Retropubic Tape Research Articles

Retropubic tape surgery for stress urinary incontinence: can women be cured without voiding dysfunction?

Retropubic tension free vaginal tape (RP-TVT) has become the gold standard for surgical management of female stress urinary incontinence but is associated with voiding dysfunction (VD). We developed for more than 10years a reproductible and totally tension free tape procedure. Our goal is to determine efficiency of this technique compared to the incidence of VD. We retrospectively reviewed patients who underwent RP-TVT in our center between 2011 and 2019. Subjective cure, VD (determined as maximum urinary flow rate (Qmax) < 15mL/s or post void residual (PVR) volume > 150mL, or tape's section or resection requirement for underactive bladder (UB) with significant PVR) was assessed at 1year. The main objective was the evaluation of subjective cure and VD at 1year. On the 319 patients reviewed, 93% of the patients were dry and 10.9% presented VD at one year. UB (OR = 5.01 [1.55-16.44], p = 0.008), preoperative Qmax < 15mL/s (OR = 0.89 [0.84-0.95], p = 0.001) and previous incontinence surgery (OR = 4.20 [1.54-11.46], p = 0.005) were associated with VD. Acute urinary retention concerned 4.7% of the population and all were resolved after 6weeks postoperatively. We reported 0.3% of de novo urgency and patients without VD showed a significant decrease of their voiding time at 1year. The placement of RP-TVT without intraoperative tightening seems to be a safe technique ensuring a high cure rate and low occurrences of bladder outlet obstruction.

Case report of vaginal erosion and recurrence of stress urinary incontinence due to shallow placement of tension-free vaginal tape

BackgroundSuburethral sling with tension-free vaginal tape (TVT) has become a popular treatment for stress urinary incontinence (SUI). Erosion of the tape into the vaginal is rare. Very few patients present with vaginal tape erosion and recurrence of SUI.Case presentationA 49-year-old female patient with stress urinary incontinence was treated with a retropubic suburethral TVT sling. 2 months later, recurrent symptoms of SUI developed. 6 months later, the patient complained of repeated vaginal discharge and foreign body sensation. Body physical examination revealed a 1-cm-long tape extrusion at the left anterior vaginal wall beside the midline. Cystourethroscopy revealed no urethral mesh erosion. Surgical removal of the extrusion tape revealed that the left arm of the tape was in the vaginal mucosa layer rather than between the whole thickness of the vaginal mucosa and urethral. The tape around the urethral was dissected and removed. A new retropubic tape was placed simultaneously. At the 8-months follow-up after surgery, the patient was continent without tape vaginal exposure.ConclusionsVaginal mesh erosion should be considered in a patient who presents with sustained vaginal discharge after being treated with a suburethral sling. It is important to place the tape between the whole thickness of the vaginal mucosa and the urethral in SUI surgery. A shallow placement of the tape may lead to vaginal tape erosion and recurrence of SUI. These complications can be avoided by following the correct manipulation procedure and referring to the tissue layer anatomy.

Use of Magnetic Resonance Imaging in women with suspected complications following insertion of implants for pelvic organ prolapse and stress urinary incontinence surgery

ObjectiveTo evaluate the role of Magnetic Resonance Imaging (MRI) in women presenting with suspected implant complications following surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Study designRetrospective single-centre cohort study in a designated tertiary referral centre. All women with vaginally and/or abdominally placed implants for POP or SUI who were referred with suspected mesh complications, and investigated with an MRI scan, between January 2018-October 2020 were included in the study. Results97 women were identified over this time-period with a total of 123 implants, a median age of 55 years (Range: 34–79) and an average insertion to presentation time of 84 months (Range: 2–300). 78% (74) had one implant in situ, with the remainder having at least 2 in situ. Transobturator tapes (TVT-O/TOT) were the most common implants [35% (43)]. Chronic Pelvic or abdominal pain was the most common clinical symptom [73.2% (71/112 primary complaints)] with provoked tenderness on examination being the most common clinical finding [27.8% (32/115 clinical findings)].MRI was more likely to detect abdominally placed implants [100% (all 30)] and Retropubic Tapes [89% (16/18)] when compared to Transvaginal POP implants [87.5% (28/32)] and TVT-O/TOT [67% (29/43)]. MRI identified both cases of Sacrocolpopexy mesh rupture as well as all 11 cases of infection (100%). In 91% (10/11) of these cases, MRI revealed the infection to be more widespread than clinical findings initially suspected. Cohen’s Kappa demonstrated excellent correlation between MRI and surgical findings in cases with implant related infection, rupture and normal findings (κ = 1; z = 4.58; p = 0.00000459). Conclusion(s)MRI can be a useful tool in assessment and management of patients with complications from implants. MRI can detect infection that may be more extensive that is initially clinically apparent in the outpatient setting. Abdominal implants appear to be easier to detect than transvaginal meshes and trans obturator tapes.

