation. Twenty-five patients were lost to follow-up, 205 were classified by Q-tip, urodynamic, and clinical criteria into ISD (109) and rSUI (96). Outcome measures included number of pads, 1 h pad-test, urodynamics and subjective satisfaction index with the procedure. After a mean follow-up of 89 months (26-159), 165 patients were cured of SUI (71.7% in the intention to treat analysis (itt), 80.5% in per protocol analysis (pp)). Forty patients remained incontinent (17.4% in itt, 19.5 in pp). Thirty-one patients (15.1%) had detrusor overactivity (DH) incontinence, 21 (10.2%) with de-novo DH and 10 with previous urodynamic mixed incontinence. Eighty-eight patients required re-adjustment of the sling during the follow-up. The tension was increased in 82 cases due to recurrence of SUI and reduced in six due to outlet obstruction. The overall complications rate was 28.8%, (3.4% clavien III). The Remeex re-adjustable sling provides a good cure rate for rSUI and ISD at long-term follow-up. The complications rate is acceptable since most complications are clavien II. The ability to re-adjust the sling tension during the follow-up allowed us to achieve cure for recurrence after the initial procedure, and to relieve obstruction in every case attempted.

Surgery for recurrent stress urinary incontinence: the views of surgeons and women

Introduction and hypothesisThe objectives were to explore the views of women with recurrent stress incontinence (SUI) with regard to treatment preferences and the acceptability of randomisation to a future trial, and to survey the views of UK specialists on treatment preferences and equipoise regarding different treatment alternatives.MethodsAn online survey of the British Society of Urogynaecology (BSUG) and British Society of Urological Surgeons (BAUS) was carried out. Qualitative semi-structured interviews with a purposive sample of surgeons and women suffering from recurrent SUI from three UK centres.ResultsTwo hundred fifty-six survey replies were received (176 gynaecology; 80 urology). Comparing the treatments offered, urogynaecologists were more likely to offer pelvic floor exercises (p < 0.05), and repeat midurethral tape (MUT) (p < 0.001). From the Surgical Equipoise Scale (SES) responses, “no preference” was rarely the commonest response. Marked differences for several options existed; midurethral tape dominated responses whenever it appeared. Twenty-one clinicians were interviewed. Treatment preferences were complex, influenced by a range of factors (reason for failure, patient comorbidity, investigations, personal experience, training). A future trial was regarded as important. Eleven women were interviewed. Most had considered more than one option, but felt that decision-making was more a process of elimination rather than a positive process. Randomisation to a study was regarded as unacceptable by most.ConclusionsNo consensus exists among surgeons about preferred treatment options for recurrent SUI, and personal experience and training dominate decision-making. For patients, choices were usually based on an elimination of options, including that of a repeat failed procedure. This contrasts with surgeons, who mostly preferred a repeat MUT above other options. Any future comparative study will be challenging.

