Recurrent Stress Urinary Incontinence Research Articles

A study of transobturator tape in stress urinary incontinence.

Background:Stress urinary incontinence (SUI) is commonly encountered in gynecological practice. Nowadays, midurethral sling surgeries in the form of transobturator tape (TOT) surgery are recommended in its treatment.Aims and Objectives:To assess the outcome and patient satisfaction of TOT surgery in the treatment of SUI.Materials and Methods:A prospective study was undertaken for patients of SUI who underwent TOT surgery by the outside in method and followed up for 5 years. The patients were assessed clinically and by the Patient Global Impression of Improvement (PGI-I) preoperatively and at postoperative day 3, discharge and 3 months follow-up.Results:Successful surgical treatment with TOT was seen in all patients at the time of discharge. There was no recurrence of SUI seen up to 1 year, but at 5-year follow-up two patients had a recurrence of SUI on examination though they did not complain of SUI. Urinary retention, tape extrusion, and groin stitch infection were the commonly seen complications following surgery. On subjective assessment, 61 patients were completely satisfied at day 3, and all patients were completely satisfied at discharge and 3 months follow-up as per the PGI-I score.Conclusion:TOT gives an excellent outcome in the treatment of SUI.

The impact of prior urethral sling on artificial urinary sphincter outcomes.

We sought to evaluate device outcomes in men who underwent primary artificial urinary sphincter (AUS) placement after failed male urethral sling (MUS). We performed a retrospective chart review of 990 men who underwent an AUS procedure between 2003 and 2014. Of these, 540 were primary AUS placements, including 30 (5.5%) with a history of MUS. AUS revisions and explantations were compared between men stratified by the presence of prior sling. Hazard ratios (HR) adjusting for competing risks were used to determine the association with prior sling and AUS outcomes (infection/erosion, urethral atrophy, and mechanical malfunction), while overall device failure was estimated using Kaplan-Meier and Cox-regression analysis. There was no significant difference in age, body mass index, prior prostatectomy, or pelvic radiation when stratified by history of MUS. However, patients with a history of MUS were more likely to have undergone prior collagen injection (p=0.01). On univariate and multivariate analysis, prior MUS was not associated with device failure (HR 1.54; p=0.27). Three-year overall device survival did not significantly differ between those with and without prior MUS (70% vs. 85%; p=0.21). Also, there were no significant differences in the incidence of device infection/erosion, mechanical malfunction, and urethral atrophy. AUS remains a viable treatment option for men with persistent or recurrent stress urinary incontinence after MUS. However, while not statistically significant, we identified a trend towards lower three-year device outcomes in patients with prior urethral sling. These findings indicate the need for longer-term studies to determine if slings pose an increased hazard.

Long-term outcomes of transobturator tension-free vaginal tapes as secondary continence procedures.

To assess the long-term patient-reported outcomes following TO-TVT as a secondary continence procedure in women with recurrent stress urinary incontinence (R-SUI). A secondary analysis of the 9-year follow-up of the E-TOT study was performed: 341 women with predominant SUI symptoms were randomised to undergo either Inside-out or Outside-in TO-TVT between April 2005 and April 2007. Forty-six women had R-SUI following previously failed continence surgery at time of randomisation and are the basis of this analysis as a one single cohort. Primary outcome was the patient-reported success rate defined as very/much improved on Patient's Global Impression of Improvement (PGI-I). Secondary outcomes included late adverse events and impact on women's quality of life and sexual function. Statistical analysis was performed using SPSS version 23. Sixty-three per cent completed the 9-year follow-up. The success based on the PGI-I was 62.1% with no significant difference between groups (OR 5.33; 95% CI 1.03, 27.76; p=0.094). Clinically significant improvement in QoL was found in 84.2%. Adverse events included vaginal erosions (n=3) and groin pain (n=2). The small sample size is a limitation in this study; nevertheless, this is one of the largest cohorts reported for women with R-SUI and the first to report the long-term outcomes of TO-TVT as a secondary continence procedure. TO-TVT operations are associated with good patient-reported success rates (62%) in women with previous failed continence surgery with up to 9-years follow-up. There is a non-significant trend towards better outcomes with the inside-out TO-TVT.

