Sling Position Research Articles

Midurethral sling position and surgical outcome: A meta-analysis.

There is still ongoing debate as to whether the outcome of the sling is determined by the position of the midurethral sling. In order to evaluate the potential impact of sling position on the outcomes of retropubic and transobturator sling procedures for stress urinary incontinence, it is necessary to conduct further investigations. We conducted a comprehensive search across various electronic databases such as PubMed, EMBASE, MEDLINE. Relevant data were extracted, organized in a table format, and analyzed using RevMan software for further analysis. This review comprised a total of 9 studies. The findings indicate that patients with TVT tape placement in the midurethra exhibited a slightly higher cure rate compared to those with proximal placement. Conversely, tape placement in the midurethra was associated with a significantly higher cure rate compared to distal placement [RR = 0.84, 95% CI (0.74-0.95), P < .05]. In the case of transobturator slings, tape positioning beneath the midurethra or distal urethra yielded better outcomes compared to placement near the bladder neck [RR = 0.74, 95% CI (0.57-0.94), P = .02; RR = 0.61, 95% CI (0.39-0.96), P = .03]. Based on 2D and 3D ultrasound imaging, differences in TVT placement appear to have minimal impact on the cure rate. However, the highest rate of failure after transobturator sling surgery is closely linked to the positioning.

Which parameters, related to the female urethra and pelvic floor, determine therapy selection for recurrent female stress urinary incontinence: ICI-RS 2023?

The evidence basis for therapy selection in women who have failed primary stress urinary incontinence (SUI) surgery is limited. The ICI-RS group discussed the available data at its meeting in June 2023, particularly the anatomical characteristics as assessed using magnetic resonance imaging (MRI) and ultrasound (US) modalities, functional characteristics associated with storage and voiding urodynamic assessment, as well as the patient characteristics that might influence outcomes. This paper summarizes the evidence base that supported these discussions and offers the basis for research proposals for future groups. A literature search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was performed, and the data is presented. Research questions are based on the knowledge gaps highlighted. Possible MRI parameters that may influence outcomes were striated urethral sphincter volume, bladder and proximal urethral funneling, pubo-urethral ligament integrity, distance of the bladder neck below the pubococcygeal line, posterior urethra-vesical angle, and bladder neck to levator ani distance. US parameters included sling distance to the urethral lumen and pubis, sling position, bladder neck mobility, and lateral arm asymmetry, twisting, or curling. Urodynamic parameters included detrusor overactivity, Valsalva leak point pressure, maximum urethral closure pressure, and bladder outlet obstruction. Important patient parameters included body mass index, age, and previous interventions. Identifying and quantifying causative factors in patients with recurrent SUI, that allow clinicians to modify subsequent treatment choices and techniques may help reduce treatment failure and complications. Formulating algorithms is the next step in optimizing patient counseling, surgical selection, and healthcare allocation.

Comparison of two outside-in transobturator midurethral slings in the treatment of female urodynamic stress incontinence

ObjectiveTo explore the difference between two brands of outside-in transobturator midurethral sling (TOT) for urodynamic stress incontinence (USI). Materials and methodsWomen who underwent an outside-in TOT procedure by either Monarc or Obtryx were retrospectively reviewed. Data of women with available information at baseline and postoperative 12-month follow-up were analyzed. The analyzed data included standardized interview, pelvic examination, as well as sling location and sling tension explored by introital four-dimensional ultrasound. Sling position were explored through the distances between the sling center and the caudal margin of the pubic symphysis (SPd) as well as sling percentile (SP) along the urethral length as a percentage in the midsagittal plane. SPd was also used to explore sling tension. Clinical outcomes were compared between two groups. Sling location and sling tension were compared in success cases between two groups. ResultsThere were 138 women in Monarc group and 140 women in Obtryx group. Rates of stress urinary continence and adverse events were not statistically different after two TOT. SPd was similar between both procedures. Obtryx located more ventrally than Monarc, indicated by a smaller SP during resting (41.6% vs 58.5%, P < 0.001), straining (38.0% vs 54.4%, P < 0.001), and coughing (39.8% vs 48.8%, P < 0.001). ConclusionAt 12-month assessment, both outside-in TOT procedures were not significantly different in terms of clinical results and sling tension, while Obtryx sling located more ventrally than Monarc.