Incontinence rates after midurethral sling revision for vaginal exposure or pain

Midurethral slings have become the preferred surgical treatment for stress urinary incontinence. Midline transection of midurethral sling for dysfunctional voiding is an effective treatment and also has a low rate of recurrent stress incontinence. Recurrent stress incontinence after sling revision for pain and mesh exposure has not been well defined. It is therefore difficult to counsel patients on risk of recurrent stress incontinence when sling revision is performed for pain or mesh exposure. We examined the rate of postoperative stress incontinence after midurethral sling revision for the indication of mesh exposure or pain, as well as postoperative pain and urinary urgency. This is a retrospective cohort of 245 patients undergoing a vaginal midurethral sling revision in a 10-year period for the indication of mesh exposure or pain. Preoperative indication for revision, baseline characteristics, and preoperative reports of stress incontinence, pain, and urgency were collected. The type of sling revision was then categorized into partial or complete removal. A partial removal of the sling was defined as removing only the portion of sling exposed or causing pain. A complete removal of the sling was defined as vaginal removal of sling laterally out to the pubic rami. Subjective reports of stress incontinence, pain, and urgency at short-term (16 weeks) and long-term (>16 weeks) follow-up visits were gathered. The primary outcome of the study was recurrent stress incontinence. In our cohort of 245 women who underwent midurethral sling revision, 94 patients had removal for mesh exposure (36 partial and 58 complete) and 151 had removal for pain (25 partial and 126 complete). All patients had a short-term follow-up with a mean time of 5.9 ± 2.8 weeks and 69% patients had long-term follow-up with a mean time of 29.1 ± 17.7 weeks. No differences were seen in preoperative reports of stress incontinence, urgency, or pain in either group. In the patients with revision for mesh exposure with no preoperative stress incontinence, there was greater postoperative stress incontinence with complete vs partial removal of sling at short-term (14% vs 42%, P= .03) and long-term (7% vs 59%, P= .003) follow-up. In the patients with revision for pain with no preoperative stress incontinence, there was no statistically significant difference in recurrent stress incontinence with complete sling removal at long-term follow-up (22% vs 56%, P= .07). In the patients with midurethral sling revision for pain, 72% of partial and 76% of complete sling removal had resolution of pain postoperatively (P= .66). No difference was seen in postoperative reports of urgency or pain improvement in either group between partial or complete sling removal. In women undergoing midurethral sling revision for mesh exposure, complete sling removal resulted in higher recurrent stress incontinence compared to partial sling removal. For the indication of pain, both partial and complete sling removal improved pain in the majority of patients, but there was no statistically significant difference in recurrent stress incontinence.

Re: Urethral bulking for recurrent urinary stress incontinence after midurethral sling failure

Re: Urethral bulking for recurrent urinary stress incontinence after midurethral sling failure

Outcomes of Autologous Fascia Pubovaginal Sling for Patients with Transvaginal Mesh Related Complications Requiring Mesh Removal

We reviewed the outcomes of the autologous fascial pubovaginal sling as a salvage procedure for recurrent stress incontinence after intervention for polypropylene mesh erosion/exposure and/or bladder outlet obstruction in patients treated with prior transvaginal synthetic mesh for stress urinary incontinence. In a review of surgical databases at 2 institutions between January 2007 and June 2013 we identified 46 patients who underwent autologous fascial pubovaginal sling following removal of transvaginal synthetic mesh in simultaneous or staged fashion. This cohort of patients was evaluated for outcomes, including subjective and objective success, change in quality of life and complications between those who underwent staged vs concomitant synthetic mesh removal with autologous fascial pubovaginal sling placement. All 46 patients had received at least 1 prior mesh sling for incontinence and 8 (17%) had received prior transvaginal polypropylene mesh for pelvic organ prolapse repair. A total of 30 patients underwent concomitant mesh incision with or without partial excision and autologous sling placement while 16 underwent staged autologous sling placement. Mean followup was 16 months. Of the patients 22% required a mean of 1.8 subsequent interventions an average of 6.5months after autologous sling placement with no difference in median quality of life at final followup. At last followup 42 of 46 patients (91%) and 35 of 46 (76%) had achieved objective and subjective success, respectively. There was no difference in subjective success between patients treated with a staged vs a concomitant approach (69% vs 80%, p = 0.48). Autologous fascial pubovaginal sling placement after synthetic mesh removal can be performed successfully in patients with stress urinary incontinence as a single or staged procedure.