Nonabsorbable urethral bulking agent — clinical effectiveness and late complications rates in the treatment of recurrent stress urinary incontinence after 2 years of follow-up

ObjectiveThose patients who failed to achieve continence after a procedure aimed to correct it, require a special attitude and precise management due to the sophisticated anatomical and functional field of interest. The purpose of the present study was to assess long-term clinical efficacy and evaluate the frequency and severity of any complications related to recurrent stress urinary incontinence treatment with a non-absorbable bulking agent periurethral injections. Study designBetween February 2012–September 2013, 66 patients with recurrent stress urinary incontinence were treated with Urolastic in the tertiary referral gynecologic department. The efficacy of the procedure was assessed objectively at each follow-up visit, scheduled at two, six weeks and 3, 6, 12 and 24 months after primary procedure. Material was injected under local anesthesia according to the manufacturer’s instructions, at 10, 2, 4 and 8 o’clock positions with 0.5–1.25ccm per spot. Statistical analyses were performed with Statistica package version 8.0 (StatSoft Inc., Tulsa, OK, USA). A p value <0.05 was considered statistically significant. ResultsObjective success rate at 24 months was found in 32.7% of patients, including 22.4% patients who were completely dry. The efficacy of Urolastic, when considering the intention to treat, is 24.2% and 16.7%, respectively. In 4.5% patients an oval shaped material was found inside the bladder. Overall, complications were observed in 17 (25.8%) patients. ConclusionsAlthough only 30% of patients will benefit from Urolastic injection on the long-term basis it seems to be a safe procedure in the treatment of recurrent stress urinary incontinence.

Urethral bulking for recurrent stress urinary incontinence after previous midurethral sling

Urethral bulking for recurrent stress urinary incontinence after previous midurethral sling

Current Practices in the Surgical Management of Female Stress Urinary Incontinence: A Survey of Canadian Urologists and Gynecologists

IntroductionWe assessed the practices of urologists and gynecologists who manage stress urinary incontinence surgically to examine the impact of the FDA (U.S. Food and Drug Administration) and/or Health Canada statements on pelvic floor mesh. We also determined how urologists and gynecologists manage recurrent stress urinary incontinence and complications of mesh mid urethral slings. MethodsWe conducted an online survey of urologists and gynecologists who were members of the Canadian Urological Association or Society of Obstetricians and Gynaecologists of Canada. ResultsMid urethral sling was the most common surgery for stress urinary incontinence performed by urologists and gynecologists (100% vs 84%, p=0.0002). The majority of respondents (87%, 119 of 137) were aware of the FDA and/or Health Canada statements and 66% of physicians altered the way they counseled patients before mid urethral sling surgery. An equal proportion of urologists and gynecologists altered their surgical management of stress urinary incontinence due to patient concerns (31% vs 36%) and due to FDA and/or Health Canada statements (16% vs 13%). Repeat mid urethral sling was the most common method of treating recurrent stress urinary incontinence and urologists were more likely than gynecologists to manage complications of mid urethral sling (58% vs 41%, p=0.0286). Chronic pain (33%) and vaginal mesh erosion (26%) were the most common concerns overall. ConclusionsMid urethral sling was reported as the most commonly performed surgery for stress urinary incontinence by urologists and gynecologists after the FDA and Health Canada statements. Both groups altered their surgical practices most commonly due to patient concerns, indicating that negative media attention is impacting the way in which urologists and gynecologists practice when surgically managing stress urinary incontinence in Canada. Variation exists between urologists and gynecologists when it comes to managing complications related to mid urethral sling.

Objective outcome and quality-of-life assessment in women with repeat incontinence surgery.