Transobturator tape versus single incision sling: how are they different? Clinical outcomes and ultrasonographic features of two mid-urethral slings.

Stress urinary incontinence (SUI) is usually treated with mid-urethral slings. The best approach is still debated and the relationship between slings and pelvic structures is not completely understood. The aim of this study is to identify any difference between trans-obturator tape (TOT) and single incision sling (minisling). Patients submitted to TOT or minisling were included in the study. Q-tip and stress test, ICIQ-SF questionnaire, PGI-I validated score, and 2D/3D transvaginal ultrasound parameters were collected at 1- and 6-month follow-up. Correlations between ultrasound parameters and clinical outcomes, PGI-I and ICIq-SF, were performed. 61 patients were included in the study. PGI-I score was significantly lower in the minisling group than in TOT group at 1-month (p = 0.016) and 6-month follow-up (p = 0.076). The median distance between the sling and the lumen of urethra was significantly higher and the angle between the branches of the sling was significantly narrower in the minisling group. There were significant differences in distances between the sling and the bladder neck at 1-month and 6-month follow-up. An inverse correlation between angle of the branches and the Q-tip test was observed (p = 0.059 Pearson's Rho -0.578). PGI-I correlated also with angle of the branches (p = 0.009, Pearson's Rho 0.503). Patients undergoing TOT or minisling are similarly satisfied but show differences at ultrasound exam at 1- and 6-month follow-up. Pelvic floor ultrasound could be used in a short-term follow-up to visualize the sling position and to plan the most appropriate follow-up strategy.

Ultrasound Evaluation of Mid-Urethral Sling Position: A Potential Predictor of Outcomes and Adverse Effects

Objective: The aim of this study was to evaluate mid-urethral sling (MUS) position and its association with postoperative outcomes and complications. Design: This was a prospective cohort study. Ninety-two women who underwent MUS procedure with a median follow-up period of 11 months (interquartile range 5–24 months) were recruited. Participants/Materials, Setting, Methods: Two-dimensional trans-labial ultrasound with an endovaginal probe was used to visualize the urethral length (UL), sling distance to the bladder neck (BN) and to the urethra longitudinal smooth muscle (LSM). Results: Mean sling-LSM, UL, and sling-BN distances were 5.97 ± 2.04 mm, 28.66 ± 3.19 mm, and 18.85 ± 4.46 mm, respectively. Sling position relative to BN (proximal vs. middle vs. distal) was not associated with surgery outcomes and complications; however, mean sling-LSM in patients with exposure (4.3%) was significantly higher compared to those who did not experience exposure (8.80 ± 1.9 mm vs. 5.8 ± 2.0 mm, p = 0.048). Moreover, the mean sling-LSM distance was associated with patient satisfaction (5.87 ± 2.0 mm in satisfied patients with VAS > 6 vs. 6.29 ± 2.1 mm in unsatisfied patients, p value = 0.043). Likewise, patients who had worsened or showed de novo overactive bladder (OAB) symptoms (8.8%) had significantly higher mean sling-LSM distance compared to patients with improved OAB symptoms (6.52 ± 2.0 mm vs. 5.37 ± 1.9 mm, p = 0.007). Mean sling-LSM distance was lower in patients with recurrent urinary tract infection (UTI), voiding dysfunction, and improved stress urinary incontinence, whereas patients with dyspareunia after surgery had higher mean sling-LSM distance; however, these differences were not statistically significant. Limitations: Both trans-obturator and retropubic procedures with or without concomitant prolapse surgery were assessed. Heterogeneity of the study population and pelvic floor ultrasound being performed by a single urogynecologist were the limitations of the current study. Conclusions: Ultrasound visualization of MUS is feasible and has the potential to predict outcomes and complications. High sling-LSM distance was associated with exposure, and low sling-LSM distance with increased satisfaction rate, probability of voiding dysfunction, and recurrent UTI.