Comparison of retropubic tension-free vaginal tape inserted on two different height positions

Introduction and hypothesisSurgical treatment using the mid-urethral tape has become a gold standard in the treatment of stress urinary incontinence in women. Many urogynecologists use ultrasound during the postoperative follow-up. The aim of this study was to investigate whether the position of the tape in the mid- or distal-urethra could influence the subjective assessment after surgery in 1-month control based on questionnaires of genitourinary symptoms, UDI6-SF and VAS scale.MethodsA group of 76 patients using a synthetic tension-free retropubic vaginal tape after anti-incontinence surgery was retrospectively included in this study. In a postoperative follow-up, the synthetic tape detection was performed using introital ultrasound, and its position was determined as a quotient T/U (T = distance between the external urethral orifice and the lower edge of the tape, U = urethral length). The patients were divided into two groups of 38 patients: one group with the position of the tape in the distal urethra (T/U ≤ 0.24) and the other group with the tape localised in the mid-urethra (T/U = 0.25–0.37). The correlation between the height of the tape position and the subjective assessment was evaluated in both groups of patients in the 1-month control.ResultsNo association was found between the height of the tape position in a group of patients after anti-incontinence surgery with a T/U value not exceeding 0.375 and the subjective assessment or the value of Vres.ConclusionsThe height of the tape position, with the T/U not exceeding 0.375, has no impact on the subjective assessment of the surgical anti-incontinence treatment in 1-month control.

Long-term efficacy and complications of a multicentre randomised controlled trial comparing retropubic and transobturator mid-urethral slings: a prospective observational study.

There are concerns regarding the risks of mid-urethral slings (MUS) for stress urinary incontinence (SUI), particularly because of the lack of long-term data. We compare patient-reported outcomes of a multicentre randomised controlled trial of retropubic (TVT, GYNECARE™) versus transobturator (TOT, MONARC™) tape surgery at 12 years. A multicentre study was performed in 11 tertiary referral centres. A cohort of 180 participants from the original trial, the majority of whom had mixed urinary incontinence. Postal questionnaire survey of patient-reported outcome measures using the International Consultation on Incontinence Questionnaire, Patient Global Impression of Improvement questionnaire (PGI-I) and a numeric rating scale pain questionnaire. Comparison of the efficacy and complications between the TVT and TOT procedures in the long term. A total of 110/180 responses were received: 55 for TVT and 55 for TOT. The mean follow-up was 12.8 ± 0.29 years (SD). TVT was significantly superior to TOT: 41.8% TVT with no SUI, versus 21.8% TOT (P = 0.04). Urgency urinary incontinence (UUI) was the most bothersome urinary symptom: 14.5% of respondents reported UUI after TVT and TOT. This was an improvement from the baseline levels: 61.8% TVT and 76.4% TOT. Seventeen patients (9 TVT and 8 TOT) out of 121 reported moderate or severe pain with severe pain in 3 with TVT and 2 with TOT. Overall, 80% TVT and 77% TOT participants reported their symptoms as improved on the PGI-I. TVT is superior to TOT for SUI cure. Efficacy is reduced by 12 years. There is low incidence of severe vaginal or groin pain. Careful patient counselling on long-term outcomes is required. The Retropubic tape appears to be an effective treatment for the majority of women with SUI. Retropubic tape has superior efficacy to transobturator tape. Complications are comparable with low rates.