To evaluate subjective and objective outcome after repeat surgery for stress urinary incontinence (SUI). Patients who underwent a midurethral tape after failed Burch colposuspension or failed midurethal tape between 1999 and 2014 were invited for follow-up. Urogynecological examination and urodynamics was performed, and objective cure was defined as a negative cough stress test; subjective cure was defined as negotiation of SUI symptoms. Quality-of-life (QoL), sexual health, and subjective success was assessed with the King's Health Questionnaire, Incontinence Outcome Questionnaire, Female Sexual Function Index, and the Patient Global Impression of Improvement (PGI-I) score. Overall 52 women underwent repeat incontinence surgery. Out of the 44 women still alive, 33 (75%) were available for follow-up. All 33 women completed the questionnaires; 23 women (70%) attended the clinic and also had an urogynecological examination. At a median follow-up of 11 years, subjective cure was 67% (22/33), objective cure was 65% (16/23), and subjective success according to PGI-I was 78% (18/23), with no significant differences between groups. No erosions of suture or tape material into the bladder, urethra, or vagina were seen. Two women had received a third anti-incontinence operation with TVT after failed tape after failed Burch, and were continent at follow-up. Two women with tape after colposuspension required division of the tape and both were continent at the time of follow-up. With regard to QoL and sexual health, no significant differences were seen for most domains. Midurethral tapes are an option for women with recurrent SUI after previous colposuspension or midurethral tape.

Tension-free Vaginal Tape–Obturator for Treatment of Pure Urodynamic Stress Urinary Incontinence: Efficacy and Adverse Effects at 10-year Follow-up

BackgroundInside-out transobturator tape (tension-free vaginal tape–obturator [TVT-O]) is currently one of the most effective and popular procedures for the surgical treatment of female stress urinary incontinence (SUI). However, data reporting long-term outcomes are lacking. ObjectiveTo assess the efficacy and safety of TVT-O 10 yr after implantation for the treatment of female pure SUI. Design, setting, and participantsA multicenter, prospective study was conducted in five tertiary referral centers in three countries. All consecutive women with urodynamically proven pure SUI treated by TVT-O were included. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. InterventionTVT-O implantation. Outcome measurements and statistical analysisData regarding subjective outcomes (International Consultation on Incontinence Questionnaire–Short Form, Patient Global Impression of Improvement, and patient satisfaction scores), objective cure (stress test) rates, and adverse events were collected during follow-up. Univariable analysis was performed to investigate outcomes. Results and limitationsOne hundred sixty-eight women had TVT-O implantation. At 10-yr follow-up, 160 patients (95%) were available for the evaluation. We did not find any significant change of the surgical outcomes during this time. At 10 yr after surgery, 155 of 160 patients (97%) declared themselves cured (p=0.7). Similarly, at 10-yr evaluation, 148 of 160 patients (92%) were objectively cured. No significant deterioration of objective cure rates was observed over time (p=0.4). The history of failure of previous anti-incontinence procedures (hazard ratio: 5.34; 95% CI, 2.61–11.9; p=0.009) was the only predictor of recurrence of SUI. The onset of de novo overactive bladder was reported by 23 of 160 patients (14%) at 10-yr follow-up. No other late complications were reported. ConclusionsThe 10-yr results of this study showed that TVT-O is a highly effective and safe option for the treatment of SUI. Patient summaryAt long-term follow up, tension-free vaginal tape-obturator is highly effective and safe for the treatment of stress urinary incontinence.

A Large Retrospective Series of Pregnancy and Delivery After Midurethral Sling for Stress Urinary Incontinence.

The aim of this study was to review the complete medical course, including safety, efficacy, and medical decision making, of patients who delivered a pregnancy after the placement of midurethral sling (MUS) within a large health maintenance organization. We conducted a retrospective case series of patients within the Northern and Southern California Permanente Medical Group who were identified based on procedural codes for placement of MUS for stress urinary incontinence. Electronic medical records with MUS code were referenced against records of live births within the health care system. Demographic and clinical data were abstracted through extensive, standardized physician review of the electronic medical records of all identified patients. Twenty-six patients were identified and included in analysis. Sixteen patients had a retropubic MUS, and 10 had a transobturator MUS. Twenty-one of 26 patients reported subjective resolution of urinary incontinence after MUS. Fourteen of the 25 first deliveries after MUS were cesarean section (CS). Of these, 5 CS were elective primary for the indication of previous MUS, 5 were elective repeat CS, and the remaining 4 were for fetal indications. Eleven patients had spontaneous vaginal deliveries. There were no MUS-related pregnancy complications. One patient developed recurrent stress urinary incontinence postpartum, for which she underwent repeat MUS within a year resulting in cure of incontinence. This case series corroborates previous series demonstrating the safety and durability of MUS after subsequent pregnancy.