Factors associated with better treatment outcome of physical therapy interventions after shoulder arthroplasty: A systematic review

Objective To summarize factors that are associated with a better treatment outcome after post-operative physical therapy in patients with shoulder arthroplasty. Data sources PubMed, Cochrane, and Web of Science. Review methods Studies examining factors that are associated with a better outcome after post-operative physical therapy interventions in patients with shoulder arthroplasty were included. Two independent reviewers performed screening, extracted data, and assessed the risk of bias and level of evidence, using the Quality In Prognosis Studies tool and Evidence-Based Guideline Development checklist. PRISMA guidelines were followed. Results In total, 460 articles were found and 14 studies were included. Two of the included articles had a moderate risk of bias, 12 high. The overall number of patients in the included studies varied from 20 to 2053. Patients had either a reverse (N = 1863), an anatomic total shoulder arthroplasty (N = 1029) or, a hemiarthroplasty (N = 133). Anatomic total shoulder arthroplasty patients with a neutral rotation sling position showed less night pain and greater range of motion, which was awarded moderate evidence. Other modifiable and non-modifiable factors such as telemedicine, immediate range of motion exercises, and pre-operative function were only awarded preliminary or conflicting evidence. Conclusion Mainly preliminary and conflicting evidence was found. The possible causes of the conflicting evidence were the different measurement methods, implant types, and follow-up times used. The methodological quality was low and physical therapy protocols differed greatly. More high-quality research with standardized protocols is needed to determine the association of various factors with treatment outcomes after post-operative physical therapy in patients with shoulder arthroplasty.

Management and Follow-Up Practices of Women With Recurrent Stress Urinary Incontinence Following Transobturator Mid-urethral Synthetic Sling Procedure: A 6-Year Retrospective Monocentric University-Based Study.

Purpose: The purpose of this study is to evaluate the efficacy of management and follow-up practices in repeat retropubic mid-urethral synthetic sling (MUS) procedure after transobturator tape/tension-free vaginal tape-obturator (TOT/TVT-O) failure, and to clarify the possible etiology of recurrent stress urinary incontinence.Methods: The charts of all women patients who underwent tension-free vaginal tape (TVT) slings after previous failed transobturator MUS procedures between February 2012 and November 2018 at a single center were reviewed retrospectively. The transperineal ultrasound was performed to assess the pre-operative or post-operative urethral mobility and location of the slings. Furthermore, some essential evaluations were also made, mainly including medical history, physical examination, 1 h pad test, and urodynamic study. Finally, primary outcomes were evaluated according to the above items at 3, 6, and 12 months after the second operation, respectively.Results: Thirty-five patients were included in the primary transobturator MUS sling procedure. At the 6 months follow-up, 32 (91.42%) patients were socially continent and negative in 1 h pad test. The transperineal ultrasound measurement results revealed that the bladder neck descent (BND) values were significantly decreased after the repeat sling operation, and better urinary continence function was observed according to the post-operative urodynamic study. Multifactorial etiologies resulted in recurrent stress urinary incontinence (SUI), including poor surgical technique, inadequate sling tension when treating ISD, and inappropriate sling position. Then the detail of the surgical procedure varied with the results of pre-operative evaluations, affecting the validity of the second sling.Conclusion: Recurrent SUI has resulted from multi factors, pre-operative urodynamic study and transperineal ultrasound might be valuable tools to guide repeat sling operation and predict post-operative outcomes. A repeat TVT procedure may be regarded as a remedial measure for a failed transobturator MUS operation.

Sonographic sling position and cure rate 10-years after TVT- O procedure.