Impact of Autologous Transobturator Sling Surgery on Female Sexual Function: A Comparative Study with Mesh Used Mid-Urethral Sling Surgeries

Introduction: To avoid mesh-related complications, autologous transobturator-tape (a-TOT) technique is a viable option in stress urinary incontinence (SUI) surgery. The method differs from TOT and retropubic tape (RT) in the usage of autologous tissue. We hypothesized that a-TOT improves female sexual dysfunction (FSD) more than TOT and RT. Methods: This is a retrospective cohort study. Patients who underwent a-TOT, TOT, and RT surgeries were surveyed regarding the cure of SUI, complications, and FSD parameters. The groups were compared according to baseline and postoperative data. Results: A-TOT, TOT, and RT groups included 37, 69, and 36 patients, respectively. The median follow-up time was 19 months. The groups were similar in terms of preoperative characteristics. The objective cure, subjective cure, and overall complication rates were comparable among the groups (p > 0.05). A-TOT group had significant improvements in mean female sexual function index (FSFI) scores, TOT group deteriorated, and RT group remained stable (p = 0.001, p = 0.001, and p = 0.226, respectively). The postoperative mean total FSFI scores were 25.73 ± 2.46, 23.17 ± 3.35, and 21.53 ± 2.47 for the a-TOT, TOT, and RT groups, respectively. The a-TOT group had better results than the TOT and RT groups (p < 0.05 and p < 0.05), and besides, the difference between the TOT and RT groups was statistically significant (p < 0.05). According to percentage changes in domain scores following the operations, the a-TOT group had significantly better results in desire, arousal, lubrication, satisfaction, and pain domains than the TOT group (p < 0.05) as well as better desire, arousal, and pain domains (p < 0.05) than the RT group. Discussion/Conclusions: Besides comparable outcomes in SUI treatment, the a-TOT technique provides improvements in female sexual functions while TOT worsens and RT does not change. Favorable outcomes in sexual functions caused by improvements in desire, arousal, satisfaction, and pain domains are observed following the a-TOT technique.

Dr Jekyll and Mr Hyde.

On the 10 July 2018, the UK Independent Medicines and Medical Devices (IMMD) safety review led by Baroness Cumberlege implemented a hiatus in the use of vaginal meshes for incontinence and prolapse because of concerns about complications. The use of vaginal mesh for prolapse has seen a natural decline over the past decade (Jha Int Urogynecol J 2018;29:795–801) with robust evidence available to suggest outcomes for native tissue repair are not significantly inferior to mesh-reinforced repair (Glazener Lancet 2017;389:381–92). However, there was considerable concern in relation to incontinence that patients would be exposed to more complex procedures with a greater complication rate because they would no longer have access to synthetic slings. The two synthetic sling procedures performed for stress urinary incontinence (SUI) are the tension-free vaginal tape (TVT) retropubic and the TVT obturator. Recently, these two devices have been referred to in the press interchangeably. The devices are made from identical mesh and are the same in their composition, size and the amount that is embedded in the patient, with similar success rates. However, that is where the similarity ends. So how did the two types of synthetic tapes become the Jekyll and Hyde of continence surgery? The Scottish review of the use of transvaginal mesh implants found greater adverse effects with obturator synthetic tapes than with retropubic tapes (https://www.gov.scot/publications/scottish-independent-review-use-safety-efficacy-transvaginal-mesh-implants-treatment-9781786528711/). The review also identified a greater need for repeat SUI surgery following the transobturator approach beyond 12 months. In addition, the number of cases under review for litigious reasons was three times greater in the obturator group than in the retropubic group. In the 2006 National Institute of Health and Care Excellence (NICE) clinical guidance (CG 40) on the management of urinary incontinence, there was only a brief mention of obturator tapes and the advice was to make women aware of the ‘lack of long term data’. When this guidance was updated in 2013 (CG 171), this advice remained unchanged. In the recent NICE consultation document published in October 2018, the advice is more directive: ‘do not offer a transobturator approach unless there are specific clinical circumstances (for example, multiple previous abdominal procedures) in which the retropubic approach should be avoided’. Obturator tapes were developed to reduce the risk of bladder injury but have been associated with groin pain and obturator neuropathies. These present as pain and restricted mobility of the thigh and hip adduction, along with sensory loss and pain across the anterior thigh. Foot drop is another rare presentation. However, the greatest problem with obturator tapes is the difficulty of complete removal, which is hampered by their placement deep in the obturator foramen, requiring dissection of the groin (usually by a plastic surgeon). In the largest series of vaginal mesh removals for all indications, the commonest type of mesh removed was the obturator tape for incontinence (Miklos Surg Technol Int 2016;29:185–9) and the removal of these meshes also had the highest complication rates. Clinicians who traditionally undertook obturator tape placement should be aware that even if the temporary ban is lifted, they will have to change their practice, as this procedure has acquired the mantle of Mr Hyde and will be off limits in most future circumstances. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