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

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

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

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

Quality of life outcomes in peri-urethral calcium hydroxylapatite injection.

Peri-urethral calcium hydroxylapatite injection is an established treatment for patients with stress urinary incontinence. Information is limited regarding calcium hydroxylapatite treatment and quality of life (QOL) outcomes. We hypothesize that patients might improve QOL after peri-urethral calcium hydroxylapatite injection, which was reflected in validated questionnaires. The peri-urethral calcium hydroxylapatite injection billing code was used to identify patients who underwent injection from 2011-2013. Female patients who completed the American Urological Association Symptom Score (AUASS), the AUASS QOL and Michigan Incontinence Symptom Index (M-ISI), and the bother score (M-ISI bother), or pad count at baseline and follow-up were included. Change in questionnaire scores and pads were assessed using the paired t test. Sixty patients underwent 1 (30), 2 (63) or 3 (7%) peri-urethral calcium hydroxylapatite injections performed by a single surgeon. Thirty-seven patients provided questionnaires and 38 provided pad counts, all with a mean age of 75years. The overall AUASS, AUASS QOL, and overall M-ISI scores improved in 67.6, 54.8, and 61.3% respectively (4.5 ± 7.9, 1.3 ± 1.7 and 5.5 ± 8.6 respectively). The M-ISI bother score improved in 44.8% with a mean improvement of 0.5 ± 2.9, but did not reach significance. There was a 1.7 ± 3.7 decrease in the mean number of pads used daily after the procedure (p = 0.006) and 19% experienced transient urinary retention. Peri-urethral calcium hydroxylapatite injections can improve urinary QOL scores in patients with initial and recurrent stress urinary incontinence. This short-term retrospective analysis suggests that larger long-term studies focusing on QOL outcomes are needed to evaluate the effect of peri-urethral calcium hydroxylapatite has on incontinence-specific QOL.

Repeat suburethral sling procedure is effective for recurrent female stress urinary incontinence

Repeat suburethral sling procedure is effective for recurrent female stress urinary incontinence

Ten-Year Followup after Tension-Free Vaginal Tape-Obturator Procedure for Stress Urinary Incontinence

Suburethral tapes are a standard surgical treatment for stress urinary incontinence. The aim of the study was to evaluate subjective and objective cure rates 10 years after a tension-free vaginal tape-obturator procedure. All 124 patients who underwent the tension-free vaginal tape-obturator procedure at a total of 2 centers in 2004 and 2005 were invited for followup. Objective cure was defined as a negative cough stress test at 300 ml. Subjects completed KHQ (King's Health Questionnaire), IOQ (Incontinence Outcome Questionnaire), FSFI (Female Sexual Function Index Questionnaire) and PGI-I (Patient Global Impression of Improvement). Overall, 55 of 112 women (49%) who were alive were available for clinical examination and 71 (63%) completed the questionnaires. The objective cure rate in the 55 women examined clinically was 69%, 22% were not cured and 9% (5) had undergone reoperation for recurrent or persistent stress urinary incontinence. Treatment was counted as having failed in these 5 women for study purposes. Subjective cure was reported by 45 of 71 women (64%). Three patients (5%) had vaginal tape extrusion at the time of clinical examination. Extrusion in all of them was small and asymptomatic, and did not require treatment for a cumulative extrusion rate of 7%. Six women (9%) had undergone reoperation for tension-free vaginal tape-obturator associated complications and 18 (26%) experienced de novo overactive bladder. Subjective and objective cure rates 10 years after the tension-free vaginal tape-obturator procedure were 69% and 64%, respectively. The vaginal extrusion rate in this study was slightly higher than in other series but major long-term complications appeared to be rare.

Clinical Case Discussion: Failure of a Midurethral Sling Procedure for Stress Urinary Incontinence in a Female Patient

The patient should have an autologous fascia sling as her next procedure because she has recurrent stress urinary incontinence after two prior transobturator synthetic slings, current urethral erosion, and intrinsic sphincter deficiency.