AimTo examine the position of the TVT-O sling 10 years postoperatively and its association with outcome.MethodsA total of 124 patients who received a TVT-O sling at two centers in 2004 and 2007 were invited for follow-up. The position of the sling on perineal ultrasound was described relative to the bladder neck and the lower margin of the pubic symphysis at rest and on Valsalva. Objective cure was defined as a negative cough stress test at 300 ml. Subjective cure was evaluated with the Kings´ Health Questionnaire (KHQ), Incontinence Outcome Questionnaire (IOQ), Female Sexual Function Index Questionnaire (FSFI) and the Patient Global Impression of Improvement score (PGII).Results78 of 124 patients (57%) were available for follow-up 10 years after surgery. I Eleven (14%) had undergone reoperation and were excluded. Tapes were visualized in the remaining 67 (54%) women. The subjective and objective cure rates in this sub-cohort were 67% (45/67) and 77% (52/67), respectively. In these 67 women the mean distances from the bladder neck to the proximal edge of the tape (BNTD) during Valsalva maneuver were significantly higher in cured women compared to the not-cured women (11.2 vs. 9.4mm). The distance between tape and urethra (TUD) was significantly lower in cured vs. not cured patients (2.6 vs. 4.1mm). All women with a TUD of >5mm (n = 5) were incontinent. Tape position was not associated with overactive bladder symptoms.ConclusionsTape position near the bladder neck and large distance to the urethra is associated with incontinence 10 years after TVT-O.

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

The aim of the present study was to investigate the effectiveness of repeat retropubic suburethral sling for recurrent stress urinary incontinence (SUI) in women. A retrospective review was performed of 35 women with SUI who underwent repeat retropubic suburethral sling procedures between May 1994 and November 2014. Treatment outcome was assessed directly or by telephone interview. Sling position and urethral incompetence during straining and coughing after the procedure were evaluated. The overall continence rate after repeat suburethral sling procedures was 60% (21/35). Among the 35 women, 19 underwent a simple retropubic suburethra sling procedure and 16 underwent combined suburethral sling and other pelvic floor surgery; the success rate for these 2 groups was 84.2% (16/19) and 31.3% (5/16; P = .001), respectively. The success rate was 60% in patients with normal detrusor function (n = 18/30) and in those with detrusor underactivity (n = 3/5; P = 1.0). For patients with intrinsic sphincter deficiency and bladder base hypermobility, the success rate was 63.6% (n = 14/22) and 53.8% (n = 7/13), respectively (P = .36). Among the 25 patients with transrectal ultrasound follow-up data, the success rate following placement of the second sling at the bladder neck, proximal urethra, middle urethra, and distal urethra was 50% (2/4), 87.5% (7/8), 36.4% (4/11), and 0% (0/2), respectively (P = .122). Repeat suburethral sling procedures for recurrent SUI are safe and effective. The position of the second sling at the proximal urethra resulted in a relatively higher continence rate relative to other sites.

Are complications of stress urinary incontinence surgery procedures associated with the position of the sling?

To evaluate whether the sling position is associated with particular types of complications in patients undergoing suburethral sling placement for stress urinary incontinence. Data from 100 women diagnosed at the Evangelical Hospital Hagen-Haspe with complications after suburethral sling insertion were analyzed. All patients underwent pelvic floor ultrasound to assess: urethral length, sling location in relation to the urethral length (%) and the sling distance to the longitudinal smooth muscle complex of the urethra (the sling-longitudinal smooth muscle distance). The shortest median sling-longitudinal smooth muscle distance was observed in patients with recurrent urinary tract infections, urinary retention and overactive bladder: 0.9, 1.1 and 1.75 mm, respectively (P < 0.05). In women with persistent stress urinary incontinence and sling erosion, the sling-longitudinal smooth muscle distance was 3.6 and 4.6 mm, respectively (P < 0.05). Persistent stress urinary incontinence was connected with the position of the sling in relation to the bladder neck - in these patients, the sling was closer to the bladder neck. Sling location plays a pivotal role in the occurrence of certain complications. The sling position in the proximal part of the urethra or between the middle and proximal urethra appears to be connected with a high rate of unsuccessful stress urinary incontinence treatment. A sling-longitudinal smooth muscle distance below 2 mm is often connected with sling complications, such as overactive bladder, urinary retention and recurrent urinary tract infections.