Success of Autologous Pubovaginal Sling after Failed Synthetic Mid Urethral Sling

There is no consensus on the management of persistent or recurrent stress incontinence after a failed synthetic mid urethral sling. After a mesh complication or sling failure many women and surgeons prefer to avoid a repeat mesh procedure and choose an autologous pubovaginal sling. However, little empirical work has been performed to assess the efficacy. We performed a retrospective review of 66 women who underwent autologous pubovaginal sling with rectus fascia after 1 or more failed synthetic mid urethral sling from 2007 to 2012. Mesh removal was performed before autologous pubovaginal sling in 21patients (31.8%) while 6 (9.1%) had mesh removed simultaneously with autologous pubovaginal sling. Indications for the autologous pubovaginal sling were pure stress urinary incontinence in 16 patients (24.2%) and mixed incontinence in 50 (75.8%), 8 of whom were deemed complex with a prior urethral diverticulum or urethrovaginal fistula/urethral mesh erosion. At a mean of 14.5 months after autologous pubovaginal sling 46 (69.7%) patients reported cure of stress urinary incontinence. Of these patients 25 (37.9%) had complete cure with no stress or urgency incontinence, 17 had cure of stress urinary incontinence but had persistent urgency incontinence, and 4 had cure of stress urinary incontinence but experienced do novo urgency incontinence. Requiring a mesh excision did not predict worse outcomes compared to cases in which mesh was not removed (p=0.13). Patients with pure stress urinary incontinence were significantly more likely to be cured of all incontinence (62.5%) than those women with preoperative mixed incontinence (30.0%) (p=0.006). Even after a failed synthetic mid urethral sling, autologous pubovaginal sling is effective and cured stress urinary incontinence in 69.7% of cases.

Management of recurrent stress incontinence following a sling.

Management of recurrent or persistent stress urinary incontinence (RSI) following primary insertion of a synthetic midurethral sling (MUS) remains a challenge for the urologist since no consensus is available to favor one treatment over another. Complete workup should be carried out, including cystoscopy, urodynamics and potentially a pelvic floor ultrasound as a diagnostic adjunct. Various surgical options have been described for RSI, apart from another MUS, including tightening of or shortening a previously placed MUS, a mini-sling, a salvage spiral sling, a colposuspension, the ACT® system, an artificial urinary sphincter or ultimately a urinary diversion. Treatment depends ultimately on the experience and the expertise of the surgeon but it appears most reasonable to offer a repeat MUS (retropubic or transobturator), a pubovaginal sling or bulking agents to women with RSI. Appropriate counseling of patients to set realistic outcomes is key as it may be more practical to aim more for symptomatic improvement than cure.

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

Treatment of recurrent stress urinary incontinence after failed minimally invasive synthetic suburethral tape surgery in women

Surgery is a common treatment modality for stress urinary incontinence (SUI), usually offered for women who fail conservative treatments. Suburethral tapes have superseded colposuspension because cure rates are comparable and recovery time reduced. However, some women will not be cured after suburethral tape surgery, and currently there is no consensus on how to manage these women. To obtain and examine evidence supporting different management strategies for recurrent/persistent stress urinary incontinence (SUI) in women after failed suburethral tape surgery. We searched the Cochrane Incontinence Group Specialised Register of controlled trials (searched 18 December 2012), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and PreMEDLINE; and handsearched journals and conference proceedings, and the reference lists of included studies and previous Cochrane reviews for randomised or quasi-randomised studies treating patients with recurrent incontinence, either as the sole population or a subset. Conservative, medical and surgical treatments were included. We included randomised and quasi-randomised controlled trials in women who had recurrent urinary incontinence after previous minimally invasive suburethral tape surgery. Abstracts of identified studies were checked by two authors to confirm eligibility. Full text reports of relevant studies were obtained, and authors were contacted directly where necessary. Outcome data were extracted onto a standard proforma and processed according to the methods in the Cochrane Handbook for Systematic Reviews of Interventions. Twelve studies were identified, but all were excluded because they did not meet the eligibility criteria. Six were randomised controlled trials (RCTs) but were not eligible because the previous incontinence surgery was not a suburethral tape. A subset of one RCT may have been eligible for inclusion because some of the women were having repeat surgery, but we were unable to obtain from the authors the data according to primary surgery for this cohort. There were no data to recommend or refute any of the different management strategies for recurrent or persistent stress incontinence after failed suburethral tape surgery. Evidence is urgently required to address this deficiency, ideally from RCTs.