The long-term effectiveness analysis of retropubic and transobturator tension-free vaginal tape in the treatment of female stress urinary incontinence

Objective To compare the long-term outcomes of the retropubic tension-free vaginal tape (TVT) versus the transobturator tension-free vaginal tape (TVT-O) for women with stress urinary incontinence (SUI). Methods From July 2001 to June 2011, data of 120 female patients with SUI were retrospectively reviewed, of which 45 patients received TVT treatment, while 75 patients received TVT-O. The median age in TVT group was 45.1 years (range 35-72 years), and the median age in TVT-O group was 50.5 years (range 39-76 years). We retrospectively analyzed the long-term subjective effect, objective effect and the rate of complications in the two groups. Results Median follow-up period was 121 months (range 72-192 months). The complete satisfaction rate was 89%(40/45) in TVT group, and 92%(69/75) in TVT-O group, with no statistical difference between the two groups. The negative rate of cough test was 84.4%(38/45) in TVT group, and 76.0%(57/75)in TVT-O group, with a statistically significant difference. The rate of urinary tract injury was 8.9% (4/45)in TVT group, and 4.0%(3/75) in TVT-O group. The rate of thigh pain was 0 in TVT group, and 6.7%(3/45) in TVT-O group. The rate of micturition frequency and urinary incomplete emptying after operations was 6.7%(5/75) in TVT group, and 5.3%(4/75) in TVT-O group. Conclusions The long-term subjective effect between TVT and TVT-O groups was similar. The objective effect in TVT group was better. There was no statistical difference in complication rate between the two groups, which showed different types of complications in different procedures. Key words: Stress urinary incontinence(SUI); Tension-free vaginal tape(TVT); Transobturator vaginal tape(TVT-O); Long-term effect

De novo overactive bladder following midurethral sling procedures: a systematic review of the literature and meta-analysis.

De novo overactive bladder (OAB) is a known complication of midurethral sling surgery for the treatment of stress urinary incontinence. To date, differences in the incidence of de novo OAB following the use of different types of midurethral sling remain relatively unknown. The purpose of the present systematic review was to evaluate this incidence and summarize current evidence. We systematically searched the literature using the MEDLINE, Embase, Scopus, ClinicalTrials.gov, LILACS and Cochrane Central Register of Controlled Trials databases as well as the grey literature and references from the electronically retrieved articles. For comparisons of proportions, we used the chi-squared test. All reported analyses were designed as two-tailed. Statistical significance was set at p<0.05. Finally, 32 studies were included in this systematic review, with a total of 3,139 patients who had undergone midurethral sling procedures that included transobturator tapes (TOT), retropubic tapes (TVT) or single-incision tapes (mini-slings). The overall incidence of de novo OAB was 11.5% in nonrandomized studies (280 women) and 6.4% in randomized studies (50 women). In relation to the type of midurethral sling, the incidence of de novo OAB was 9.7% for mini-slings, 11.2% for TVT-O, 8.7% for TOT and 9.8% for TVTs. The chi-squared test did not reveal significant differences (p=0.58). Current evidence suggests that the overall incidence of de novo OAB following midurethral sling procedures is approximately 9%. There is not enough evidence to support differences in the effects of the different types of sling with regard to this particular postoperative complication.

Surgeons' views on sling tensioning during surgery for female stress urinary incontinence.

Little is known regarding the use of various techniques for sling tensioning. Our objective was to determine which techniques are most commonly used by surgeons and surgeons' views on sling tensioning. An Internet-based survey designed to assess the use of various tensioning evaluation methods, different sling tensioning techniques, and views and beliefs regarding the importance of tensioning was sent to members of major sub-specialty professional organizations. The responses were analyzed using descriptive statistics, and univariate and multivariate logistic analyses were performed to assess the effect of various surgeon characteristics on operative techniques. A total of 596 surgeons (63% gynecologists, 37% urologists) from 56 different countries were included in the analysis. Over 30% of respondents reported performing >50 sling operations/year. Use of objective intraoperative tension evaluation methods was 15.6, 7.8, and 1.9% for intraoperative stress tests, cystoscopic evaluation of urethral coaptation, or Q-tip tests respectively. Sixty-three percent indicated that they tension retropubic transvaginal tape (RP) and transobturator tape (TOT) slings similarly, whereas 26.2% place more tension on TOT than RP slings and 10.4% place more tension on RP than TOT slings. Those with fellowship training were 66% more likely to utilize leak point pressure results to inform the degree of tensioning (OR 1.66, CI 1.04-2.66). Our results indicate that there is a wide degree of variation in technique among surgeons. Prospective studies assessing the utility of various techniques could provide more evidence-based approaches to midurethral sling surgery and potentially improve quality and patient outcomes.