Fast Fourier transform analysis as a new tool for Olympic rifle coaches

The aim of this study was to examine the possibility of using data collected with an electronic training system to determine the influence of a shooter’s heartbeat on shooting precision. Shooting sessions of a rifle in prone position were studied with the use of an electronic training system. As a case study, results of an experienced shooter were analyzed. Fast Fourier transform was applied to raw data extracted from the system and then results were interpreted. The spectrum obtained revealed a wide peak at the frequency f = 2.6 Hz that was considered as the second harmonics of the average frequency corresponding to the heartbeat decreasing down to 69 beats/min when releasing a shot. The session finished with a very modest score of 611.3 points. When a small intentional change in the shooter’s equipment (a sling position) was introduced, the spectrum obtained did not reveal any peaks and the shooter reached a much better score of 621.8 points. The use of fast Fourier transform analysis is proposed as a new tool for Olympic rifle shooters and coaches. This new tool does not require any complicated procedures and provides quantitative information on the influence of a heartbeat on the stability of a shooter’s aim.

Ultrasound Evaluation of Midurethral Sling Position and Correlation to Physical Examination and Patient Symptoms.

The primary objective was to evaluate the position and angle variation between 3 different midurethral slings (MUSs) using 3-dimensional ultrasound (US) technology. The secondary objective was to compare differences in findings on physical examination and symptoms of incontinence and sexual dysfunction between subjects. This was a cross-sectional study of 61 subjects who had undergone MUS placement without concomitant anterior or apical compartment prolapse surgery (21 retropubic [RP], 19 out-to-in transobturator [TOT], 21 in-to-out transobturator [TVT-O]). Subjects completed validated questionnaires (Sandvik Incontinence Severity Index, Urogenital Distress Inventory 6) and underwent a pelvic examination and standardized 2-dimensional and 3-dimensional ultrasonography evaluation. On translabial US, the median RP sling angle was 108.2 degrees (72.6-135.9), significantly more acute than the angle of TOT and TVT-O slings (119.3 degrees [72.3-140.4, P = 0.02] and 118.5 degrees [99.0-154.7, P = 0.004]). There was no difference in the sling angles between the TOT and TVT-O slings (P = 0.86). No difference was noted in the position of the sling along the urethra (P = 0.82). The TOT sling was more often palpable (57.8%, P = 0.02) compared with the RP or TVT-O groups.Fifteen patients (4 RP, 5 TOT, 6 TVT-O) reported discomfort during intercourse that they attributed to the MUS. Three of 19 TOT subjects reported that their partner experienced pain with intercourse because of the sling. However, sexual function and urinary symptoms were not statistically different between the 3 groups. On 3-dimensional US, RP sling angle was found to be significantly more acute than the angles of the TOT and TVT-O slings, and there was no difference between the 2 transobturator slings. The TOT sling was more often palpable on examination, but this finding did not correlate with increased pain on palpation.

Effects of bridge exercise on trunk core muscle activity with respect to sling height and hip joint abduction and adduction.

[Purpose] This study evaluated the effects of bridge exercise on trunk core muscle activity with respect to sling height and hip joint abduction and adduction. [Subjects] Fifteen healthy adult males participated. [Methods] In the bridge exercise, the height of the sling was set low or high during hip joint abduction and adduction. Electromyography was used to compare the differences between the muscle activities of the transverse abdominis, rectus abdominis, and erector spinae muscles. [Results] The muscle activities of the transverse abdominis, rectus abdominis, and erector spinae were significantly higher in the high sling position. Furthermore, the activities of the transverse abdominis and erector spinae were significantly higher during hip joint adduction than abduction regardless of sling height. [Conclusion] A high sling height is the most effective intervention for increasing the muscle activities of the transverse abdominis and erector spinae muscles during hip joint adduction in a bridge exercise.

Ultrasonography and clinical outcomes following surgical anti-incontinence procedures (Monarc vs Miniarc)