Atsinaujinusio šlapimo nelaikymo gydymas minimaliai invaziniu būdu: klinikinis atvejis

Įtampos šlapimo nelaikymas – dažniausiai pasitaikantis šlapimo nelaikymo tipas, kai šlapimas nevalingai išteka fizinio krūvio metu, kosint ar čiaudint. Dėl šios priežasties blogėja žmogaus gyvenimo kokybė, atsiranda fizinių, psichologinių, seksualinių, socialinių ar ekonominių problemų. Gydymo galimybių yra daug, tačiau norimas rezultatas ne visada pasiekiamas, todėl atsinaujinęs šlapimo nelaikymas – dažnai klinikinėje praktikoje pasitaikanti problema. Literatūros duomenimis, šlapimo nelaikymo chirurginis gydymas būna neveiksmingas iki 20 % atvejų. Sintetinių pošlaplinių raiščių implantavimo operacijos minimaliai invaziniu būdu – pirmo pasirinkimo metodas gydant atsinaujinusį šlapimo nelaikymą. Aprašome ir aptariame atvejį moters, kuri buvo tris kartus operuota dėl šlapimo nelaikymo. 2012 metais, diagnozavus vezikocelę ir įsisenėjusį tarpvietės plyšimą, atlikta priekinė kolporafija ir kolpoperineoplastika. Po operacijos šlapimo nelaikymas fizinio krūvio metu išliko. 2014 metais pacientė buvo operuota pakartotinai ir atlikta pošlaplinio raiščio implantavimo operacija per užtvarinę angą, tačiau norimo rezultato nepasiekta, šlapimo nelaikymas išliko. 2015 metais pacientei diagnozuotas III laipsnio atsinaujinęs šlapimo nelaikymas. Atlikus pošlapininio raiščio implantavimo operaciją užgaktiniu būdu, moteris gerai sulaiko šlapimą, liekamojo šlapimo nėra. Pošlaplinio raiščio implantavimas užgaktiniu būdu – efektyvi operacija gydant atsinaujinusį šlapimo nelaikymą.

Urethral bulking for recurrent stress urinary incontinence after midurethral sling failure.

To assess the effectiveness of a polyacrylamide hydrogel (PAHG; Bulkamid®) in treating recurrent stress urinary incontinence (SUI) following a previous midurethral sling (MUS) implant. This observational study, conducted since 2009, included 60 patients with recurrent SUI or mixed urinary incontinence (MUI) after a previous MUS and who chose to be treated with PAHG. Objective and subjective outcomes were assessed at 1, 6, and 12 months after the initial injection. Patients were classified as cured based on a negative cough test (supine and standing) and <2 g urine on 1-hr pad test and a VAS score improved by ≥90%. Improved were those with the loss of only a few drops of urine during the cough test and 2-10 g urine on 1-hr pad test or a reduction >50% compared with preoperative urine loss and a VAS score improved by ≥75%. The volume of PAHG injected in the current study ranged from 1-3 ml. Cured/improved rates were 93.3% (56/60), 88.3% (53/60), and 83.6% (46/55) at 1, 6, and 12 months, respectively. Patients with MUI had a cured urgency urinary incontinence rate of 36.8%, 47.4%, and 38.9%, respectively. Voiding dysfunction rates were 13.3% (8/60), 8.3% (5/60), and 1.8% (1/55) at 1, 6, and 12 months and urinary tract infection rates were 5% (3/60), 11.7% (7/60), and 3.6% (2/55), respectively. Other adverse events were short-term and/or observed in <4% of patients. PAHG can be used to treat recurrent SUI after MUS failure with good outcome and low complication rates. Neurourol. Urodynam. 36:722-726, 2017. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.

Le succès thérapeutique après bandelette Monarc® est-il durable à moyen terme ?