What can we learn from large data sets? An analysis of 19,000 retropubic tapes.

Retropubic tapes are successful for treating stress urinary incontinence (SUI), but there is controversy around risk profiles. The British Society of Urogynaecology (BSUG) database allows analysis of surgery for patient safety, surveillance and benchmarking. Objectives of this study were to establish success and complication rates in routine practice, determine complication rates for trainees and consultants, explore reasons for outliers and assess perforation as a surrogacy of quality. Approval was obtained from BSUG to use data on retropubic tapes. Data was anonymised, and patients gave prior consent. Analysis was done using the χ2 test, and a funnel plot of bladder perforation rate was calculated. There were 18,763 procedures recorded: 14,156 were performed by consultants, 64 by associate specialists (64), 1140 by subspecialty trainees, 2549 by registrars, 201 staff grades and 377 other. We found a 3.5% bladder perforation rate, which was statistically higher for trainees than consultants (p < 0.05). The rate of other "standard" complications were low: 95.8% of patients felt better on the Patient Global Impression of Improvement of Incontinence (PGI) scale. There was a significant difference (p < 0.05) in PGI and SUI outcome between patients who did and did not experience perforation. Success rates with retropubic tapes are high, with low complication rates. Bladder perforation in "real", not "trial" data was 3.5%, which is lower than reported by the Cochrane review (4.5%). Trainees have a higher perforation rate (p < 0.05) because of learning curves. Outliers are easily identified, and reasons for this should be explored, including proportion of trainees doing the surgery. This analysis confirms that bladder perforation is a valid surrogate for quality with a small but measurable difference. We have a responsibility to analyse data to improve patient care and encourage colleagues to support the International Urogynaecology Association (IUGA) database initiative.

Obturator Neuralgia: Complete Resolution after Laparoscopic Retropubic Sling Removal: A Report of 2 Cases

Background: Groin pain has been reported more frequently with transobturator mesh tape slings (TOT) compared to retropubic mesh tape slings (RP) secondary to the position of the mesh in the groin relative to the obturator nerve. However, if the mesh of a RP sling is placed on or near the region of the obturator neurovascular bundle in the retropubic space, the potential for similar groin pain does exist. Cases: We report two cases of severe leg and groin pain following the placement of a RP mesh tape sling. Two premenopausal women suffered groin pain after RP sling insertion. The RP slings were successfully removed by a combined laparoscopic and vaginal approach and both patients’ pain resolved. Conclusion: Laparoscopic RP sling removal from the retropubic space is safe and should be consider in patient who has obturator neuralgia after RP sling insertion.

Vaginal Revision of a Haematoma after Placement of Retropubic Tapes in Two Cases.

Formation of a haematoma after placement of retropubic tapes for stress incontinence is a rare but typical complication potentially requiring a subsequent operation. Under certain circumstances, haematoma removal by a vaginal approach represents a milder alternative to the subperitoneal laparotomy approach under general anaesthesia. We present two cases of vaginal haematoma revision after placement of retropubic tapes. By means of this gentle alternative to the standard laparotomy approach we could avoid general anaesthesia in one case and perform the operation under analgosedative local anaesthesia. In the second case, use of the vaginal approach enabled us to avoid a laparotomy in this obese patient with a superinfected haematoma that could have led to a possible secondary wound healing problem.

Which Works Better for Stress Urinary Incontinence — Surgery or Physiotherapy?