ObjectiveTo evaluate the ultrasound morphology and its clinical outcome among women who had undergone Miniarc™ vs Monarc™ in the treatment of stress urinary incontinence (SUI). Study designThis was a prospective study on 140 patients with USI and undergone either Miniarc or Monarc surgery. From March 2010 to December 2011, patients with clinically SUI and urodynamic stress incontinence (USI) were included in the study. Objective cure of SUI was defined as no urinary leakage on provocative filling cystometry and 1-h pad test of <2g. Subjective cure of SUI was the negative response to UDI-6. Introital ultrasound at one-year explored the sling and bladder neck's position, mobility, sling tension, percentile of urethra where the sling was located and urethral kinking. ResultsPostoperative data was available from 130 women. The ultrasound objective data for successful treatment post-operative follow-up was available from 119 women (46 Monarc, 73 Miniarc), the rest failed to follow-up. A bladder perforation was diagnosed in the Monarc group and 15 cases (7.1% of Monarc and 16.3% of Miniarc, p=0.082) of urinary retention was reported due to over-tensioning of the sling, majority of cases came from the Miniarc group. At rest and during Valsalva, analogous distances of the bladder neck and sling as well as the center of the urethral core were similar for both procedures. In both groups, shortest (Us) and longest diameters (Ul) of the urethral core were comparable at Valsalva which was significantly shorter and longer, respectively, compared to the values at rest. Sling position and percentage of urethral kinking were similar. Statistical analysis failed to detect any significant difference between the two groups with regards to the objective and subjective cure (p>0.05). ConclusionsIn conclusion, a Miniarc and Monarc exhibit similar mechanism of action with comparable subjective and objective clinical outcomes. Majority of urethral impingement was noted in the Miniarc group. A higher maximum urethral closure pressure (MUCP), longer resting Ul, and shorter resting Us suggested these observations. Postoperative ultrasonographic evaluation may give a promising future perspective for the evaluation of sling tension.

MP38-12 THE ROLE OF TRANSPERINEAL ULTRASOUND IN EVALUATION OF THE FAILED MALE TRANSOBTURATOR SLING – SEPARATING TECHNICAL FAILURE FROM TRUE FAILURES

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence Therapy II1 Apr 2014MP38-12 THE ROLE OF TRANSPERINEAL ULTRASOUND IN EVALUATION OF THE FAILED MALE TRANSOBTURATOR SLING – SEPARATING TECHNICAL FAILURE FROM TRUE FAILURES Lewis Chan, Vincent Tse, and Audrey Wang Lewis ChanLewis Chan More articles by this author , Vincent TseVincent Tse More articles by this author , and Audrey WangAudrey Wang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1269AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is increasing use of transobturator slings in treatment of post-prostatectomy stress urinary incontinence. Our previous ultrasound studies have demonstrated the phenomenon of ‘dynamic compression’ of the urethra during Valsalva and cough in patients with AdVance slings. The aim of this study was to assess the role of transperineal ultrasound in the evaluation of patients with failed slings. METHODS Transperineal ultrasound was performed on 20 patients with unsatisfactory outcomes post AdVance transobturator sling. 16 patients had persisting incontinence post sling and 4 patients had voiding dysfunction. 2D/3D ultrasound examinations were conducted using a Philips IU22 ultrasound machine and matrix transducer. Patients were imaged at bladder volumes of over 150mls, at rest and on Valsalva. Imaging findings included bladder neck position, urethral mobility and position of sling relative to urethra on dynamic imaging. 3D datasets were analysed to assess sling position. RESULTS All 20 slings were well visualized on transperineal ultrasound. Malposition of sling was observed in 7 of 12 patients with early sling failure. 3 patients reported worsened incontinence post sling and paradoxical distraction/opening of the urethra on Valsalva was demonstrated. 2 patients had partial detachment of the central portion of the sling and 2 had distal location of the sling in the perineum. Satisfactory sling position (sub-urethral portion of sling at level of inferior border of the pubic symphysis) and dynamic compression of the urethra by sling was demonstrated in 2 patients with early failure and in all 4 patients with gradual deterioration of continence indicating true failure (significant intrinsic sphincteric deficiency). Sling position was satisfactory in all 4 patients with voiding dysfunction post sling. However indentation/kinking of the urethra was not observed in obstructed male slings unlike obstructed female slings. 3D ultrasound did not provide additional information compared to dynamic 2D imaging in assessing sling position. CONCLUSIONS Transperineal ultrasound may have a role in the evaluation of the failed male transobturator sling. Patients with early failure can be categorized into technical failure (malpositioning) and true failures. Patients with malpositioned slings and absence of dynamic compression of the urethra by sling can be considered technical failures and may be suitable for a re-do sling procedure. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e405 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Lewis Chan More articles by this author Vincent Tse More articles by this author Audrey Wang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Could the Sling Position Influence the Clinical Outcome in Male Patients Treated for Urinary Incontinence? A Magnetic Resonance Imaging Study With a 3 Tesla System