Suburethral sling is the gold standard treatment for stress urinary incontinence (SUI). Short-term cure rates are high, but only few studies are available for longer assessment after transobturator tape procedure. The objectives of this study were to assess mid-term functional outcome for Monarc(®) transobturator tape after initial success, and to identify risk factors for recurrence. We conducted a single centre retrospective study (2004-2013) on consecutive women with SUI who underwent Monarc(®) transobturator tape procedure and were initially cured at the postoperative medical consultation. Pre- and postoperative data (age, weight, height, body mass index, hormonal status, surgical history, associated organ prolapse [Baden and Walker], associated urinary symptoms, postoperative complications [Clavien-Dindo]) were extracted from the electronic medical record. Subjective cure was defined by a score of zero from the ICIQ-SF questionnaire, no second intervention for recurrent SUI and no need for pads at latest news. Statistical analysis was performed using SAS(®) v9.3 (P<0.05). One hundred and thirty-three consecutive women underwent TOT Monarc(®) procedure, and 125 women were cured in the short-term. Among these women, 103 (82%) were available for mid-term evaluation. Sixty-four women (62%) had pure stress urinary incontinence. The mean follow-up period was 51 months [2-119]. At last follow-up, cure rate was 61%. Seventy-eight percent of women with recurrent urinary incontinence had SUI. Other women had mixed urinary incontinence (3/40), or de novo urgency (6/40). In univariate analysis, we could not identify pejorative prognostic factors for mid-term failure. In our experience, mid-term functional outcome after Monarc(®) transobturator tape procedure seems to deteriorate. After 4 years of follow-up, 61% of the women who were initially cured were still free from any leakage. 4.

Laparoscopic-assisted Retropubic Midurethral Sling Placement: A Technique to Avoid Major Complications

Study ObjectiveTo describe a technique for the safe placement of retropubic midurethral slings in patients undergoing concomitant laparoscopic surgery in order to avoid major complications associated with this procedure such as bladder perforation and retropubic hematomas. DesignStep-by-step video demonstration of the technique. SettingA university tertiary care hospital. PatientsPatients with an indication for retropubic midurethral sling placement because of recurrent stress urinary incontinence, intrinsic sphincter deficiency, or severe pelvic organ prolapse in whom a concomitant laparoscopic surgery has to be performed for other medical conditions. InterventionLaparoscopic opening and dissection of the Retzius space and insertion of the sling under a laparoscopic view of this space. Measurements and Main ResultsThis technique has been mainly used in patients undergoing laparoscopic pelvic organ prolapse repair. No complications have been identified so far, even in high-risk patients such as those with previous Burch colposuspension. ConclusionThis is a simple and reproducible technique for preventing major complications associated with retropubic sling placement in patients undergoing laparoscopic surgery for other reasons. It also permits the immediate detection and even resolution of complications in case any arise. Even high-risk patients may be safely approached.

A Valuable Option in the Management of Female Recurrent Stress Urinary Incontinence: Re-Adjustable Sling (Remeex Sling System)

Introduction: This study was conducted to evaluate the effectiveness and safety of adjustable slings in the treatment of recurrent stress urinary incontinence (SUI) after mid-urethral sling (MUS) failure. Materials and Methods: A prospective study was performed among women with recurrent SUI at the Urogynecology Division of Istanbul School of Medicine between February 2010 and March 2015. All women were preoperatively evaluated with detailed urogynecologic evaluations, which included pelvic examination, Q-tip test, pad test, urodynamic studies and a compilation of the Kings Health Questionnaire (KHQ). Postoperative follow-up was performed at 1, 6 and 12 months and annually thereafter. Our primary outcome was objective cure and patient's satisfaction with treatment. Secondary outcomes included perioperative complications and adverse events. Results: Nineteen women were included in the study. The patients' mean age was 55.3 ± 6.9 years (range 43-66 years). The median follow-up time was 20.7 ± 14.0 months (range 6-55 months). The overall cure and improvement rates were 84.2 and 10.5%, respectively. In the satisfaction questionnaire, 15 (79%) patients responded that they were very satisfied and 3 (15.7%) were moderately satisfied. Sling tension re-adjustment was needed during follow-up in 1 patient (5.3%), 13 months after the initial surgery. The preoperative mean KHQ score was 545.9 ± 243.0 and changed to 237.0 ± 217.5 (p < 0.05). Postoperative complications were slight and easily manageable. Conclusions: Recurrent SUI is a challenging condition in urogynecology. The Regulation Mechanical External (Remeex) system has been found to be effective in the treatment of recurrent SUI after MUS failure with acceptable adverse effects. The Remeex system has the advantage of re-adjustment as a valuable option in the long-term management of patients.