Treatment options for stress urinary incontinence consist of pelvic-floor muscle training (physiotherapy) and/or surgery; however, success rates vary for both approaches and direct comparisons have been limited. Dutch investigators conducted a 12-month, multicenter, randomized trial to compare physiotherapy with midurethral-sling surgery (retropubic or transobturator polypropylene tape) for moderate-to-severe stress-predominant urinary incontinence in 417 women. Crossing over between groups was permitted. Among women in …

Self assessment questions

Below is a list (A–P) of management options for urinary difficulties experienced by women. For each of the cases (i)–(iv) which follow, choose the most appropriate option from the list. Each option may be used once, more than once or not at all.(A)Midstream urine sample for microbiology(B)Pelvic floor exercises(C)Multichannel cystometry(D)Weight loss(E)Duloxetine(F)Oxybutynin(G)Tolterodine(H)Solifenacin(I)Pre-operative counselling in a clinic setting(J)Case discussion in multidisciplinary setting(K)Joint management with urology(L)Botulinum toxin(M)Midurethral retropubic tape(N)Midurethral transobturator tape(O)Open colposuspension(P)Laparoscopic colposuspension(i)A 40-year old presents with leaking urine. Her symptoms mainly occur while coughing, sneezing and gardening. There is also some degree of urgency. There is no incontinence demonstrated on examination. Urodynamics suggest evidence of urodynamic stress incontinence.(ii)A 76-year old with a BMI of 40 presents with symptoms of incontinence which is affecting her daily life. She is on treatment for heart failure, unstable angina and COPD. Pelvic examination reveals a small cystocele and minimal uterine descent with leakage on coughing. She has already been referred for physiotherapy which has made little difference to her symptoms.(iii)A 35-year old woman presents with leaking on exercise. She is a fitness instructor and routinely does two sessions a week. She gives a history of straining while voiding. There are no symptoms of urgency or increased frequency. Examination is essentially unremarkable. She wants a definitive solution to her problem in order to improve her quality of life. She has done 3 months of pelvic floor physiotherapy. Uroflowmetry shows max flow rate of 12 ml/second and average flow rate of 8 ml/second.(iv)A 45-year-old lady presents with symptoms of leaking urine on walking, light running and every time she laughs or sneezes. She does not have any voiding problems. There are no other medical co-morbidities. Bladder diary shows a daily intake of around 1.5 litres. Examination is unremarkable. She has already tried supervised pelvic floor exercises.

Evaluation of Endoscopic Laser Excision of Polypropylene Mesh/Sutures Following Anti-Incontinence Procedures

We reviewed our experience with and outcome of the largest series to our knowledge of patients who underwent endoscopic laser excision of eroded polypropylene mesh or sutures as a complication of previous anti-incontinence procedures. A total of 12 female patients underwent endoscopic laser excision of suture/mesh erosions at 1 center during a 10-year period. Primary outcome variables were the requirement of additional endoscopic or open surgery to remove mesh/sutures. Secondary outcome variables were persistence of urinary symptoms, postoperative complications, continence status and requirement of additional anti-incontinence procedures. The mean interval from previous surgery to erosion was 59 months (range 7 to 144) and the duration of presenting symptoms ranged from 3 to 84 months (mean 19). Ten patients underwent endoscopic excision of the mesh/suture with the holmium:YAG laser and 2 underwent excision with the thulium laser. Mean operative duration was 19 minutes (range 10 to 25) and followup was 65.5 months (range 6 to 134). Postoperatively 6 patients remain asymptomatic and 2 required a rectus fascial sling for recurrent stress urinary incontinence. Four patients underwent a second endoscopic excision due to minor persistence of erosion. Only 1 patient ultimately required open cystotomy to remove the eroded biomaterial. No intraoperative complications were recorded and all patients are currently asymptomatic. Endoscopic laser excision is an acceptable first line approach for the management of eroded biomaterials due to its high long-term success rate and minimally invasive nature.

Effectiveness of midurethral slings in recurrent stress urinary incontinence: a systematic review and meta-analysis

Midurethral slings (MUS) are the gold standard primary procedure for the surgical treatment of stress urinary incontinence (SUI). There is no robust evidence on the success with MUS in the treatment of recurrent SUI. Our objective was to evaluate the effectiveness and complications of MUS in women with recurrent SUI by systematic review and meta-analysis of the literature. A systematic literature search was carried out (up to August 2011) using relevant search terms in MEDLINE, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis of cure stated in prospective cohort studies was performed with a random effects model using Stata 8. There was 1 randomised trial and 11 good quality prospective studies included in this systematic review. The overall subjective cure rate per meta-analysis of prospective cohort studies following MUS for recurrent SUI after any previous surgery was found to be 78.5 % [95 % confidence interval (CI) 69-88] at the follow-up of 29.72 ± 29.49 months. The subjective cure rate following MUS after previous failed MUS was 73.3 % (95 % CI 55-97) at the follow-up of 15.7 ± 7.7 months. The studies report good cure rates of SUI after MUS surgery following previous incontinence surgery (62-100 %). There seems to be a lower cure rate with transobturator compared to the retropubic tape for recurrent SUI after previous surgery.