To analyze the morphologic changes visible on magnetic resonance imaging (MRI) after sling procedure in continent patients and to compare MRI findings with the incontinent ones, to detect possible factors explaining the different clinical outcomes. Twenty-seven male patients who were treated with Advance sling for urinary stress incontinence after prostate surgery were enrolled: 16 had clinical recovery, whereas 11 had persistent incontinence. Patients after sling were defined as continent if used 0-1 dry "security pad" or incontinent >1 pad. Magnetic Resonance examinations were performed with a 3 Tesla system and included 3-dimensional T2-weighted sequence. Three readers performed a qualitative (representation of the bulb and indentation of the sling) and a quantitative analysis (length of the bulb posterior to the sling and distance of the sling from a line bisecting the pubic symphysis). The sling was clearly recognizable in all 16 continent patients but only in 2 of 11 incontinent ones. The length of the bulb posterior to the sling was >10 mm (range, 10-28) in all continent patients and in 2 of the incontinent ones. The sling was coincident with a line drawn through the long axis of the pubic bone in 9 of 16 continent patients. A statistically significant association was found between MRI qualitative findings and continence status (P <.0001). On the basis of our MRI results, the position of the sling and, in particular, the length of the urethral bulb posterior to the sling seem to be correlated with continence and must be considered in case of treatment failure.

Visualization of polypropylene and polyvinylidene fluoride slings in perineal ultrasound and correlation with clinical outcome.

Introduction and Hypothesis. Complications and malfunctioning after TOT can occur due to several factors, such as the material of the sling. The aim of the present study is to evaluate morphology and functionality of two types of slings (PVDF; polypropylene) in vivo using perineal ultrasound (PUS). Materials. In n = 47 women with TOT four criteria for PUS were taken and checked for possible differences: vertical stability of the sling position during Valsalva manoeuvre and contraction; distance “sling to urethra”; width of the sling and condition of the selvedges. Results. We observed an increased vertical displacement of the PP-slings, a significantly smaller variance to the extent of the displacement in PVDF-slings (P < 0.01), a significantly larger distance between sling and urethra (P < 0.001) in PVDF-slings, and a significantly smaller width of the PP-slings (P < 0.0001). Conclusion. Significant differences were found between the slings according to the four criteria. There was no difference established between the slings in the improvement of continence and no significant influence of the parameters was found for the resulting state of continence. In future studies, PUS may help to link differences in the morphology and functionality of in vivo slings to their material properties.

Positioning of a Suburethral Sling at the Bladder Neck Is Associated With a Higher Recurrence Rate of Stress Urinary Incontinence

The purpose of this study was to investigate the relationship between the suburethral sling position and the outcome of anti-incontinence surgery. From 1998 to 2010, the medical records of 153 consecutive women with stress urinary incontinence undergoing the pubovaginal sling procedure were retrospectively reviewed. All patients received preoperative and postoperative transrectal sonography of the bladder and urethra, and the suburethral sling position was used to compare the postoperative continence status and lower urinary tract symptoms. The mean patient age ± SD was 60.7 ± 10.6 years (range, 34-85 years), and the mean follow-up was 66.3 ± 42.1 months (range, 6-149 months). The slings were located at the bladder neck in 18 patients (11.8%), proximal urethra in 81 (52.9%), middle urethra in 45 (29.4%), and distal urethra in 9 (5.9%). The overall rate of recurrent stress urinary incontinence was 24.2% (37 patients). Among the 153 patients, there was a significantly higher stress urinary incontinence recurrence rate in the bladder neck group (bladder neck, 50.0%; proximal urethra, 18.5%; middle urethra, 22.2%; and distal urethra, 33.3%; P = .037). De novo urge and voiding symptoms occurred in 19.0% and 20.3% of overall patients, respectively. There was no significant difference in either de novo urge or voiding symptoms among groups. Positioning of the suburethral sling at the bladder neck appears to be associated with a higher stress urinary incontinence recurrence rate. Patients with slings located at the proximal and middle urethra had the best postsurgical continence rates. The suburethral sling position had no direct association with de novo urge or voiding symptoms.