Slings in surgery of genuine stress incontinence

To summarize the available evidence concerning efficacy and safety of standard mid-urethral sling (SMUS) operations for the treatment of stress urinary incontinence (SUI). A non-systematic literature review was carried out in order to collect the available evidence concerning efficacy and safety of SMUS operations for the treatment of SUI. According to the data of our prior meta-analysis, patients receiving SMUS had significantly higher overall and objective cure rates than those receiving Burch colposuspension, although they had a higher risk of bladder perforations. Patients undergoing SMUS and pubovaginal slings had similar cure rates, although the latter were slightly more likely to experience storage lower urinary tract symptoms and had a higher reoperation rate. Patients treated with retropubic SMUS had slightly higher objective cure rates than those treated with transobturator tape (TOT); however, subjective cure rates were similar, and patients treated with TOT had a much lower risk of some complications. Meta-analysis demonstrated similar outcomes for TOTs. With regard to the novel mini-sling, another meta-analysis from Abdel-fattah et al. demonstrated that repeat continence surgery and de novo urgency incontinence were significantly higher in the patients treated with mini-slings. Patients treated with retropubic tape (RT) experienced slightly higher continence rates than those treated with Burch colposuspension, but they faced a much higher risk of intraoperative complications. RT and pubovaginal slings were similarly effective. The use of RT was followed by objective cure rates slightly higher than TOT and by higher risk of complications. The novel mini-slings do not seem to be more effective than the SMUS.

Recurrent stress urinary incontinence after synthetic mid-urethral sling procedures

Synthetic mid-urethral slings (MUSs) have been widely adopted for female stress urinary incontinence (SUI). Practitioners are encountering increasing numbers of women with recurrent SUI after a failed MUS. Several studies over the past 18 months have reported outcomes for secondary continence procedures in this context and form the basis of this review. Expert consensus supports a trial of conservative therapy for recurrent SUI, although a sound evidence base is lacking. As regards repeat surgical intervention, retrospective studies on repeat synthetic MUSs have demonstrated medium-term cure rates of 60-70%, which is lower than that achieved with primary surgery. Secondary transobturator tape appears inferior to secondary retropubic tape in women with intrinsic sphincteric deficiency. Promising early results have been reported with spiral slings and the adjustable continence procedures, although these interventions are technically more challenging and longer-term follow-up is warranted. Artificial urinary sphincters show high efficacy rates for severe, refractory SUI, although complication rates are higher in women with prior failed MUS. Repeat synthetic MUSs are likely to form the mainstay of secondary continence procedures presently. Longer-term follow-up of promising newer modalities, including adjustable continence therapies, is required. Above all, there is an urgent need for good quality, prospective data to guide practitioners in this growing clinical challenge.

Comparison of late complications of retropubic and transobturator slings in stress urinary incontinence

To compare the late complication profiles between retropubic and transobturator slings used for stress urinary incontinence was the objective of the study. Between the years 2003 and 2010, 338 complications of midurethral slings were surgically managed in a tertiary referral center. For the purpose of study, we excluded slings that had materials other than monofilament polypropylene, patients with previous anti-incontinence surgeries, and patients who were suspected of having a neurologic bladder condition. This is a prospective and retrospective study of the complications of midurethral slings. The characteristics of complications in retropubic and transobturator routes were compared and analyzed. Two hundred eighty cases with midurethral sling complications were suitable for analysis. Of these, retropubic slings constituted 210 and transobturator 70. The time interval between the insertion of tape and onset of complications was similar in both groups. Within the two groups, obstructive symptoms were seen more frequently in the retropubic tapes group. Compared to the retropubic tapes group, the transobturator group had more number of complications related to persistent pain (10% tension-free vaginal tapes vs. 32% transobturator tapes), dyspareunia (3% vs. 18%), and tape-related infections (4% vs. 18%). There were no significant differences among the complication rates pertaining to de novo overactive bladder (49% vs. 44%), obstructive symptoms (48% vs. 30%), and contraction of sling material (5% vs. 8%). Obstructive complications were seen more commonly in the retropubic tapes compared to the transobturator tapes. Transobturator tapes were more frequently associated with persistent pain, dyspareunia, and tape-related infections as compared to retropubic tapes.