Complications of synthetic slings used in female stress urinary incontinence and applicability of the new IUGA-ICS classification

To analyze different complications of synthetic suburethral slings, and to apply the new "IUGA-ICS classification of complications directly related to the insertion of prosthesis (meshes, implants, tapes) and grafts in female pelvic floor surgery" to the list of complications, check its applicability, and give suggestions regarding possible improvements. This study is an analysis of complications of synthetic suburethral slings. Data on type of complication, time interval between the insertion of the prosthesis and the onset of symptoms of complication, type and nature of prosthesis, and management process were documented. Additional descriptions of the sling position in relation to lower urinary tract, shrinkage or prominence of the prosthesis, and intra-operative nature of the prosthetic material were collected for analysis. From the year 2003 to 2010, 376 women with complications of synthetic suburethral slings were managed surgically and the data were analyzed. Overactive bladder (OAB) at 54%, lower urinary tract obstruction (48%), vaginal exposure (19%), and pain (14%) were the most frequent complications. Infection, fistulae, urinary tract penetration, and groin/thigh pain were other complications. The new IUGA-ICS classification could be applied to most of the types of complications, a notable exception being de novo development of overactive bladder. Also category 4B of IUGA-ICS classifications encompasses a wide clinical variety of complications and may need reconsideration. De novo OAB seems to be the commonest complication of synthetic suburethral slings, followed by obstruction, vaginal exposure, and long term pain. The new IUGA-ICS classification on complications has good general applicability; some minor changes may be useful in the future.

1346 TRANSLABIAL ULTRASONOGRAPHY OF SUBURETHRAL SLINGS IN PATIENTS WITH RECURRENT URINARY INCONTINENCE AFTER SYNTHETIC SLING PLACEMENT

INTRODUCTION AND OBJECTIVES: Treatment for stress urinary incontinence using suburethral slings fails in 10–20% of surgeries. The underlying pathophysiology is not fully understood. In this study, we use translabial ultrasonography (US) to evaluate sling type, position, and morphology in patients after suburethral sling placement. We hypothesize that sling position and morphological changes have an impact on sling failure. METHODS: In this retrospective observational study, 51 consecutive patients were evaluated with translabial US for type, position, and morphology of suburethral slings between 2009 and 2010. Axial, coronal, and sagittal planes were obtained using a curvilinear 4-9mHz transducer. The patients were stratified, by cough test and bother scores, into patients with recurrent incontinence (n 33) and continent patients (n 18). Student’s t-test was performed for statistical evaluation comparing sling type, position, and morphology in both groups after suburethral sling procedures. RESULTS: By evaluating the sling type, translabial US revealed a similar number of patients in the incontinent and continent group treated with a transobturator (45% vs. 56%) or retropubic sling (55% vs. 44%), respectively. Comparing the position of suburethral slings in incontinent and continent patients with translabial US reveals that more patients in the incontinence group were found with slings located at the proximal urethra (48% vs. 16%, p 0.0123), less patients in the incontinence group were found with slings at the midurethra (39% vs. 67%, p 0.0323), and a similar number of patients in both groups were found with slings at the distal urethra (12% vs. 17%), respectively. Only incontinent patients presented with urethra or bladder perforation (6%). Morphologically, slings were significantly more folded in the incontinent group than in the continent population (73% vs. 6%, p 0.0016). CONCLUSIONS: In this study, we have shown that US can distinguish transobturator and retropubic slings and determine sling position. The type of sling does not seem to have an impact on recurrent UI, whereas the position, close to the bladder neck and/or folding of the sling, might be related to recurrent incontinence. Because it is the only diagnostic tool to determine the type of sling, locate the sling position, and follow up on its morphology, translabial US helps to elucidate the pathophysiology responsible for sling failure.